Analysis Of Functional Outcome Of Proximal Humerus Fractures Treated By Closed Reduction And Percutaneous Fixation – A Prospective Study

*Dr. V.Vimal Kumar, Dr. Nitesh, Dr. M. Mohan Kumar, Prof. C. Subramanian

*Dept. of Orthopaedics, Sri Ramachandra Medical College and  Research       Institute (Deemed Institute), Chennai, India.
 

Address for Correspondence
Dr. V Vimal Kumar,
Dept. of Orthopaedics, Sri Ramachandra Medical College and  Research   Institute (Deemed Institute), Chennai, India.
 

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).

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).

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).

The average restriction of movement as noted (Table 4).

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

            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).

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).

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).

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).