Abstract
Introduction: Fractures of the proximal humerus account for 4–5% of all fractures. The number one cause of this type of fracture is age related osteoporosis associated with minimal trauma. Approximately 80% of these fractures are non or minimally-displaced, and can be treated conservatively with good results. However, treatment of displaced complex fractures is still controversial. The disadvantage of open procedures is the risk of damaging the blood supply to the humeral head, leading to a higher incidence of avascular necrosis.
Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation.
Purpose: The guide wire loosening leads us to improve the technique by adding an external fixator to stabilize the guide wires and secure fragment positioning. We report our experience of treating displaced fractures of the proximal humerus with Closed Reduction and External Fixation (CREF).
Materials and methods: Between the years 1996–2001 we operated on 37 patients for 38 complex fractures and fracture dislocations of the proximal humerus. We had 16 two part fractures, 13 three part fractures, 3 four part fractures, 5 two part fracture dislocation and 1 four part fracture dislocation according to the Neer’s classification.
The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF.
Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises.
Results: The average follow up was 31.6 months (range 6–60 months). No loosening was observed upon removal of the external fixator, however the following complications were encountered: 5 patients had superficial pin tract infections, 1 patients developed an avascular necrosis of the humeral head, 1 patient had a non union of the fracture. Of the remaining patients, 13 patients had an excellent result, 15 patients had a good result and 5 patients had a fair result.
Conclusions: CREF is a minimal invasive technique for complex fractures of the proximal humerus, greatly reducing the damage to the blood supply when compared to open surgical procedures. It offers a better stabilization than CRPF, thus reducing the complication rate. The percutaneous technique causes less scaring and therefore a shorter rehabilitation program. Consequently, this procedure is recommended for complex fractures of the proximal humerus.
The abstracts were prepared by Orah Naor. Correspondence should be addressed to him at the Israel Orthopaedic Association, PO Box 7845, Haifa 31074, Israel.
