Locked plate osteosynthesis of humeral head-splitting fractures in young adults

What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period?

BACKGROUND

Proximal humeral fractures (PHFs) often occur in elderly individuals who experience low-energy falls. Open reduction and internal fixation (ORIF) of the proximal humerus is typically performed in young, active patients because of their good bone quality and high functional demands. Although good short-term results have been reported after ORIF in young patients, few studies have specifically evaluated long-term outcomes.

QUESTIONS/PURPOSES

(1) What are the long-term clinical outcomes scores and (2) radiologic outcomes of nonosteoporotic three-part and four-part PHFs treated with locking plates? (3) What complications occurred after treatment, and what factors are associated with poor postoperative functional outcomes scores and avascular necrosis (AVN) of the humeral head after ORIF?

METHODS

Between June 2005 and December 2012, we surgically treated 774 patients for displaced two-, three-, and four-part PHFs. Approximately 75% (581 of 774) underwent ORIF, 10% (77 of 774) underwent hemiarthroplasty, 7% (54 of 774) underwent intramedullary nailing, 5% (39 of 774) underwent reverse shoulder arthroplasty, and the remaining 3% (23 of 774) underwent other surgical treatments. We considered those who had ORIF as potentially eligible. Based on that criterion, 75% (581) were eligible. However, only patients with nonosteoporotic three- and four-part PHFs (cortical thickness of the proximal humeral diaphysis greater than 6 mm on a preoperative AP radiograph of the affected shoulder) and a minimum of 10 years of follow-up were included. Sixty-four percent (498 of 774) of the patients were excluded because of simple or osteoporotic fractures, 1% (7 of 774) were excluded because of ipsilateral limb multiple fractures, 0.3% (2 of 774) were excluded because of pathologic PHFs, and another 2% (13 of 774) were lost before the minimum study follow-up of 10 years, leaving 8% (61 of 774) for analysis here. The mean age at surgery was 45 ± 12 years, with a mean follow-up of 13 years. Fifty-seven percent (35 of 61) of the patients were men. Patient-reported outcomes were evaluated using the University of California Loas Angeles (UCLA) score (range 0 to 35; higher scores represent better shoulder function) and Constant score (range 0 to 100; higher scores represent better shoulder function) at least 10 years postoperatively. Postoperative radiographs were reviewed to assess the cortical bone thickness of the proximal humerus, neck-shaft angle, head-to-tuberosity distance, and radiologically confirmable complications. Logistic regression analysis was performed to evaluate factors associated with poor postoperative functional scores (UCLA score ≤ 27 or Constant score ≤ 70) and AVN of the humeral head; the association between AVN and postoperative functional outcomes was also assessed.

RESULTS

At the most-recent follow-up, these patients had a mean UCLA score of 31 ± 3 and a Constant score of 88 ± 10. The mean neck-shaft angle was 133° ± 10°, and 23% (14 of 61) of patients experienced AVN of the humeral head during follow-up. Twenty-nine complications in 30% (18 of 61) of patients were reported. After controlling for potentially confounding variables such as age and gender, we found that the presence of greater tuberosity malposition (odds ratio 18 [95% confidence interval 2 to 167]; p = 0.01) and immediate postoperative neck-shaft angle less than 130° (OR 19 [95% CI 3 to 127]; p = 0.002) were associated with poor postoperative functional scores. Four-part PHFs (OR 13 [95% CI 2 to 82]; p = 0.008) and metaphyseal extension less than 8 mm (OR 7 [95% CI 1 to 35]; p = 0.03) were associated with AVN of the humeral head. For patients who met the criteria for anatomic reduction (achievement of all of the following three criteria: neck-shaft angle ≥ 130°, head-shaft displacement < 5 mm, and head-to-tuberosity distance greater than or equal to 3 mm and less than or equal to 20 mm), there were no differences in postoperative functional scores between patients with AVN and those without.

CONCLUSION

ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. When encountering complex PHFs in patients with good bone quality, every effort must be made to achieve an anatomic reduction of the fracture as far as possible, which may not reduce the risk of AVN (this occurred in nearly one-fourth of patients). However, good outcomes can usually be expected, even in patients with AVN. Because this was a retrospective study with a high risk of bias owing to sparse data, the factors associated with poor postoperative functional outcomes must be further investigated in large prospective studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

A Standardized Operative Protocol for Fixation of Proximal Humeral Fractures Using a Locking Plate to Minimize Surgery-Related Complications

The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28-92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant-Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.

Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system

BACKGROUND

Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate.

METHODS

Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed.

RESULTS

In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis.

CONCLUSION

There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis.

LEVEL OF EVIDENCE

IV.

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Long-stemmed Hemiarthroplasty with Cerclage Wiring for the Treatment of Split-Head Fractures of the Proximal Humerus with Metaphyseal Extension: A Report of 2 Cases

Introduction

Complex fractures of the proximal humerus with splitting-head component and metaphyseal propagation are very rare injuries that are difficult to treat. Preservation of the humeral head is always considered except in cases with severe comminution and compromised vascularity where shoulder hemiarthroplasty is an alternative option.

Case Report

We present two male patients, 57- and 62-years-old who sustained such a complex proximal humeral fracture after a high-energy injury. They both managed with long-stemmed shoulder hemiarthroplasty and cerclage wiring of the metaphyseal area. They both demonstrated good clinical and radiological outcome at 32- and 24-months postoperatively.

Conclusion

We report the functional and radiological outcomes of two cases of a rare proximal humeral fracture's pattern - combination of splitting-head and metaphyseal comminution – that were managed with long-stemmed hemiarthroplasty and cerclage wire and demonstrated good midterm clinical outcome.

Hinge plate technique for osteosynthesis of comminuted proximal humeral fractures

BACKGROUND

Several surgical techniques of osteosynthesis have been described for treatment of proximal humeral fractures. There is evidence that the quality of reduction improves the clinical outcome and decreases the number of complications. Reduction of the medial calcar is tricky when standard manoeuvres are performed. We have therefore augmented our standard surgical technique with a low-profile medial hinge plate which aims at better reconstructing the medial metaphysis without extensile soft tissue dissection in combination with proximal humerus locked plating.

OBJECTIVE

Evaluate the radiological and clinical outcome after application of an augmented fixation with a low-profile medial hinge plate. We questioned: (i) The quality of reduction, (ii) The rate of complications, (iii) The clinical function in terms of the Oxford Shoulder Score (OSS).

METHODS

A retrospective single-centre case series. Between 2016 and 2019, patients who had undergone open reduction and osteosynthesis by an anatomical locking plate associated with a 2.0 mm locking compression plate used as a hinge to support the medial metaphysis. Thirty-four patients, with an average age of 64 years had a clinical and/or radiological average follow-up of 36 months.

RESULTS

The preoperative imaging identified three fractures in two parts, 19 fractures in three parts and 12 fractures in four parts. Seven cases with fracture-dislocation were identified, one head-split fracture, and 14 cases with a metaphyseal head extension of less than 8 mm. After comparing head-shaft displacement, cranialisation of the greater tuberosity as well as head-shaft alignment in the preoperative and postoperative radiographs, overall anatomical or near-anatomical fracture reduction was achieved in 27 of the patients. Only two cases presented postoperative complications. The two cases were complicated with nonunion without screw perforation requiring surgical intervention by re-osteosynthesis. The clinical outcome assessed by the OSS showed an average of 45/48. The age of the group with anatomical or near anatomical reduction and the group with at least one parameter of malreduction was significantly different, 65 and 74 years respectively (p<0.05). No significant differences were found when comparing the sex, surgical time, time to operation or the number of fracture parts.

CONCLUSION

The technique described provides a surgical treatment option with lower complication rates and a quality of reduction consistent with the current literature as well as a satisfactory clinical outcome.

Implant Selection for Proximal Humerus Fractures

Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.

Operative treatment of 2-part surgical neck type fractures of the proximal humerus in the elderly: Cement augmented locking plate PHILOS™ vs. proximal humerus nail multiloc®

INTRODUCTION

The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients.

PATIENTS AND METHODS

Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%).

RESULTS

The mean DASH-Scores at 24 months was 32.6 ± 9.7 points in Group LP versus 37.8 ± 8.3 points in Group IN (p = 0.04). The mean Constant Murley Score at 24 months follow-up was 76.2 ± 7.7 points in Group LP compared to 72 ± 9.1 points in Group IN (p = 0.08). The ASES at 24 months follow-up was 75.1 ± 9 points in Group LP versus to 73.5 ± 8.9 in Group IN (p = 0.51). The OSS at 24 months was 43.7 ± 8.1 in Group LP compared to 38.2 ± 10 in Group IN (p = 0.03). The SF-36 at 24 months was 74.7 ± 12.5 in Group LP versus to 70.9 ± 12.8 in Group IN (p = 0.29). Screw cutting out was observed in n = 2 (6,7%) cases of Group LP, and in none of Group IN (p = 0.49). Revision surgery was necessary in n = 2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p = 1).

CONCLUSION

Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component

BACKGROUND

Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type.

METHODS

Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated.

RESULTS

The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069).

CONCLUSIONS

Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.

Subscapularis Peel for Open Reduction and Internal Fixation of Proximal Humerus Fractures With a Head Split

Proximal humerus fractures involving an articular head split are rare and complex injuries. In the elderly population, arthroplasty is the optimal treatment, whereas in younger patients, the utility of arthroplasty procedures is limited by concerns of long-term implant survival. As a result, open reduction and internal fixation is still often the first-line treatment option for head-splitting injuries. The traditionally described deltopectoral or anterolateral surgical approaches to the proximal humerus rely on indirect reduction and limited visualization of the articular fragments. We present a case series of younger patients with head-split proximal humerus fractures treated with open reduction and internal fixation through a deltopectoral approach with a subscapularis peel to improve humeral head visualization, reduction, and fixation. The improved reduction may lead to better long-term outcomes and reduce the need for additional surgical procedures. In addition, there were no cases of avascular necrosis in this series.

Open reduction and internal fixation of displaced proximal humeral fractures. Does the surgeon's experience have an impact on outcomes?

INTRODUCTION

To evaluate outcomes following open reduction and internal fixation of displaced proximal humeral fractures with regards to the surgeon's experience.

MATERIAL AND METHODS

Patients were included undergoing ORIF by use of locking plates for displaced two-part surgical neck type proximal humeral fractures. Reduction and functional outcomes were compared between procedures that were conducted by trauma surgeons [TS], senior (>2 years after board certified) trauma surgeons [STS] and trauma surgeons performing ≥50 shoulder surgeries per year [SS]. Quality of reduction was measured on postoperative x-rays. Functional outcomes were assessed by gender- and age-related Constant Score (nCS). Secondary outcome measures were complication and revision rates.

RESULTS

Between 2002-2014 (12.5 years) n = 278 two-part surgical neck type humeral fractures (AO 11-A2, 11-A3) were included. Open reduction and internal fixation was performed with the following educational levels: [TS](n = 68, 25.7%), [STS](n = 110, 41.5%) and [SS](n = 77, 29.1%). Functional outcome (nCS) increased with each higher level of experience and was significantly superior in [SS] (93.3) vs. [TS] (79.6; p = 0.01) vs. [STS] (83.0; p = 0.05). [SS] (7.8%) had significantly less complications compared with [TS] (11.3%; p = 0.003) and [STS](11.7%; p = 0.01) moreover significantly less revision rates (3.9%) vs. [TS](8.2%) and [STS](7.4%) (p<0.001). Primary revision was necessary in 13 cases (4.7%) due to malreduction of the fracture.

CONCLUSION

Quality of reduction and functional outcomes following open reduction and internal fixation of displaced two-part surgical neck fractures are related to the surgeon's experience. In addition, complications and revision rates are less frequent if surgery is conducted by a trauma surgeon performing ≥50 shoulder surgeries per year.

Acute proximal humeral fractures in adults

STUDY DESIGN

Clinical commentary.

INTRODUCTION

Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options.

PURPOSE

The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF.

METHODS/RESULTS/DISCUSSION

N/A for clinical commentary.

CONCLUSIONS

The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation.

LEVEL OF EVIDENCE

5.

Humeral Tip-apex-distance as a Prognostic Marker for Proximal Humeral Fractures in 203 Patients

BACKGROUND

Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare.

OBJECTIVE

Determination of predictive factors for the failure of osteosynthesis with the loss of fixation or migration of screws in humeral head fractures.

METHOD

From 1995 to 2011, 408 patients with proximal humeral fractures [mean age 66.6 years, 50.9-82.3 years] and osteosynthesis were analyzed. Two hundred and three received open reduction internal fixation (ORIF) with the PHILOS® plate. The non-locking plate was used in 80, the locking plate in 16 and humeral head prosthesis in 26 patients, in addition to 23 patients undergoing other procedures. Intraoperative reduction that achieved an anatomical alignment of the medial aspect of the humerus (humeral calcar) was assessed in 94 patients by postoperative X-ray analysis. The loss of fixation was evaluated by a follow-up of three to five X-rays and measurement of the humeral tip-apex-distance (HTAD).

RESULTS

For stable fixed fractures with an intact calcar, percentual HTAD was significantly higher than for unstable fixed fractures (p=0.04). Morbidity, such as hypertension, orthopedic operations or diabetes, strongly influenced the HTAD, while postoperative passive motion treatment modestly affected the HTAD over time.

CONCLUSION

The anatomic reconstruction of the calcar, leading to stable fixation of humeral head fractures, can significantly prevent an overproportioned decrease in the HTAD in postoperative X-rays and seems to be vital in multimorbid patients. Measurement of the HTAD over time delivers a tool for early detection of secondary loss of fixation.

Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures

BACKGROUND

The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures.

METHODS

Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of <50%) was determined according to the quality of fracture reduction and fracture pattern (disruption of the medial hinge; type-C3 fracture) and patient-related factors (age; comorbidities).

RESULTS

After a mean of 3.1 ± 1.5 years, the mean CS% and DASH score were 54.8% ± 28.0% and 31.9 ± 24.8, respectively. The complication rate was 32.7% (n = 32), and 27 patients (27.6%) required revision surgery. Anatomical or acceptable fracture reduction was achieved in 40 (40.8%) of the patients. This resulted in a significantly lower complication rate (20.0% compared with 41.4% among the patients with malreduction; p = 0.027), a trend of lower revision rate (20% compared with 32.8%; p = 0.165), and better clinical outcome (mean CS% of 65.4% ± 28.2% compared with 47.6% ± 25.7%; p = 0.002) without a higher risk for osteonecrosis of the humeral head (5% compared with 10.3%). Cranialization of the greater tuberosity of >5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8).

CONCLUSIONS

Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sword-Like Trauma to the Shoulder with Open Head-Splitting Fracture of the Head

Head-splitting fractures occur as a result of violent compression of the head against the glenoid; the head splits and the tuberosities may remain attached to the fragments or split and separate. Isolated humeral head-splitting fractures are rare injuries. Favorable results with osteosynthesis can be difficult to achieve because of the very proximal location of the head fracture and associated poor vascularity. We present a case of a 67-year-old man who sustained a severe, sword-like trauma to his left shoulder after a road traffic accident with associated isolated open Gustilo-Anderson IIIA humeral head-splitting fracture. Bony union was achieved with minimal internal fixation but the clinical outcome deteriorated due to accompanying axillary nerve apraxia. To our knowledge, this type of sword-like injury with associated humeral head-split fracture has not previously been reported.