Abstract
Introduction: Fracture of the proximal humerus are challenging for diagnosis and treatment. The vast majority of these fracture associated with osteoporosis in elderly. Decision making for the treatment must include all arguments of fracture type, physical demands and rehabilitation cooperation of patients. This is particularly crucial in proximal humerus fracture. Results of surgery including hemiarthroplasty are difficult to predict and many times type of surgical treatment can be determined intra-operative or at least after closed manipulation attempt.
Material and methods: Between September 1998 to September 2000, 68 patients underwent surgery for proximal humerus fracture. Patients who underwent hemiarthroplasty were not included in this study. Diagnosis of the fracture was based on Neer classification system and was aided by CT scan. Type of surgery was made finally after closed manipulation attempt under anesthesia. Patients were consented for closed manipulation, open reduction and internal fixation or hemiarthroplasty. Data was collected retrospectively from outpatients notes. 32 males and 36 females, age 40–88 (mean: 62), underwent closed manipulation and pinning (30), ORIF included pinning and PDS suture (32) and ORIF included PDS suture only (6). Fracture type distributed as follows: 2 parts surgical neck – 9, 2 parts GT – 6, 3 parts – 29, fracture dislocations – 6, 4 parts – 12, impacted valgus fracture 6.
Four threaded pins were inserted retrograde and trimmed under the skin. Two antegrade pins were left out of the skin and banded to prevent migration to the axilla. Patients were immobilized in shoulder immobilizer for 6 weeks when pins were removed in outpatient clinic. Control X-ray was taken at 2, 4, 6, 12 weeks. If fracture was noted to be unstable, X-ray was taken every week up to 4 weeks. In case of any deterioration after 12 weeks X-ray was taken to detect signs of AVN.
Rehabilitation program commenced after clinical union with passive and assisted active for 4 weeks followed by active mobilization. Follow-up ranged from 10–34 months (mean: 22) and range of motion with X-ray description were documented.
Results: All fractures but one were united, fracture position was noted in 31 patients as normal in 46 (68%), head-shaft in extension in 8 (11.7%), varus head – 7 (10%), valgus head – 1 (1.4%), prominent GT – 4 (6%), prominent LT – 3 (4.4%), complete displacement – 2 (2.8%), dislocated – 1 (1.4%).
Mean range of motion for all groups was: Elevation – 144 (60–180), External Rotation – 54.6 (−10–80), Internal Rotation – L1 (Throchanter – T8). Statistical analysis for fracture groups showed best results for impacted valgus and greater tuberosity fracture after open reduction and worst results were noted for 4 parts fractures and fracture dislocation. Although the study was not randomized there was no significant difference between the group of closed pinning and open surgery.
Complications: Six patients had revision surgery during the early follow up due to fixation failure. In one case repinning was performed, in 2 cases closed pinning transformed to open surgery and suture of GT, in one case osteotomy and re-insertion of LT was needed, one case complete lost of fixation ended in hemiarthroplasty and one case of fracture dislocation failed to closed and open surgery and need bone block (Laterget) to prevent re-dislocation. AVN was noted in 5 cases – 2 partial and 3 complete (3% and 4.4%, respectively). Pin tract infection occurred in the 6 of prominent antegrade pins and resolved after early removal of these pins without the retrograde pins. G-H arthrosis was noted in one case after 2 years.
Conclusions: Surgical treatment of proximal humerus fracture and attempt to preserve the humeral head is alternative to conservative treatment or hemiarthroplasty from the other hand. High surgical are demanded and fixation cannot be guaranteed due to minimal bone stock for fixation. Partial loss of fixation still leave better position and reasonable functional results. Further attention is needed to the lesser tuberosity which could be seen better under fluoroscopy under anesthesia.
The abstracts were prepared by Orah Naor. Correspondence should be addressed to him at the Israel Orthopaedic Association, PO Box 7845, Haifa 31074, Israel.
