Three And Four Part Fractures Of Proximal Humerus- Is Percutaneous K-wire Fixation A Good Option?

Daljit Singh*, Mohd. Yamin **, Ashwini Soni ***

*Senior Resident, Department of Orthopaedics,
Post Graduate Institute of Medical Education and Research,
Chandigarh, India

** Professor and Head, Department of Orthopaedics,
Dayanand Medical College and Hospital,
Ludhiana, Punjab, India.

*** Senior Resident, Department of Orthopaedics,
Post Graduate Institute of Medical Education and Research,
Chandigarh, India

Address for Correspondence:

Daljit Singh
Senior Resident, Department of Orthopaedics,
Post Graduate Institute of Medical Education and Research,
Chandigarh, India.

Abstract:

Three and four-part fractures of proximal humerus provide therapeutic challenge to orthopaedic surgeons. Treatment is controversial and functional outcome is difficult to predict. We treated twenty patients having three and four part fractures of proximal humerus with closed reduction and percutaneous K-wire fixation between Dec 2005 and Jan 2008. The minimum follow up was 18 months. The average period for hospitalisation was 7.5 days. Average union time for fractures to unite was found to be 6.3 weeks. Four patients had pin site infection for which antibiotics were given and regular dressings were done. Four patients had malunion. No patient was found to have non-union or avascular necrosis of the humeral head. Average Constant score was 73.65 % with minimum constant score was 49 % and maximum constant was 89 %. Out of twenty patients 10 % had excellent, 55 % had good, 20 % had moderate and 15 % had poor results.

J.Orthopaedics 2010;7(3)e11

Keywords:

Three and four part fractures; proximal humerus: percutaneous K-wire fixation.

Introduction:

The fractures of proximal humerus account for 4% to 5% of all fractures^1,2. 85% of these fractures are minimally displaced or undisplaced and are effectively treated symptomatically with immobilization followed by early motion^{3, 4, 5}. The remaining 15% of these are displaced and provide a therapeutic challenge⁶.

Neer classified proximal humeral fractures based on the position of the articular segment, the greater and lesser tuberosities, and the humeral shaft. He divided these fractures into four types depending on the degree of displacement or angulation of four segments. Most of one-part and two-part fractures can be managed conservatively⁵. The real problem arises in three-part and four-part fractures.

For three part fractures, Neer recommended minimal osteosynthesis and for four part injuries he advocated the use of prosthetic replacement because of high risk of avascular necrosis⁷. However the soft tissue exposure to reduce the fracture and insert implants puts the viability of head at risk further increasing the chances of avascular necrosis^{8, 9, 10}. There is disagreement regarding the use of prosthesis in four-part fractures in young adults due to the limited survival of the implants¹¹.

The theoretical advantages of closed reduction and percutaneous pinning include avoidance of devascularisation of fracture fragments, minimisation of risk of injury to the blood supply of the humeral head, and reduced operative morbidity by avoidance of open procedure^{12, 13}. Disadvantages include the potential of pin migration, loss of reduction, and pin site infection^{12, 13}. In the present study we evaluated the results of percutaneous pinning in three and four-part fractures of proximal humerus.

Materials and Methods:

This was a prospective study done between Dec 2005 and Jan 2008, to analyse the results of 20 cases of three and four part proximal humeral fracture managed with K-wires fixation. The study was done by taking informed consent from the patients willing to be a part of study and willing to come for regular follow up.

The patients were investigated on the date of admission with routine investigations as per the standard protocol and X-rays. All life threatening injuries were evaluated and managed on priority basis before fixing the fractures.  Antibiotic regime was given as per the treatment protocol of closed or compound fractures. For closed fractures a combination of cefuroxime and gentamycin was given and for compound fractures a combination of Cefuroxime, metronidazole and gentamycin was preferred. Prolonged use of antibiotic was continued where needed.Patients were taken up for orthopaedic surgery after obtaining fitness from concerned departments.

After adequate preparation fractured limb was grasped and fracture ends were manipulated under fluoroscopic control to do a closed reduction of the fragments. Reduction checked under c-arm. After adequate reduction, wires were drilled into the fracture fragments in antegrade/retrograde fashion under c-arm guidance, preventing damage to neurovascular structures. Fixation checked under c-arm for stability.

Preoperative antibiotic prophylaxis was given with a second generation Cephalosporin and an aminoglycoside. Post operative check x-rays were taken. First dressing was done after 24 hours and subsequent dressings were done after every 48 hours. Shoulder immobiliser was given for first ten days. Pendulum exercises were started by the second or third week. Gentle passive forward flexion and internal, external rotation exercises were started by the third or fourth week. Active physiotherapy was started by the fourth to sixth week. Patient was sent home with advice of daily physiotherapy. They were examined regularly on follow-up visits at 4, 12, and 24 weeks interval in the outpatient department. Clinical and radiological examination was done until healing of fractures and union time was noted. Daily activities were started once pain improved and heavy work was allowed once there was clinical or radiological evidence of union at fracture site. Final range of motion was noted in degrees after fracture was united and outcome was graded as excellent, good or poor. Average follow up period was 6 months. Outcome was also assessed on the basis of how easily patient can do activities of daily life.

Evaluation of results was done on the basis of scoring system given by Constant et al¹⁴. Results were graded as excellent (Constant score 86% - 100%), good (Constant score 71% - 85%), moderate (Constant score 56% - 70%) or poor (Constant score 0% - 55%).

Results :

A total of 20 patients with three or four part fracture proximal humerus managed with percutaneous k-wires fixation were evaluated. The minimum age of the patients in our series was 32 years and the maximum was 78 years with mean age of  50.25 years. Of all the 20 cases, 12 of them were in third and fourth decade of life comprising 60 % of the total patients.

Males predominated with incidence of 70% of the total number of patients while females constituted 30% of the total number of cases.The involvement of left and right extremity was almost equal. 11 patients had injury on right side and 9 had injury on left side.

Road side accidents were the mode of injury in 18 out of 20 cases. In one patient the mode of injury was fall and in another patient the mode of injury was assault.

Ten out of twenty patients had no associated injury. Seven patients had other fractures along with proximal humerus fracture. Out of these seven patients one patient had BTC and one had BTC, BTA and HI. One patient had HI and one had BTC along with proximal humerus fracture without any other associated fracture. HI, BTA and BTC in these patients were managed by surgery team. One patient had soft injury over arm along with proximal humerus fracture for which regular dressings were done and skin grafting was done once wound become red granulating. 

The average period for hospitalisation was 7.5 days. The minimum period was 1 day and the maximum was 35 days. Three patients had hospitalisation period of more than ten days. Out of these three patients one had associated compound ankle with BTC, BTA and HI. One had associated HI. These patients were managed along with surgery team. One patient had soft injury over arm along with proximal humerus fracture for which regular dressings were done and skin grafting was done once wound become red granulating. 

Average union time for fractures to unite was found to be 6.3 weeks which was not very different from other modalities of treatment. The minimum time for union was one month and maximum time was three months. Post operative splintage did not help in early union of fractures.

Out of twenty patients four had pin site infection for which antibiotics were given and regular dressings were done. Four patients had malunion. No patients found to have non-union or avascular necrosis of the humeral head.
 Functional results were evaluated by Constant score. The Constant score was graded as poor (0 % – 55 %), moderate (56 % - 70 %), good (71 % - 85 %) or excellent (86 % - 100 %). In our study, average Constant score was 73.65 %. Minimum Constant score was 49 % and maximum Constant was 89 %. Patient with Constant score 89 % had three part proximal humerus fracture. K-wire fixation was done and mobilisation was started after four weeks. Patient was well educated 40 years male with great motivation. He attained range of motion up to 180º in front and lateral elevation. The only problem was mild pain while sleeping on the affected side. The union time was 1.5 months and there was no complication. Patient having minimum Constant score (49 %) was a 65 year male with four part proximal humerus fracture. Front and lateral elevation was up to 80 %. The union time in this case was also 1.5 months quite similar to average union time in our study. 

Out of twenty patients of two or three part fracture proximal humerus managed with percutaneous k-wires in our study, 10 % had excellent, 55 % had good, 20 % had moderate and 15 % had poor results.

Discussion :

The ideal management of the three and four part fracture of proximal humerus should results in a fully functional shoulder and upper limb with pain free mobility. Comminuted displaced fractures of the proximal humerus have a poor functional prognosis when left untreated because of severe displacement of the fragments.

Though Neer recommended minimal osteosynthesis for three-part fractures and prosthetic replacement for four part fractures but no subsequent studies matched the excellent results presented by Neer^{15,16,17,18,19}. The best method, thus, would be the one that involves least disruption of the soft tissues and the minimal fixation necessary to maintain stability with early post operative mobilization.

Chen CY et al.²⁰ found no further collapse or avascular necrosis when 19 patients with three or four part proximal humerus fractures managed with percutaneous management. Jaberg H et al¹³ found complete avascular necrosis in 4% patients when managed with percutaneous fixation of unstable proximal humerus fractures. Resch H et al²¹ found no signs of avascular necrosis in three part fractures when managed with percutaneous fixation in 9 patients. Avascular necrosis was seen in11% of four part fractures. Avascular necrosis of humeral head was not seen in our study of twenty patients.

Darder et al²² described treatment of four part fractures of proximal humerus with tension band wiring and k-wires and found excellent and satisfactory results in 64% cases, non-satisfactory in 30% cases and poor in 6% cases. Zyto et al²³ compared tension band wiring with nonoperative management in 40 patients with displaced three and four part fractures with a mean age of 74 years the mean overall constant scores were 60% in surgically treated patients and 65 % in those treated conservatively.

Resch et al²¹ with percutaneous reduction and screw fixation found average constant score of 91% in three part and 87% of four part fractures of proximal humerus. Chen CY et al²⁰ found 84% good or excellent results according to Neer’s classification when unstable proximal humerus fractures managed with percutaneous fixation. Jaberg H et al¹³ found good or excellent results in 71% patient, fair in 21% and poor in 8% patients when percutaneous fixation done in unstable proximal humerus fractures.

In our study we found excellent or good results in 65 % cases, moderate in 20 % cases and poor in 15 % cases. The average constant score was 73.65 % with minimum score 49 % and maximum score 89 %.

Infection was found in 11% cases by Jaberg H et al¹³. In present study we found superficial infection of k-wire in four patients out of twenty. 

In conclusion, fixation of three or four part fracture proximal humerus with percutaneous k-wire after stabilization of the patient gives good functional results in terms of final range of movement achieved and acceptable rate of complications. 

The few limitations with our study include its small sample size, lack of comparison group and heterogeneity of patients.

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This is a peer reviewed paper 

Please cite as: Daljit Singh: Three And Four Part Fractures Of Proximal Humerus- Is Percutaneous K-wire Fixation A Good Option?

J.Orthopaedics 2010;7(3)e11

URL: http://www.jortho.org/2010/7/3/e11

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