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Analysis of the surgical management of the proximal humeral fractures

AS Sidhu MS*, HS Mann MS**, Jaswinder Paul MBBS***, Yashwant Singh Tanwar MBBS***, Gursukhman DS Sidhu MBBS**** *Professor & Head, **Assistant Professor, ***Junior Resident, ****Intern Department of Orthopedics, Government Medical College & Rajindra Hospital Patiala ABSTRACT Controversy surrounds the ideal management of unstable proximal humerus fractures. Different surgical options are available to achieve optimum results in these challenging fractures. Then choice of a particular method depends on a variety of factors such as bone quality, nature of the fracture, surgeons experience and expertise and the functional demands of the patient. The present study was carried out for evaluation & analysis of the different modes of the surgical management of the proximal humeral fractures. Total of 30 patients were taken up & after proper pre-operative assessment different modalities of treatment were used for different patients. The patients were evaluated using Constant score for shoulder and good results could be obtained in 77% of cases. Keywords: Proximal humeral fractures-buttress plating, rush nail, interlock-nailing, hemiarthroplasty INTRODUCTION Treatment of unstable displaced fractures of the proximal humerus has remained controversial in literature. The management of displaced fractures of the proximal humerus is a challenge for every orthopaedic surgeon, and the results are often frustrating. Osteosyntheses may be followed by osteonecrosis, malunion, and soft tissue damage with reduced postoperative mobility 1, 2. Displaced fractures generally require operative repair & in young patients with good bone quality the results are usually satisfactory. In contrast the osteoporosis found in the elderly patients makes internal fixation problematic & frequently contributes to failure of fixation3. Various surgical treatment modalities for displaced proximal humeral fractures are pins, wires, heavy sutures, staples, rush nails, screws & plates, hemiarthroplasty, intramedullary nailing, retrograde nails & pins, external fixation & tension band wiring4-9. Primary hemiarthroplasty is favoured
Corresponding Author Dr. A S Sidhu, Professor and Head Department of Orthopaedics, Government Medical College and Rajindera Hospital, Patiala. E mail:

by many authors but is associated with a large number of complications and objective functional results which are disappointing10. Conservative management may be associated with nonunion, malunion and avascular necrosis resulting in painful dysfunction11. The present study was carried out for evaluation & analysis of the different modes of the surgical management of the proximal humeral fractures. MATERIAL& METHODS Thirty adult patients of displaced proximal humeral fractures were taken up for surgical management. Mean age of the patients was 52.7 years (range 24 to 75 years) of which 23 were males & 7 were females. The shoulder was approached either by the anterior deltopectoral or lateral deltoid splitting approach. Buttress plating (LCP/T Plate) was done in two/three part fracture of the surgical neck of humerus. In patients with good bone stock, T buttress plate was applied to the lateral surface of the humerus, lateral to the long head of biceps (Fig. 1). It was fixed to the head with 6.5mm cancellous screws & to the shaft with 4.5 mm cortical screws. In three part fracture s of the greater tuberosity, the latter was fixed by screw passing through posterior limb of the buttress plate.

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Sidhu et al

Fig. 1: Pre-operative x-ray of 2 part fracture, through surgical neck of humerus and x-ray on follow-up showing union

Fig. 2: Pre-operative x-ray of a 2 part fracture and Post-operative x-ray after fixation with rush nail

Tension band wiring was done in two-part displaced fractures of the greater tuberosity. Intramedullary nailing was done in 2 part fracture of the surgical neck of the humerus in osteopenic patients (Figure 2). The entry point of the nail was 1 to 1.5 cm posterior to the bicipital groove at the juncture of the greater tuberosity & the lateral edge of articular surface of the head of humerus. Through this either rush nail or the standard intramedullary nail was put in. The indications of hemiarthroplasty (Figure 3) were: 1. 2. 3. Four part fractures Three part fractures & fracture dislocation in elderly patients with osteoporotic bone Chronic anterior or posterior humeral head dislocations with impression fractures that involve > 40 % of the articular surface

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Head splitting fracture Anatomic neck fracture in which internal fixation is not possible

A shoulder immobiliser was given in the post-operative period. Adequate antibiotic cover consisting of a 3rd generation cephalosporin & Amikacin was given for 5 days postoperatively. Rehabilitation was done in three phases. Phase 1 : Passive assisted mobilization as soon as pain subsided. Phase 2 : Active mobilization when there is evidence of fracture union usually at 4-6 weeks Phase 3 : Strengthening & stretching exercises Patients were followed up after every four weeks for a total of 6 months from the date of operation and clinical and radiological progress monitored.

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Analysis of the surgical management of the proximal humeral fractures

Fig. 3: Head splitting fracture, intra-operative picture showing pieces of the head and post operative x-ray

Results were evaluated using the MURLEY CONSTANT12 score (max. score 100)
FUNCTION Pain Activities of daily living Range of motion Forward elevation MAXIMUM POINTS 15 20 10 10 10 10

Results were graded as follows: Excellent 90 points Good 70 to 90 points Fair 50 to 70 points


Poor < 50 points

Lateral elevation External rotation Internal rotation

Right limb was involved in 16 & the left limb in 14 cases. Mode of injury was road traffic accident in 21 cases (70 %) & fall on an outstretched hand in 7 cases (30 %) Table 2 Modalities of fracture fixation
Mode of fracture fixation Number of cases 16 4 2 2 6 30 Percentage of cases 53.33 13.33 6.66 6.66 20 100

Strength of abduction


Table 1 Type of fracture as per Neers classification

Neers Type One part fracture 2 part displaced fracture of anatomical neck 2 part displaced fracture of surgical neck 2 part displaced fracture of greater tuberosity 3 part displaced fracture of greater tuberosity 3 part displaced fracture of lesser tuberosity 4 part displaced fracture Fracture dislocation of neck humerus 3 part greater tuberosity fracture dislocation Total Number of cases Nil Nil 18 2 2 Nil 2 5 1 30 Percentage Nil Nil 60 6.66 6.66 Nil 6.66 16.66 3.33 100

ORIF with Buttress Plate ORIF with Intramedullary nail ORIF with Rush nail Tension Band Wiring Hemiarthroplasty Total

Table 3 Return to Daily Activities

Time period after surgery 4-6 weeks 6-8 weeks Total Number of cases Percentage 23 7 30 76.66 23.33 100

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Table 4 Complications
Type of complication Superficial infection Stiffness Avascular necrosis Number of cases 2 2 1 Percentage 6.66 6.66 3.33

Table 5 Grading of results

grade Good Fair Total Number of cases 23 7 30 Percentage 76.7 23.3 100

neck united at an average of 10.3 weeks & that of greater tuberosity united at an average of 9.5 weeks. 3 part displaced fracture of greater tuberosity united at an average of 11 weeks & 4 part displaced fractures & fracture dislocation united at an average of 13 weeks. Although the locking compression plate (PHILOS plate) has proved to be a useful implant in the management of proximal humerus fractures; we didnt use it in our study in patients with good bone stock. Similar results have been reported by other authors also13,14. Satisfactory function of the shoulder joint after arthroplasty for fracture depends on rigorous attention to the tuberosity stabilization & anatomic fixation15. Restoration of humeral length and placement of the prosthetic component in the appropriate degree of retrovemsion are other factors for optimal result16. Pain relief is good, but function and range of movement are less predictable11. Our study also conforms to these findings. As the shoulder is particularly susceptible to stiffness, following injury because of formation of adhesions, follow-up care & intensive rehabilitation programmes are extremely important for the favorable outcome9. CONCLUSION

Table 6 Grading of result in relation to type of management

Mode of fracture fixation ORIF with Buttress Plate Tension Band Wiring Hemiarthroplasty Total Number of cases 16 2 6 30 14 4 2 3 23 2 2 Nil 3 7 ORIF with intra medullary nail 6 Good Fair

DISCUSSION Treatment options for the displaced fractures of proximal humerus include nonoperative treatment, open reduction and internal fixation, and arthroplasty. The preferred treatment varies depending on the patients age and bone quality, the expertise of the surgical team, and patient expectations5. The outcome & treatment of displaced fractures of the proximal humerus is dependent on the surgeons ability to analyze the fracture pattern & to execute appropriate techniques to restore anatomy & function. Meticulous handling of the soft tissues & the use of low-profile implants is important to achieve optimum results5. The best results are obtained if the fractures are well reduced and maintained reduced until healing has occurred. It must therefore be a goal to select those fractures for open reduction and internal fixation which can be anatomically reduced and an appropriate implant to maintain this reduction should be used. In our series the average time taken for radiological union was 11.1 weeks (range from 9 to 14 weeks). There were no cases of non-union or malunion . 2 part displaced fracture of surgical
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T-Buttress plating offers good functional outcome in two-part displaced fractures & fracture dislocations of surgical neck of humerus & 3 part displaced fractures of the greater tuberosity in patients with good bone stock. Osteosynthesis with tension band wiring of displaced 2 part greater tuberosity fracture gives good functional results. 4 part fractures, fractures > 4 weeks old unreduced fracture dislocation & head splitting fractures in elderly give satisfactory results with hemiarthroplasty. REFERENCES
1. Klein M, Ostermann PAW, Juschka M, Hinkenjann B , Scherger B: Treatment of comminuted fractures of proximal humerus with Delta III reverse prosthesis: J Orthop Trauma 2008;22: 698704. Okcu G, Aktuglu K. Management of proximal humerus fractures with intramedullary flexible nails. Osteo Trauma Care 2003;11: 52-55. Sadowski C, Riand N, Stern R, Pierre H. Fixation of fracture of proximal humerus Early expierence with a new implant. J Shoulder Elbow Surgery 2003;12:148-151 Rockwood CA, Green CP. Fractures in adults.6 th edition. Philadelphia: JB Lippincott Co;2006.1162-1163 Wjigman AJ, Roolker W, Patt TW, Raaymakes ELFB, Marti RK. Open reduction & internal fixation of three & four part fractures of proximal humerus. Journal of Bone & Joint Surgery 2002;84(11):1919-25 Robinson CM, Page RS et al. Primary Hemiarthroplasty for treatment of proximal humeral fractures. Journal of Bone & Joint



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Analysis of the surgical management of the proximal humeral fractures

Surgery 2003;85(7):1215-23 7. Bhatt SS, Rao SK. Functional outcome of antegrade unreamed humeral interlocking in adults. Journal of orthopedics 2005;2(11):21-25. Hintermann B, Trouilier HH, Schafer D. Rigid internal fixation of fracture of proximal humerus in older patients. J Bone & Joint Surgery . 2000;82B:1107-12 Hawkins RJ, Bell R, Gurr K: The Three-Part Fracture of the Proximal Part of the Humerus: Operative treatment: J Bone & Joint Surgery. 1986:68A; 1410-1414.

12. Constant CR, Murley AHG. A clinical method of functional assessement of the shoulder. Clinical Orthop 1987 ; 214:160-4 13. Park MC, Murthi AM, Roth NS, Blaine TA,Levine WN, Bigliani LU: J Orthop. Fractures of the proximal humerus treated with suture fixation. J Orthop. Trauma 2003;17:319-325 14. C. Gerber, C. M. L. Werner, P. Vienne : Internal fixation of complex fractures of the proximal humerus: J Bone Joint Surg [Br]2004; 86-B:848-55. 15. A. Sosna,D. Pokorny,R. Hromdka,D. Jahoda,V. Bartk, V. Pinskerov: A new technique for reconstruction of the proximal humerus after three- and four-part fractures: J Bone Joint Surg [Br] 2008;90-B:194-9. 16. BH Moeckel, DM Dines, RF Warren and DW Altchek: Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg Am. 1992;74:884-889.



10. Zytoo K: Non-operative management of comminuted fractures of proximal humerus in elderly patients: Injury 29: 349-352. 11. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute threeand four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-6.

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