ABSTRACT
Introduction: In
dealing with displaced 2 part and 3 part proximal humerus
fractures there is still much controversy in treatment
modalities. This study emphasizes the concept of minimal
invasive and stable fixation with closed reduction and
percutaneous pinning as the treatment of choice.
Materials and Methods: The technique of closed reduction
and percutaneous fixation were analyzed in 18 consecutive cases.
The functional outcome was evaluated using Neer scoring system
with a mean follow up of 10 months.
Results: 2 part fractures had 100% good outcome and 3
part fractures had 83% good results. The poor results in 3 part
fractures were due to improper patient selection. Patients of
age more than 60 years had poor results. Varus malunion did not
affect the functional outcome unlike valgus malunion. No
incidence of avascular necrosis in our series.
Conclusion: In this era of biological fixation, the
method of closed reduction and percutaneous fixation yields
satisfactory results in 2 part and 3 part proximal humerus
fractures and can be a treatment of choice.
Key
Words: Neers fracture, percutaneous fixation, biologic
fixation.
J.Orthopaedics 2005;2(3)e3
Introduction
Fractures of the proximal humerus are challenging to diagnose
and treat. Proximal humerus fractures are not uncommon,
comprising to about 4 to 5 percentage of all fractures (Habermeyer
and Schweiberer 1989).
Neer
was among the first to recognize the deficiency of traditional
methods in classification as well as standardization of
treatment policy. He proposed two, three and four part fractures
and fracture dislocation based on the observation first made by
Codman in 1934 (Neer). Emphasis is placed on formulation of safe
and simple technique for restoration of anatomy, stability,
fracture healing, cuff integrity, motion and function.
Based
on the Neer’s work, hemiarthroplasty has become widely accepted
for the management of severely comminuted and grossly displaced
fractures of the proximal humerus. However the optimal treatment
in displaced two and three part lesion has remained a matter of
controversy. Non surgical treatment of these fractures often
results in severe malunion and poor functional outcome.
Traditional open reduction may lead to more accurate reduction
but the extensive tissue dissection doubles the risk of
avascular necrosis and fracture disease.
Percutaneous reduction and fixation of such fractures would
therefore seem to be desirable since this has (Resch et al,
1997) Minimal fixation, Maintains cuff integrity, Minimal scar /
No scar, Maximizes anatomical restoration, Fracture hematoma
undisturbed, Enhances fracture healing, Early post operative
rehabilitation, Prevents avascular necrosis, Biological
fixation, Easy implant removal.
Patients and
method
From
December 2002 to October 2004, consecutive patients with
proximal humerus fractures were evaluated. We had 18 patients
with proximal humerus fractures treated with closed reduction
and percutaneous fixation for our functional outcome analysis.
There
were 12 male (66%) and 6 female (34%) patients.
The
average age was 45 years (Range 27 – 65 yrs).
After
the injury, once the patients general condition became
stabilized, routine radiographs of the injured shoulder were
taken and the characteristics of the fracture were evaluated.
2
patients (11%) had anatomical neck fracture, 14 patients (78%)
had surgical neck fracture, 14 patients (78%) had greater
tuberosity fracture and one patient (5%) had lesser tuberosity
fracture.
The
fracture pattern, amount of displacement, communition and bone
quality were assessed with anteroposterior view and dislocation,
tuberosity displacement and articular surface defects were
assessed in axial views. If needed CT scan was performed in
selected patients to assess fracture pattern. The fractures were
classified according to the criteria of Neer (Table 1).
Neer Classification |
Number of patients |
2
part |
6 |
3
part |
11 |
4
part |
1 |
Fracture dislocation and head splitting fractures were excluded
from the study. Those fractures which were identified as having
unstable pattern, that could be satisfactorily reduced by
manipulation with the patient in anesthesia but not stable,
underwent percutaneous fixation with either Kirchner wires,
schanz screws or cancellous screw .
15 of
our patients (83%) had fixation with Kirchner wires (smooth K
wires – 13 and threaded K wires – 2). Threaded K wires were used
in patients with significant osteoporosis. 2 patients (11%) had
schanz screw for 3 part fracture and 1 patient (5%) had
cancellous screw fixation for 2 part fracture
The
prerequisites for percutaneous fixation were that patients who
had minimal communition at fracture site, good bone quality,
could tolerate general anesthesia and there was no or minimal
skin compromise of the injured shoulder. Patients who had a
minimum follow up for 5 months were only included in our study.
The average follow up was 10 months ranging from 5 months to 22
months. Patients who had conservative treatment, open fractures
and open reduction were also excluded.
OPERATIVE TECHNIQUE
Reduction Maneuver
Closed reduction was performed
under the guide of a C arm image intensifier. Special care was
taken concerning posterior sagging of the humeral shaft caused
by gravity. According to the study by Keene et al of 25 control
patients in 1983, we defined eligibility criteria of “acceptable
reduction” with regard to (1) neck-shaft angle on
anteroposterior view of shoulder radiograph and (2) posterior
angulation on lateral view.
Pinning Technique
Stabilization of head shaft
fragments was started with K-pins inserted from lateral sides,
anterior and greater tuberosity. Internal fixation of the
humeral head fragment to the shaft was done with 2 lateral
distal to proximal pins. Following this fixation, the shoulder
was externally rotated by 20 to 30 degrees during placement of
greater tuberosity pins to move the axillary nerve and the
posterior humeral circumflex artery farther away from the
humeral neck.
Schanz
screws are also inserted in the same way as described above but
instead of K wires, 2.5 mm schanz screws were used.
In
cases of isolated greater tuberosity fractures, once reduction
was achieved and held by K wire, partially threaded 4.5 mm
cancellous screw without washer was inserted to maintain
reduction and the temporary K wire was removed.
Postoperative Care
Passive and pendulum exercises
were initiated as soon as pain and swelling subsided and the
wound started to heal averaging 4 weeks, ranging from 1 week to
10 weeks. Immediate post operative radiographs and follow up
radiographs were taken at 4 weeks to 6 weeks interval. The
k-pins were removed when there is radiological evidence of union
at 4 to 10 weeks, averaging 5 weeks. More aggressive motion and
rotation exercises were then instituted to regain the range of
motion of the shoulder.
The
treatment results were assessed according to the grading scale
of Neer at the maximum follow up of the patient (Table 2).
Parameters |
Points Given |
Pain |
35 |
Function |
30 |
Range Of Motion |
25 |
Anatomy |
10 |
Total |
100 |
Neer
system allows a total of 35 points for pain, 30 points for
function, 25 points for motion and 10 points for reconstruction
of anatomy with a maximum of 100 possible points. Pain, the most
important consideration to the patient, is assigned 35 units.
Functional range, more important in the shoulder than in most
other joints, is accorded a greater unit value than strength and
anatomy. To grade anatomy, the radiographs were evaluated with
special regard to placement of pins, maintenance of reduction,
implant migration, joint penetration, malunion, neck shaft
angle, lateral angulation, nonunion, myositis, metal failure and
avascular necrosis of the humeral head. More than 89 points
constitutes an excellent result; 80 to 89 points, a good result;
70 to 79 points, a fair result; fewer than 70 points, a poor
result (Neer 1970).
Results
RANGE OF MOVEMENT
The
average and available range of movement as recorded with
goniometer (Table 3).
|
In Degrees |
Neer |
Abduct |
F.Flex |
Int.Rot |
Exten |
Ext.Rot |
Adduct |
2
Part |
170 |
163 |
70 |
60 |
100 |
37 |
55
– 180 |
110 – 180 |
MAX |
1
PT HAD 30 |
0
– 100 |
20
– 45 |
3
Part |
161 |
160 |
70 |
45 |
87 |
37 |
20
– 170 |
30
– 170 |
MAX |
10
– 60 |
0
– 100 |
0
– 45 |
4
Part |
5 |
5 |
20 |
10 |
0 |
5 |
The
average restriction of movement as noted (Table 4).
|
2
part |
3
part |
4
part |
Abduction |
10 |
20 |
175 |
Adduction |
8 |
8 |
40 |
Extension |
Nil |
Nil |
50 |
Forward flexion |
17 |
20 |
175 |
Internal rotation |
Nil |
Nil |
50 |
External rotation |
Nil |
13 |
-10 |
10
degrees loss of abduction for 2 part and 20 degrees for 3 part
fractures
17
degrees loss of forward flexion in 2 part and 20 degrees loss in
3 part fractures.
The
maximum attainable abduction and forward flexion in 3 part is
170 degrees.
Extension is unaffected in 2 part and loss of 15 degrees in 3
part fractures.
Internal rotation is unaffected in both 2 and 3 part fractures.
13
degrees loss of external rotation for both 2 and 3 part
fractures.
8
degrees loss of adduction for both 2 and 3 part fractures.
The
four part patient had deep infection and the movements are
grossly restricted.
NEER’s SCORING
|
Excellent |
Good |
Fair |
Poor |
Total |
2
Part |
4 |
2 |
- |
- |
6 |
3
Part |
4 |
5 |
1 |
1 |
11 |
4
Part |
- |
- |
- |
1 |
1 |
Total |
8 |
7 |
1 |
2 |
18 |
According to Neer’s functional outcome scoring 15
patients (83%) had excellent/Good result and remaining 3
patients (17%) had fair/poor results (Table 5).
On
analyzing our functional outcome result with the age, it was
noticed that patients with age more than 60 years had poor
outcome irrespective of fracture classification (Table 6).
|
AGE IN YEARS |
21
– 30 |
31
– 40 |
41
– 50 |
51
– 60 |
61
– 70 |
Patients |
2 |
7 |
4 |
1 |
4 |
Pain (35) |
30 |
31 |
29 |
30 |
29 |
Function (30) |
29 |
28 |
25 |
14 |
21 |
Rom (25) |
25 |
22 |
16 |
7 |
16 |
Anatomy (10) |
9 |
8 |
9 |
8 |
6 |
Neers Average |
92 |
92 |
78 |
84 |
72 |
COMPLICATIONS
Union
Two patients had non union of
greater tuberosity. Malunion of the greater tuberosity occurred
in 1 patient leading to limitation of abduction to 60 degrees.
Malunion in the coronal plane (more than 160 degrees or less
than 130 degrees) was observed in 8 patients (44%).
Of the
8 patients who had malunion in coronal plane, 3 patients (10%)
had malunion with less than 130 degrees angulation (Range 90 to
130 degrees) and all had excellent/good outcome. But out of the
remaining 5 patients who had malunion more than 160 degrees
(Range 160 to 190) 3 patients (60%) had fair/poor result (Table
7).
Degrees |
Patients |
Excellent/good |
Fair/poor |
<130 |
3 |
3 |
Nil |
>160 |
5 |
2 |
3 |
Infection
No 2 part fracture patients had infection
Two
patients (11%) of 3 part fracture had mild superficial pin track
infection. The superficial infection resolved with removal of
pin and local care.
Deep
infection developed in one patient who had 4 part fracture and
it required multiple debridments.
Hardware Complications
3 patients (17%) had
unsatisfactory fixation of the fracture.
2
patients (11%) had joint penetration and it did not affect
functional outcome.
1
patient (5%) had k wire migration.
In one
patient tip of the pin broke during the attempt of pinning.
Others
No myositis ossificans
No
Avascular necrosis
No re
reduction or secondary procedure
No
axillary nerve injury postoperatively
Discussion
There has been great
controversy about management of complex fractures of the
proximal humerus. Many articles dealing with displaced fractures
of the proximal humerus present varied options based on the
classification of Neer. Despite lack of interobserver and
intraobserver reliability as criticized by many authors, Neer’s
classification bears the comprehensive advantage of prognostic
implication and remains the standard. According to the
recommendation of Neer, operative approaches with minimal
dissection and rigid fixation have been emphasized with the
objective of preservation of vascularity to the articular
fragment. The method of closed reduction and percutaneous
fixation bears the inherent advantage of minimizing tissue
destruction that, hence, preserves vascularity to the humeral
head and facilitates early tissue healing.
Other investigators have
suggested that open reduction with limited dissection and
minimal fixation may reduce the prevalence of avascular
necrosis. However, minimal exposure can seldom be achieved
without the expense of insufficient fixation that may hinder the
initiation of early rehabilitation.
We compared our study with
Roland et al’s study on internal fixation for 2 and 3 part
fractures and found we had superior results (Table 8).
|
Our study, 2004
(closed reduction and
percutaneous fixation) |
Roland
Jakob et al, 1991
(open reduction) |
Number of patients |
17 |
18 |
Mean age in years |
45 |
49.5 |
Average Neer score |
89 |
81 |
Excellent/good |
83% |
74% |
Also we compared our
results with various published results of nonoperative methods
and again we had better results except our 4 part fracture
(Table 9).
|
Our study,
2004 |
Svend et al,
1974 |
Rezemon Baux et al,1965 |
Baudin et al,
1977 |
2 part
Ex/G |
6
100% |
|
|
|
3 part
Ex/G |
11
81% |
22
50% |
26
77% |
8
75% |
4 part
Ex/G |
1
0% |
15
33% |
6
67% |
7
71% |
However, it is advisable to
identify the actual fracture type, age and bone quality, which
fulfills the criteria for percutaneous fixation.
The method of closed
management for displaced proximal humerus fractures was proposed
in 1984. Results have been improving because various kinds of
fixation techniques continue to evolve.
In our series all the
patients with 2 part fractures had good outcome. The poor
outcome in 2 patients with 3 part fractures were because, they
were aged more than 60 yrs and one patient had inadequate
fixation and nonunion of greater tuberosity.
Patients of older age
group, more than 60 years, had poor outcome probably because of
poor bone quality and lack of motivation. Also, our patients
with age more than 60 years had nearly the same result as Court
brown et al’s non operative treatment.
The common technical error
were few pins were used, pins were placed close in head and pins
placed through fracture. These can be avoided with careful
assessment of fracture preoperatively and orientation to image
intensifier intraoperatively.
Nonunion can occur due to
many reasons namely loss of blood supply to the fractured
fragment, interposition of soft tissues, inadequate holding
power of pins in elderly osteoporotic bone or early mobilization
in the absence of adequate fixation.
Comparing our study with
Chao Yu Chen et al’s study of closed reduction and percutaneous
fixation, both had 83% good results even though our average
followup was only 10 months when compared to Chao’s average of
21 months (Table 10).
|
Our study, 2004 |
Chao et al, 1998 |
Duration |
Jan 2002 to Aug 2004 |
Jul 1995 to Aug 1996 |
Total number of
patients |
18 |
19 |
M : F |
12 : 6 |
12 : 7 |
Average age |
45 years |
43 years |
Average follow up |
10 months |
21 months |
Excellent/Good results |
83% |
84% |
Average neck shaft
angle |
156 degrees |
141 degrees |
Pin Migration |
1 patient |
2 patients |
Average union |
8 weeks |
10 weeks |
Pin tract infection |
3 patients |
Nil |
Pin breakage |
1 patient |
Nil |
Avascular necrosis |
Nil |
Nil |
Closed reduction and
percutaneous reduction makes sense from the standpoint of
retention of vascularity, provided done in selected cases of 2
and 3 part fractures with adequate reduction (neck shaft angle
<160) and stable fixation. By this, the dreadful complication
like avascular necrosis is avoided and also less period of
immobilization with faster healing rate. This makes this
technique of closed reduction and percutaneous fixation a
reasonable alternative to conservative and open reduction
methods, perhaps can be the treatment of choice.
Conclusions
In our series, 83% of
the patients who had proximal humerus fractures had excellent
and good functional outcome graded according to the criteria of
Neer, after closed reduction and percutaneous pinning.
2 part fracture yields
good results when treated by this procedure.
The 19% fair/poor
result in 3 part fractures were due to improper patient
selection.
Functional outcome was
poor for patients more than 60 years and this should be
considered in patient selection with communition and bone
quality.
Residual varus
angulation in any fracture did not affect functional outcome.
Residual valgus
angulation (>160 degrees) has deterious effect on functional
outcome.
There is always mild
restriction of abduction and forward flexion in 3 part fractures
without affecting the functional outcome.
Though technically
demanding, with indirect reduction and adequate fixation, the
results are good (83%).
In this era of biological
osteosynthesis, closed reduction and percutaneous pinning can be
the treatment of choice for 2 part and 3 part fractures.
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