Multifocal humeral fractures

Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing

INTRODUCTION AND OBJECTIVE

Proximal humerus fractures with metaphysodiaphyseal extension represent a challenge for the orthopedic surgeon due to their reduced incidence and the difficulty in the treatment decision. These can be treated with an intramedullary nail or using the MIPO technique, associating different advantages and complications depending on the procedure. The objective of this study was to compare metaphyseal-diaphyseal fractures of the humerus treated with antegrade intramedullary nailing and those operated using the MIPO technique to see if there were significant differences in terms of functional, clinical, and radiological results.

MATERIAL AND METHODS

retrospective, analytical and unicentric review of 29 patients with proximal fracture with metaphyseal-diaphyseal extension treated by MIPO technique and 33 patients surgically treated by antegrade intramedullary nailing (IMN) in our hospital from 2014 to 2020. Demographic, functional, radiographic and clinical data were obtained..

RESULTS

No significant differences were observed between both groups in terms of fracture mechanism (p=0.34), fracture type (p=0.13) or Maresca classification (p=0.32). Surgical time was significantly shorter in the IMN group compared to the MIPO technique (p=0.014). No significant difference was observed regarding the need for blood transfusion (p=0.32). The mean consolidation in the MIPO group was 21 weeks compared to 21 weeks in the IMN, with no significant differences between both groups (p= 0.88). No significant differences were observed between CONSTANT test at one year in the MIPO group versus the IMN group (p=0.79), nor in radial nerve palsies (p=0.28).

CONCLUSIONS

Proximal fractures with metaphyseal-diaphyseal extension are a challenge for the orthopedic surgeon due to the infrequency, the complexity of these fractures and the fact that there is no established consensus on the ideal treatment for this type of injury. Both the MIPO technique with the Philos plate and the intramedullary nail are valid options for the treatment of these fractures, with no differences observed in terms of fracture consolidation time or in terms of functional results.

Minimally invasive plate osteosynthesis for segmental humerus fractures with a helical plate. Which distal fixation—the anterior or lateral—is superior?

Aim: In order to achieve adequate stability in segmental humerus fractures, the PHILOS fixation with minimal invasive approach comes into use instead of conventional plating. However, according to the AO classification, 12C type segmental humerus fractures treated with minimally an invasive method are prone to complications. The purpose of this prospective study is to compare functional outcomes and complication rates following two different angled helical PHILOS plate fixation. Material and Method: This multicenter study is a prospective review of cases with a final follow-up outcome. Twenty-two patients with AO 12-C humerus fractures underwent PHILOS fixation with contoured PHILOS plates between January 2016 and June 2019. Patients evaluated in two groups. Group 1 consisted 12 patients who were treated with a 30° helical plate and Group 2 consisted 10 patients who were treated with 70° helical plate. Clinical outcomes were noted according to the Constant-Murley scoring system. Results: The mean age of patients treated in groups 1 and 2 were 49±15.8 and 50.7±17, respectively. Fractures healed in an average of 13.1±3.9 weeks in Group 1 and 13.8±3.1week in Group 2, respectively. The mean follow-up period of the patients was 18±6.1months in Group 1 and 22±4.2 months in Group 2. Mean Constant-Murley scores at final follow-up were 88±2.7 and 90±2.5 in Groups 1 and 2 respectively (p=.665). Radial nerve neuropraxia was seen in 2 cases in Group 1, and a sensorial injury of the musculocutaneous nerve was seen in 1 patient in Group 2 (p=.365). Conclusion: Similar union rates and successful clinical results were obtained from both groups. However, this study suggests that the 70° angled helical PHILOS technique could be performed relatively easily in AO 12-C fractures with fewer complication rates. Musculocutaneous nerve affliction can be as functionally destructive as radial nerve affliction.

Multifocal Humeral Fractures: Clinical Results, Functional Outcomes and Flowchart of Surgical Treatment

Aim and objective

Materials and methods

Results

Conclusion

Clinical significance

How to cite this article

How to treat proximal and middle one-third humeral shaft fractures: the role of helical plates

PURPOSE

To evaluate the outcomes of patients affected by proximal and middle one-third humeral shaft fractures treated with humeral helical plates.

MATERIAL AND METHODS

From October 2016 to June 2020, twenty-four (twenty women, four men) underwent humeral reduction and fixation with humeral helical plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet) that preserve deltoid muscle insertion and reduce the risk of iatrogenic radial nerve injury. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (eighteen months on average), clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. Only descriptive statistical analysis was conducted.

RESULTS

At six months, all fractures have healed. At last follow-up (average eighteen months, 13-28) mean Constant score was 71 (range 33-96), mean Dash score was 19.2 (range 1.7-63). The average range of motion was calculated as follows: flexion 137.8° (range 90-180); abduction 125.8° (range 85-180°); external rotation 55° (range 20-80°), internal rotation at L3 (range between scapulae-trochanter). Three patients experienced temporary radial nerve palsy from injury, while in one case, a temporary iatrogenic palsy occurred.

CONCLUSIONS

In our opinion, the helical plate may be an effective surgical tool for management of proximal and middle one-third diaphyseal humeral fractures. The humeral helical plate allows stable fixation avoiding the deltoid tuberosity proximally and radial nerve distally, thus increasing the possibility of rapid functional recovery after surgery.

A New Surgical Technique and Clinical Outcomes of Operated Proximal Metadiaphyseal Humeral Fractures and Nonunions With the Use of Reversed Anatomic Distal Femoral Locking Plate

Introduction

Proximal humeral fractures complicated with metaphyseal and diaphyseal extension are usually treated operatively with 3.5 mm long anatomic proximal humerus plates. However, frequently these comminuted and segmental fracture types may be associated with delayed union, nonunion, and/or plate failure. We present a technique for addressing this fracture pattern by using an anatomic contralateral 4.5 mm distal femoral plate in a reversed fashion.

Methods

Eleven patients (eight women and three men) with a mean age of 70 years (range, 52 to 84 years) were operated on with the described technique. The dominant hand was involved in seven out of 11 patients. There were seven acute metadiaphyseal fractures and four nonunions. In one patient, humeral shaft nonunion was associated with segmental metadiaphyseal defect and a free fibular graft was applied.

Results

All fractures healed and patients regained almost normal function of the affected shoulder and upper limb. Shoulder abduction and forward elevation ranged from 80 to 110 degrees (mean, 97 degrees) and 90 to 120 degrees (mean, 102 degrees), respectively. The disabilities of the arm, shoulder and hand (DASH) score varied from 6 to 11 points (median 8). No major trauma or systemic complications were recorded.

Conclusion

The morphology, strength, and characteristics of the plate could effectively conform to the anatomy of the proximal humerus and offer adequate stability for fracture union. The described technique is more useful in case of osteoporosis and/or presence of previous failed internal fixation that further compromise the vascularization and the mechanical properties of the bone.

How to treat proximal and middle one-third humeral shaft fractures: The role of helical plates

Complex proximal third diaphyseal humeral fractures are uncommon patterns of injury mainly caused by high energy trauma. The anatomical shape of the humerus, the presence of the deltoid tuberosity and the close proximity of the radial nerve into the radial groove represent challenge elements to deal with. Historically, straight plates were manually twisted; subsequently, helical plates created for other anatomical sites (as distal tibia) were used in humeral fractures. In both these experiences surgeons observed several disadvantages. More recently, dedicated helical plates have been created. In this study, we expose our surgical technique for using helical humeral plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet), with its advantages and operative recommendation. From 2019 to 2021, nine patients who were admitted to our institution for humeral fractures involving the proximal third diaphysis have been treated with humeral helical plates. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (fourteen months on average) clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. At six months, all fractures have healed. At last follow-up (fourteen months on average, 6-22) the average range of motion were flexion 135° (90°-180°); abduction 124° (85°-180°); external rotation 52° (20°-80°), internal rotation at L3 (between scapulae-trochanter). Average Constant Shoulder Score was 70 (33-96), average Dash score was 21 (range 1,7-63). Three patients experienced temporary radial nerve palsy from injury, with subsequently improvement at EMG analysis within eight months from surgery. In our opinion this strategy avoids the deltoid tuberosity and reduces the risk of radial nerve injury, increasing the possibility of a rapid functional recovery after surgery.

Exploring the difficulties to improve minimally invasive application with long PHILOS plate in multifocal metadiaphyseal fractures of the proximal humerus: analysis of intraoperative procedure and clinical outcomes

The MIPO (Minimally Invasive Plate Osteosynthesis) technique for treating metadiaphyseal fractures of the proximal humerus has gained great attention during the past years. The purpose of this retrospective study was to underline all the important difficulties when the MIPO technique is applied, to propose practical solutions and to evaluate the overall clinical outcome of our patients treated with this technique. A total of 14 patients had been operated in two different surgical units, at San Carlo Borromeo Hospital (Milan, Italy - 11 patients) and in Policlinico Umberto I Hospital (Rome, Italy - 3 patients), between June 2013 and November 2016. The humeral fractures were divided according to the Maresca et al. classification system. A lateral deltoid-split or an anterolateral deltopectoral approach was performed in the proximal humerus. In distal approach, an anterior or a lateral window was performed for plate fixation. After a follow-up of 17,4 (range 3-31) months all patients showed fracture healing and there were no non-unions or infected cases. MIPO of the humerus is a tissue sparing technique and in expert hands can improve healing rates and can also reduce complications like nerve damages and infections. In conclusion, we would like to highlight the importance of the MIPO technique as a possible alternative option to the traditional ORIF technique. (www.actabiomedica.it)

Is it safe to assist proximal humeral nailing to residents? An analysis of 1134 cases

INTRODUCTION

Intramedullary nailing is a common procedure for the treatment of proximal humeral fractures. In practical resident training this standardized operation plays an important role in the introduction to osteosynthesis. Our aim was to investigate whether assisting this operation to residents influences the surgical complication rate both in-house and on re-admission.

METHODS

All 1134 patients who received a proximal humeral Targon PH nail (Aesculap) for proximal humeral fractures were included between 2000 and 2013. Several age groups (≤60 years, 61-70 years, 71-80 years, 80-90 years, and over 90 years) were analyzed separately. Complications including screw/nail protrusion, displacement, infection, humeral head necrosis, nonunion, stiffness, hematoma, impingement, screw loosening, implant failure, dislocation were recorded. 803 (70.7%) of the patients were female. Mean patient age was 71.7 years (standard deviation: 14.0 years). For detection of significantly different complication frequencies between operations performed by residents or attending physicians, we used the χ² test in cases with all expected values greater than five, otherwise we used the two-sided Fisher's exact test.

RESULTS

Supervised residents performed 204 operations. Overall complication rate was 12.6% (95% CI: 10.7-14.5%). The complication rate of the attending operations was 13.2% while it was 9.8% for resident operations. The difference was not significant. No statistically significant relation between age group and complication rate was found. In all patients older than 80 years the complication rate was higher when operated by residents compared to those operated by consultants, whereas in younger patients it was lower. Whereas the difference was not significant in patients younger than 60 and older than 80, we found significantly less complications in the group of patients between 61 and 80 years of age. On the other hand patients between 81 and 90 years displayed a 1.46 fold higher risk after training operations. No significant differences in the frequency of the different complications were found.

CONCLUSION

We conclude that proximal humeral nailing is an operation suitable for teaching purposes. However, patients between 81 and 90 years of age seem to be at an increased risk for complications if operated by a resident.

Simultaneous bilateral "floating arm" of the humeri: an uncommon presentation of a rare complex injury and review of the literature

The timing of definitive fixation for simultaneous fractures of the humerus in polytrauma patient is controversial. We report on the management of a patient that sustained bilateral "floating arm" fractures of the humeri. When dealing with such injury patterns, it is important to always carry out stabilization of the humeral diaphysis first and afterwards to treat the sub-injury or over-injury fractures. Our patient healed after twelve weeks in both humeri. After seven years MEPS showed excellent and good results in the right and left arms, while UCLA scores proved excellent in both sides. We encountered no intraoperative and postoperative complications.