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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 403-407

Treatment of three-part fracture of proximal humerus in adults with plate and screws


Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University (for Girls), Cairo, Egypt

Date of Submission05-May-2020
Date of Decision19-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication2-Oct-2020

Correspondence Address:
MBBCh Ahmed K Gaafar
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University (for Girls), zip code: 31633, Elsanta, Gharbeya
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_55_20

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  Abstract 


Objective The aim of this study was to evaluate our results for the treatment of three-part fracture of proximal humerus in adults with plate and screws.
Patients and methods The study was done and followed up on 15 patients for 2 years. Deltopectoral approach has been used for all the patients. All patients had clinical and radiological evaluation at regular periods during their follow-up. The age of patients range from 23 to 77 years with a mean age of 51.9 years.
Results The constant score was used for clinical evaluation of patients. In the constant method of functional assessment, a 100-point score is based on the assessment of a number of individual subjective and objective parameters in an entirely clinical setting.We have four cases representing 26.67% of all patients who had complications; one patient was complicated by stiffness, two patients with nonunion, and one patient with infection.
Conclusion With short-term follow-up, the internal fixation with plate and screws is effective in the treatment of three-part fractures of the proximal humerus in adults.

Keywords: plate and screws fixation, proximal humeral fractures, proximal humerus,


How to cite this article:
Yehya MA, Hassan YE, Gaafar AK. Treatment of three-part fracture of proximal humerus in adults with plate and screws. Sci J Al-Azhar Med Fac Girls 2020;4:403-7

How to cite this URL:
Yehya MA, Hassan YE, Gaafar AK. Treatment of three-part fracture of proximal humerus in adults with plate and screws. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 26];4:403-7. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/403/296948




  Introduction Top


Successful treatment of three-part fractures of the proximal humerus presents a challenge for physicians. Many factors must be considered when making a treatment plan. Proper assessment of the fracture, patient compliance, medical comorbidities, and time from injury to treatment are critical factors affecting the outcome. Also, technical factors in the reconstruction of these fractures require surgical experience that few surgeons have the opportunity to develop [1].

Initially, treatment of these fractures consisted of closed reduction, traction, casting, and abduction splints. In the 1930s, operative treatment for displaced fractures gained popularity, which continued in the 1940s and 1950s. Replacement of the humeral head for severely displaced fractures of the proximal humerus was introduced the 1950s. In 1970, the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation group popularized plates and screws for fracture fixation, and humeral head prostheses were redesigned. Currently, fixation methods involving limited fixation and limited dissection are becoming more popular, and prosthetic replacement for severe fracture is being refined further [2].

Surgical repair of proximal humerus fractures may be categorized either according to fracture type (e.g. Neer type, anatomic type, greater tuberosity, surgical neck, anatomic neck, articular surface, or lesser tuberosity fragments) or according to the method of fixation [e.g. closed reduction with no fixation, percutaneous fixation, open reduction with internal fixation (ORIF), or humeral head replacement associated with tuberosity fixation] [3],[4].

In our study, we evaluated our results for the treatment of three-part fracture of proximal humerus in adults with plate and screws.


  Patients and methods Top


A written informed consent was taken from all participants after proper explanation of the study. The ethics committe of Al Zahraa University Hospital approved this study.

A study was conducted involving 15 cases. The cases were operated in Al Zahraa University Hospital.

Of the patients, eight were men and seven were women in the age range from 23 to 77 years; 10 patients were having right-sided fracture and five were left sided.

Inclusion criteria include fracture of the proximal humerus in adults with or without dislocation and systemic affection with exclusion of pathological fractures.

The age of patients range from 25 to 75 years with a mean age of 51.9 years and there were eight (53.3%) men and seven (46.67%) women with Neer classification type III. The mechanism of injury was five patients due to road traffic injury, five patients from falling down, and five patients due to fall from height. There were four patients with history of smoking. There were five patients with a history of diabetes mellitus. There were six patients with a history of drug intake. Patients were administered diabetic drugs, antihypertensives, anticonvulsants, and antipsychiatric drugs.

Ten patients had fracture on the right side while five patients on the left side. All patients were right handed. One patient was associated with a tibial plateau fracture.

Clinical evaluation after the surgery

The constant score (CS) was used for clinical evaluation of patients for 1 year after surgery. In the constant method of functional assessment, a 100-point score is based on the assessment of a number of individual subjective and objective parameters in an entirely clinical setting.


  Results Top


The CS system was used to assess every patient postoperatively, based on pain, activity of daily living, range of motion, and power. The pain level was mild pain in three patients and no pain in 12 patients. The result was: eight excellent cases, three good cases, and four poor cases.

In this study, four patients representing 26.67% of all patients had complications; one patient was complicated by stiffness but after physiotherapy a good range of motion is achieved, two patients were with nonunion and may need a second repair and one patient was with infection and was treated by the proper antibiotics.

The age of the patients range from 23 to 77 years with a mean age of 51.9 years. All were treated with a proximal humeral locking plate. The results showed that the average age of the patients with radiographic evidence of a complication was 62 years, compared with 48 years for patients without an evident complication.

CS assessment [Inline 1] [Inline 2]


  Case report Top


A 44-year-old-male patient with right-sided three-part fracture of the proximal humerus, Neer type III classification. The CS was 44 after 2 years of follow-up ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
Figure 1 Preoperative radiograph.

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Figure 2 Preoperative computed tomography of the fracture.

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Figure 3 Postoperative radiograph.

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Figure 4 Postoperative radiograph after plate removal.

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  Discussion Top


Proximal humeral fractures are a result of low-velocity injuries and are complicated by osteoporosis and poor general condition. In the younger population injuries usually involve a high-velocity injury and the fractures are usually complex with greater comminution and soft tissue injury. These fractures need to be fixed in a stable manner, especially in younger patients to allow early mobilization, faster recovery, and minimize loss of function. Surgical options for two-part, three- part, and four-part fractures of the proximal humerus include percutaneous fixation techniques, plating, transosseous wiring, and hemiarthroplasty [5].

Despite advances in new implant designs, pin fixation with Kirschner wires is still an appropriate option for the treatment of some fractures and dislocations around the shoulder. Percutaneous or open pinning techniques are cost-effective and have the potential advantage of preventing additional damage to the blood supply of the humeral head. However, pin fixation can be problematic, especially in osteoporotic elderly patients, in whom loss of fixation and related pin problems are not rare. Close follow-up is necessary, and the pins should be removed at the conclusion of therapy or whenever migration is noted. Because smooth pins tend to migrate, they should be used cautiously in osteoporotic bone around the shoulder girdle [6].

Surgical treatment is one of the most commonly acceptable forms of management for displaced and unstable proximal humeral fractures and a variety of fixation devices are available. The use of conventional plate fixations through the deltopectoral approach involves a higher risk of avascular necrosis of the humeral head, as this technique often requires an extensive soft-tissue disruption, which might compromise the vascular supply of the humeral head [7].

The deltopectoral approach remains the most widely used in the treatment of proximal humeral fractures. Proper evaluation of bone quality prior to surgery is a critical factor on which depends the overall prognosis for proximal humeral fractures. The outcomes of internal fixation in elderly patients with poor bone quality are disappointing. In order to prevent implant loosening, original proximal humeral locking plate systems featuring multiple angle screws were recently developed [7].

In this study, we examined a group of patients with fractures of the proximal humerus, operated with plate and screws to improve fixation. Each patient in this study was carefully assessed clinically by taking a detailed clinical history and by performing a thorough examination. Radiological evaluation consisted mainly of plain radiography and computed tomography scans. Deltopectoral approach has been used for all the patients.

A well-structured rehabilitation program can significantly influence the final outcome of the surgery. Patients were well informed about the importance of full compliance to the rehabilitation program with no underdoing or overdoing of the exercises.

The study was done and followed up 15 patients for 2 years; all patients had clinical and radiological evaluation at regular periods during their follow-up. The CS was used for clinical evaluation of patients. In the constant method of functional assessment, a 100-point score is based on the assessment of a number of individual subjective and objective parameters in an entirely clinical setting.

The CS consists of four parameters that are used to assess the function of the shoulder: including pain, daily activity (sleep, work, recreation/sport), range of motion, and strength. The minimum score is 0 and the maximum score is 100. A low score means a worse functional outcome, while a higher score is correlated with better shoulder function [8].

The age of patients range from 23 to 77 years with a mean age of 51.9 years. Pain level was mild pain in three patients and no pain in 12 patients. Obviously, because men are engaged more in vigorous activity, they are more susceptible to injury. It is demonstrated in our study that there were eight men (53.3%) and seven women (46.67%).

According to the mode of injury, the mechanism of injury was five patients due to road traffic injury, five patients from falling down, and five patients from falling from height.

In our study, there were four patients with a history of smoking. There were five patients with a history of diabetes mellitus. There were six patients with a history of drug intake. Patients were administered diabetic drugs, antihypertensives, anticonvulsant drugs, and antipsychiatric drugs. Also, 10 patients had fracture on the right side while five patients on the left side. All patients were right handed. One patient was associated with fracture tibial plateau. According to Neer’s classification system, all patients had a three-part fracture.

In this study, four cases representing 26.67% of all patients had complications; one patient was complicated by stiffness, two patients with nonunion, and one patient with infection.

The results obtained by Gerber et al. [9] included 15 patients with three-part fractures. Those 15 patients were managed by ORIF. The mean age of the patients was 44.9 years and the mean follow-up period was 63 months. The mean final CS for those patients was 80.4 points.In another study by Hintermann et al. [10], 34 patients with three-part fractures were managed by ORIF plates. The mean age of the patients was 71 years and the mean follow-up period was 3.5 years. They had a mean final CS of 75 points.

The study that was done by Bjorkenheim et al. [11] which included 12 patients with four-part fractures who were managed by ORIF with locking plates. The mean age of the patients was 67 years. At the 12th-month follow-up, the mean CS was 60 points.

The effect of the patient’s age on the results of the operation was discussed by Owsley and Goreczyca [12] in their study that included 53 adult patients with a displaced proximal humeral fracture (28 three-part fractures and 25 four-part fractures). All were treated with a proximal humeral locking plate. The mean age of the patients was 52 years (range, from 18 to 89 years). The results showed that the average age of the patients with radiographic evidence of a complication was 62 years, compared with 48 years for patients without an evident complication.


  Conclusion Top


Plate and screws offer more advantages especially when dealing with osteoporotic bone. It is recommended to use a locking plate whenever an elderly patient is indicated for internal fixation. Inferomedial comminution of the proximal humerus can lead to failure of locking plate. It is important to decrease preoperative lag period to obtain good results. Early passive motion and a well-scheduled rehabilitation program have an obvious benefit on the final result. More accurate length measurement and shorter screw selection is required to prevent screw perforation. Obtaining anatomic reduction of the tubercles and restoring the medial support should reduce the incidence of secondary screw perforations, varus collapse, and secondary loss of reduction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dimakopoulos P, Potamitis N, Lambiris E. Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus. Clin Orthop 1997; 341:7–11.  Back to cited text no. 1
    
2.
Hartsock LA, Estes WJ, Murray CA. Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998; 29:467–475.  Back to cited text no. 2
    
3.
Iacobellis C, Serafini D, Aldegheri R. PHN for treatment of proximal humerus fractures: evaluation of 80 cases. Musculoskelet Surg 2009; 93:47–56.  Back to cited text no. 3
    
4.
Brunner F, Sommer C, Bahrs C et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 2009; 23:163–172.  Back to cited text no. 4
    
5.
Ashok S, Gavaskar, Muthukumar S, Naveen C. Biological osteosynthesis of complex proximal humerus fractures: surgical technique and results from a prospective single center trial. Arch Orthop Trauma Surg 2010; 130:667–672.  Back to cited text no. 5
    
6.
Kazimoglu C, Bozkurt A, Sener M. Delayed radial nerve palsy caused by pin migration in a surgically treated proximal hmeral fracture: a case of axonamonosis. J Bone Joint Surg Am 2012; 94:e7.  Back to cited text no. 6
    
7.
Rouleau M, Laflamme Y. Proximal humerus fractures treated by percutaneous locking plate internal fixation. Orthop Traumatol 2009; 95:56–62.  Back to cited text no. 7
    
8.
Faraj D, Kooistra BW, Stappen WAH, Werre AJ. Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. Eur J Orthop Surg Traumatol 2011; 21:7–12.  Back to cited text no. 8
    
9.
Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br 2004; 86B:848–855.  Back to cited text no. 9
    
10.
Hintermann B, Trouillier HH, Schafer D. Rigid internal fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br 2000; 82B:1107–1112.  Back to cited text no. 10
    
11.
Bjorkenheim J, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate. Acta Orthop Scand 2004; 75:741–745.  Back to cited text no. 11
    
12.
Owsley KC, Goreczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures. J Bone Joint Surg Am 2008; 90:233–240.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Patients and methods
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Case report
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