Modified-tension band wiring of displaced surgical neck fractures of the humerus

Effectiveness of Locked Nailing for Displaced Three-Part Proximal Humeral Fractures

BACKGROUND

Published reports about locked nailing for displaced comminuted proximal humeral fractures are few and the results contradictory.

METHODS

Locked nailing was used to treat 27 selective patients with displaced three-part proximal humeral fractures. The average age of patients was 54.3 years. The operative indications were persistent severe displacement, intact or minimally displaced lesser tuberosity, tolerance of anesthesia, and adherence to rehabilitation programs. Three patients had associated shoulder dislocation and two had fractures with diaphyseal extension. By transdeltoid approach, the fractures were reduced and then fixed by antegrade nailing with either upward or downward locking screws. The patients were prospectively followed up for an average of 24 months.

RESULTS

All fractures achieved eventual union. Three patients with proximal screw loosening required screw removal. On the basis of Neer criteria, excellent or satisfactory results were obtained in 21 patients whose scores averaged 87.5 points. Six patients had unsatisfactory outcomes, with an average of 75.8 points. Two patients with the complication of avascular necrosis still had a satisfactory outcome. Varus deformity of shoulder joints, deformity of the greater tuberosity, collapse of the humeral head, and old age could adversely affect shoulder elevation. However, the anatomic abnormalities might have limited effects on the pain scale, muscle power, and shoulder stability.

CONCLUSIONS

Locked nailing can be an effective treatment for selected severely displaced three-part proximal humeral fractures. It is particularly useful for fractures with diaphyseal involvement. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful treatment results.

[Results of the provision of unstable proximal humeral fractures in geriatric patients with a new angle stabilizing antegrade nail system]

Treating unstable proximal humeral fractures in elderly patients with osteoporosis and limited compliance is still demanding for trauma surgeons. The failure rate of operative treatment is high. We studied the use of a new antegrade intramedullary humeral nail with special locking bolts for head fixation. The first 41 procedures in 39 patients with a mean age of 81 years (61-102) were analyzed. Half of the patients were mentally deranged. There were 16 two-part, 22 three-part, and 3 four-part fractures of the humeral head treated. After closed or partial open reduction, antegrade nailing was performed via a delta split and limited incision of the rotator cuff. Greater and lesser tuberosities were fixed with screws through threaded holes of the proximal nail leading to high stability. Early functional active treatment was performed avoiding maximal rotation. Follow-up was 13 months (7-21 months). Clinical examination was performed in 32 cases. Four patients were questioned by phone. Three patients died (mean age: 92 years) before follow-up. The mean Constant score was 57+/-12. The mean age-related and side-related Constant scores were 86+/-17% and 90+/-7%. All fractures healed. Activities of daily life were possible in every case. There was only one loss of reduction after a fall out of bed. After hemiarthroplasty the patient was excluded from the study. One shaft fissure occurred during distal interlocking and healed uneventfully. Because of stable fixation, rehabilitation without immobilization was possible and led to good functional results. In comparison to common implants, the new antegrade intramedullary nail allowed a stable osteosynthesis in unstable proximal humeral fractures in old and very old patients with limited compliance without the usual implant-related complications.

Fixed-angle plate fixation in simulated fractures of the proximal humerus: a biomechanical study of a new device

This study was performed to evaluate the biomechanical properties of a new device for displaced fractures of the proximal humerus. The device is a low-profile, fixed-angle plate specially designed for percutaneous application. With the use of embalmed cadaveric humeri, we simulated both noncomminuted and comminuted 2-part surgical neck fractures of the proximal humerus. Each humerus of a pair was then randomly fixed with either the new experimental device or the Association for the Study of Internal Fixation (ASIF) T-plate and mechanically tested to failure in an axial shear-loading model. The two fixation devices were evaluated in paired humeri with regard to mode of failure, stiffness, displacement at physiologic loads, and displacement, load, and energy at the point of ultimate load before failure. In the noncomminuted fracture trials the experimental device exhibited significantly greater stiffness (P <.001; P =.002 for normalized values) and ultimate load before failure (P =.015) and significantly less displacement at higher physiologic loads (P =.031). In the comminuted fracture trials the experimental device exhibited significantly greater stiffness (P =.048), ultimate load (P <.001) and energy absorbed (P =.048) before failure, and significantly less displacement at higher (P =.004) and lower physiologic loads (P =.011). The study demonstrates improved biomechanical properties for the new experimental device over the T-plate in simulated fractures of the proximal humerus. We extrapolate that these improved biomechanical properties may prove advantageous in future clinical investigation.

Displaced three- and four-part proximal humerus fractures: evaluation and management

Three- and four-part fractures are the most severe injuries in the spectrum of fractures of the proximal humerus. Despite the shortcomings of the currently available imaging techniques, fracture displacement remains an important principle in guiding management. As a result, increasing emphasis has been placed on the use of Neer's criteria in intraoperative decision making. Patients with four-part fractures with valgus impaction of the head fragment should be treated with limited open reduction and minimal internal fixation, as the blood supply to the humeral head is better preserved than with other fracture patterns and the potential for osteonecrosis is less. In the case of displaced three- and four-part fractures, the physiologic age and bone quality also help guide treatment selection. In young patients with good bone quality, attempts to preserve the humeral head by meticulous handling of soft tissues and the use of low-profile implants to secure fracture fragments is recommended. Vertical fixation alone with Rush rods in patients with poor bone quality and in those with four-part fractures is no longer considered adequate and should not be used. For selected patients with three-part fractures and satisfactory bone quality, fixation with Ender rods and tension-band wiring may be appropriate. Elderly patients and those with poor bone quality have a greater risk of loss of reduction after open reduction and internal fixation, and the current consensus is that early hemiarthroplasty is the appropriate treatment. Late reconstruction necessitated by malunion and soft-tissue contracture is technically difficult, and the outcome is less favorable. The outcome of treatment of three- and four-part fractures is dependent on the surgeon's ability to analyze the fracture pattern and execute appropriate techniques to restore anatomy and function. The use of cement for prosthetic fixation and rigorous attention to tuberosity stabilization and anatomic reduction are two factors that will optimize outcome. Adequate pain relief after hemiarthroplasty has been consistently demonstrated, but return of motion and function is less predictable.

Locked nailing for displaced surgical neck fractures of the humerus

OBJECTIVE

To report experience with a newly devised humeral locked nail for treating surgical neck fractures of the humerus. This device has the advantages of a small diameter for minimal tissue trauma and transfixing locking screws for reliable fixation.

METHODS

From 1993 to 1996, 21 consecutive severely displaced surgical neck fractures of the humerus were antegrade nailed with humeral locked nails; 2 fractures were associated with dislocation and 1 fracture was a comminuted metaphyseal fracture with a failed plating. The average age of patients was 65.8 years; average follow-up time was 19.2 months. The proximal screws were applied upward in 5 patients and downward in 16 patients. Static locking was performed in 8 patients, dynamic locking in 13 others.

RESULTS

The average operation time was 55 minutes. No patients needed blood transfusion. All fractures eventually achieved union with an average time to union of 14.8 weeks. On the basis of Neer criteria for outcome analysis, excellent or satisfactory results were obtained for 86% of the patients (18 of 21 patients). No patients had deep infection, implant failure, malunion, osteonecrosis, or nail migration that interfered with joint motion. Due to technique errors, one patient had shoulder joint impingement caused by protrusion of the proximal nail tip.

CONCLUSION

The operative method reported here has the advantages of minimal tissue trauma, minimal hardware application, sufficient fixation, and easy operative technique, and it can be a worthy alternative for the treatment of severely displaced surgical neck fractures of the humerus.

Surgical neck fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques

OBJECTIVE

A biomechanical cadaver study was performed to compare the stability and ultimate strength of ten standard fixation techniques used for the treatment of surgical neck fractures of the proximal humerus.

DESIGN

One hundred twenty (60 fresh frozen, 60 embalmed) proximal humerus specimens were selected and divided into two groups: fresh frozen specimens represented a nonosteopenic group and embalmed specimens an osteopenic group. Simulated fractures were created at the level of the surgical neck, reduced, and randomly assigned to one of ten methods of fixation (six fresh frozen and six embalmed specimens per fixation group). These constructs were then mechanically tested with the humeri oriented to create primarily shear loading of the fixation.

RESULTS AND CONCLUSIONS

The T-plate and screws provided significantly stronger fixation (p < 0.005) in the fresh frozen specimens than all other methods. The Ender nails/tension band construct was the second strongest fixation technique, providing significantly stronger fixation (p < 0.01) than all the remaining techniques. Four Schanz pins with one pin placed through the greater tuberosity followed by the T-plate and screws provided the strongest fixation in embalmed specimens. Tension band fixation in both humeral groups was shown to provide the least effective fixation.

Displaced Proximal Humeral Fractures: Evaluation and Treatment

Successful treatment of proximal humeral fractures relies on the surgeon's ability to make an accurate diagnosis. Treatment must be predicated on a thorough understanding of the complex shoulder anatomy, a precise radiographic evaluation, and use of a well-designed classification system. Appropriate and realistic goals must be established for each patient. The patient's general medical health, physiologic age, and ability to cooperate with intense and prolonged rehabilitation are all considerations when selecting the optimal treatment.