Results  Of Of Treatment Of Neer’s Four Part Fractures Of Proximal Humerus Using Different Modalities

*Shirish  Shivanand Pathak, Rajeev Arora, Parag  K. Sancheti

*Sancheti Institute for Orthopaedics &  Rehabilitation, Shivajinagar, Pune -411005.

Address for Correspondence
Dr. Shirish S. Pathak   
Dewesh Society, S.no.34/3,  Erandwana,
Near Ameya Clinic,   Pune-411004, India.
Phone: +91 20-25461409,  +91 9822522362

Abstract

A retrospective and prospective study was carried out from Jan  2001 to  Dec 2005 to study  results of treatment of   Neer’s four part fracture proximal humerus using different modalities of treatment. In our study 30 cases were selected with age group ranging from 20 yrs. to 90 yrs. 26 were male patients. The follow up length was average 2 years with range from 18 months to 3 yrs. Each patient was treated with one of the following procedures: closed reduction and arm chest strapping, closed reduction & percutaneous k wire fixation , open reduction & internal fixation with plate or hemiarthroplasty. Patients were evaluated with Neer’s scoring system at specific intervals. Overall 73 % of patients showed satisfactory to excellent results. Satisfactory to excellent results were noted in  7 out of  8   patients treated with open reduction and internal fixation with plate, while 5 out 7 for percutaneous k wire fixation and 2 out of 6 for closed reduction and arm chest strapping. All 8 patients undergone hemiarthroplasty showed satisfactory to excellent results. We conclude that appropriate selection of the modality of treatment depending on age, bone quality & comminution etc. gives good results.
Key words: Four part fracture proximal humerus, Arm-chest strapping, Open reduction, Internal fixation, Percutaneous k-wire, Hemiarthroplasty.

J.Orthopaedics 2006;3(4)e9

Introduction:

Fractures of the proximal humerus was initially considered to be geriatric injury. It is now increasingly seen in young people with good bone stock and predominantly male patients are seen. There were relatively few reports of treatment of the more complex fractures until Neer’s report emphasized the need to be more aggressive with what he described as three and four-part fractures of the proximal part of the humerus

Many authors advise that prosthetic replacement for four-part fractures should be reserved for elderly patients with osteoporosis and patients with irreparable fracture-dislocations. While others reported variable results after using osteosynthesis , percutaneous k wire fixation & arm chest strapping  for treatment of four-part fractures.

Aim of this study was to evaluate results of different modalities to treat four part fracture of proximal humerus.

Material and Methods :

Retrospective and prospective study was carried out from Jan 2001 to Jan 2005 for evaluation of different modalities to treat Neer’s four part fracture of  proximal humerus. In our study 30 cases were selected. 26 were male patients. Age group was from minimum 20 to maximum 90 yrs of age. The length of follow up was average 2 years with range from 18 months to 3 yrs. Anteroposterior, lateral scapular or axillary radiographs were taken. Fractures of proximal end humerus with X ray showing 4 part fracture with displacement >1 cm or 45degrees were selected.5,1 Initial temporary treatment was given in the form of sling support and arm chest strapping.

All patients were treated by one of the following options

• Closed reduction and nonoperative treatment –immobilization with arm to chest strapping

• Closed reduction and percutaneous k wire fixation

• Open reduction and internal fixation with clover leaf plate,

• Hemiarthroplasty

Modality of the treatment was selected on following guidelines:

• Closed reduction and nonoperative treatment

1. elder age group >60yrs.

2. without dislocation with better alignment.

3. unfit for surgery-medical problem.

4. patient not willing for the surgery.

• Closed reduction and percutaneous k wire fixation

1. young individuals.

2. closed reduction possible.

3. good bone quality.

• Open reduction and internal fixation

1. young individuals < 60 or physiologically active.

2. with dislocation.

3. closed reduction not possible.

4. good bone quality.

• Hemiarthroplasty

1. elder age group > 60.

2. osteoporotic bones.

3. with dislocation.

4. with comminution.

Approach used for surgery was deltopectoral. Implants used were cloverleaf plate, 4mm cancelloue screws, 4.5mm, 3.5mm cortical screws Neer’s prosthesis. For K wire fixation 3-4 wires were used. Patients who needed surgery were posted for the surgery at the earliest.

Postoperative protocol:

1.  The extremity was placed in an arm chest strapping for  3 weeks. If secure fixation was achieved, gentle  pendulum exercises were begun. Careful judgment is required here. If the bone is severely osteoporotic and fixation is less than rigid, motion was delayed.

2.  Pendulum exercises were permitted by the second or third week when the fragments are rigidly fixed,

3.  Gentle passive forward flexion and internal and external rotation exercises were permitted by the third or fourth week.

4.  After e 4 to 6 weeks active or resistive exercises were permitted.

Then patient was asked to follow up at 3 weeks , 6 weeks, 3 months and 6 months and then 6 monthly. 10 old follow-up patients were also evaluated retrospectively after variable periods .The average stay of the these patients after the surgery was 10 days.

At each follow up following points were taken into consideration. 1.pain   2. function  3.range of motion  4.anatomy. These criteria are proposed by Neer. The maximum points-  100 units.

Pain -                             35 units
Function -                       30 units
Range of movement -      25 units
Anatomy -                      10 units

On overall scores the patients were grouped into

Excellent-             >89 units
Satisfactory-         80-89 units
Unsatisfactory-     70-79 units
Failure-                 < 70 units

Results :

     1. Age distribution:

Out of  30 patients 9  were from age group 20 – 40 yrs, while 13 patients  were > 50 yrs, rest were in age group 40 –50. 

2. Mechanism of injury:

Out of 30 patients 13 patients had mechanism of injury as fall on outstretched hand. Other 17 patients had road traffic accident and direct injury to shoulder. All patients having history of fall on outstretched hand were > 40 yrs. In 17 patients of direct injury 12 were of age group 20-40 yrs. And remaining were 40-50 yrs. 

3. Male to Female ratio

Out of 30 cases , 4 were female patients.

4. Modality of treatment offered:

5. Age group wise selection of modality of treatment:

6. Results of each procedure according to Neer’s criteria:

a.      Closed reduction & arm chest strapping:

Out of 30 patients 6 patients were treated with CR & AC strapping.  Out of which 5 patients were above 50 yrs. Age. 1 patient who was  was trearted with Ac strapping was 30 yrs old and was a case of rheumatic heart disease –unfit for surgery.

2 patients showed satisfactory results while 4 patients showed unsatisfactory results.All patients who showed unsatisfactory results had painful and stiff shoulder .

b.  Open reduction & internal fixation:

9 patients were treated with ORIF , out of which 8 were in age group of 20 to 40 yrs. 

7 of patients showed satisfactory to excellent outcome while 2 showed unsatisfactory outcome. Implants used was Cloverleaf plate. One patient had plate and screw loosening while one patient developed AVN and delayed posttraumatic arthritis. One patient had painful shoulder due to migration of screw intrarticularly which was removed later .Patient was painfree after that. 

c. Closed reduction & percutaneous Kwire:

7 out 30 patients were treated with CR  followed by percutaneous k wire fixation. All were in the age group of 40 to 60 years. 

5 patients  showed satisfactory to excellent outcome and  2 showed unsatisfactory to poor outcome. One patient showed inferior subluxation of head in follow up visit. 

d.   Hemiarthroplasty: 

5 cases were more than 60 yrs. All patients were severely osteoporotic with comminution and elderly age group except one. 

6 patients showed excellent outcome and 2 patient showed satisfactory outcome. 

7.  Overall  Outcome of the patients in our study: 

Overall 70% of patients showed satisfactory to excellent outcome  

COMPLICATIONS:

Discussion :

Fractures of the proximal humerus are seen in all age groups, now increasingly seen in younger age group  with good bone stock and predominantly male patients are seen. Selection  of modality of treatment of four part fracture as per the indications already mentioned gives good results. Adequate preoperative planning and necessary equipment for the fixation has to be ensured.

In decision making of selection of modality of treatment, following factors are found to play important role:

Fracture factors:

1.      Degree of displacement, 2.Comminution,3. Bone quality,4. Articular surface involvement

Patient factors:

1.      Functional needs,2.Preexisting disabilities,3.Age,4.Ability to participate in the rehabilitation programme

Technique of closed reduction and arm chest strapping was opted in the elderly patients who did not have high functional demands, unfit for surgery, were not ready for the surgery . These patients were cases of 4 part fracture without dislocation. In 1 case there was fracture dislocation but we could reduce the head fragment by closed reduction under short GA. We could achieve  satisfactory results in only 2  . Out of 5 patients 3 patients had restricted abduction ( up to  90degrees) , flexion and internal rotation and painful shoulder on further movement. But because of their sedentary life style & less demands they could carry out day to day household work. Few series like Leyshon (Acta orth Scand 1984), Stableforth (JBJS 1984), Svend Hansen (Acta orth Scand 1974) report satisfactory result upto 5 %.3,7.  Few other series report satisfactory results. 9

We found that while dealing with fixation of displaced or irreducible proximal humeral fractures open reduction and internal fixation appears to provide secure fixation and rotational control of the fracture complex with minimal hardware and risk of soft tissue impingement. We opted for open reduction and internal fixation in  9 out of 30 patients who all were young age group patients(20-40yrs) with good bone stock, and high  demands in the form of strong functional shoulder. 3 patients had fracture dislocation which was reduced first intraoperatively. Position of the plate should not be too high . We could achieve satisfactory to excellent results in 7 out of 9 patients. A. J. Wijgman, MD, W. Roolker (JBJS 2002) have shown  in their series of ten years of follow-up 87% had a good or excellent result on the basis of the Constant score when treated with open reduction and plating 8. Pavolainen et al.(Acta Orth Scand 1983) 6 and Dr. S.K. Moda have also shown similar results (JBJS 1990) 4.

Advatages of ORIF were:

• It was useful for severly displaced as well as dislocated 4 part fractures
• Less pain with early physiotherapy.

Disadvantages were:

• wider exposure,
• high chances of AVN,
• subacromial impingement,
• implant related complications,
• nerve lesions.

The technique of closed reduction and percutaneous pinning is quite demanding technically .It may appear deceptively simple . This technique makes  sense , biologically, from standpoint of retention of vascularity. It is useful alternative to open reduction and internal fixation for displaced fractures of proximal humerus that can be reduced but unstable. We treated 7 patients with closed reduction and percutaneous pins. Age group was 40 –60yrs. 5 of patients showed satisfactory to excellent results & 2 showed unsatisfactory to poor results. Jakob, Jaeberg & Warner 1984  series of same modality of treatment  showed 70 % good or excellent results.2

We found that while dealing with 4 part fracture in elderly age groups with osteoporotic bone ,prosthetic replacement provided good results. We performed  hemiarthroplasty in 8 cases. 5 patients were > 60 yrs. Outcome was excellent in 6 and satisfactory in 2 of patients. Pain relief was good and fair function was possible. Choice of closed reduction/open reduction and internal fixation  versus Hemiarthroplasty was a multifactorial decision. We believe that the success of the operation depends not only on the prosthesis but also other several well defined  factors . These include proper operative techique based on principles of restoration of humeral length , anatomical fixation of tuberosities with ultimate healing to the shaft and appropriate degree of retroversion. Nonunion and nonanatomical position of tuberosities  definitely affects the outcome. Different  series world wide show variable outcome 20-90% satisfactory results. Fischer , Nicholson, Mcllveen 1992 showed 86% satisfactory results.(> 90 degrees elevation and pain free) &  Neer Mcllveen (Chir. orthop. Suppl. 1988) showed 85 % satisfactory results. 9,10

We had our share of the complications. We had malunion problem in 8 patients. Pin tract infection, wound healing problem could be taken care of and did not affect the outcome. Screw purchase in osteoporotic bone was poor sometimes leading to early loosening and migration. Appropriate length of the screws is must which can be confirmed under image intensifier to avoid complication of migration of screw in the joint.

Conclusion:

Our study brought out following findings which need further study and analysis.

Most of the four part upper end humeral fractures > 40 yrs. are primarily related to osteoporosis and caused due to slip and fall on outstretched  hand  i.e. indirect injury .

Nowadays increasing number of 4 part fractures seen in young age group with good bone stock predominantly in males due to increase in the high velocity road traffic accidents i. e. direct injury.

In four part fractures in  young age group (20-40yrs.) which are irreducible , with good bone stock and  high demands in the form of strong functional shoulder –open reduction and internal fixation gives good results.

In a very old patient with less functional demands and who is unfit for surgery or not willing for surgery, closed reduction and arm chest strapping remains a viable option with the patient accepting restricted range of movement and pain.

Closed reduction and percutaneous pinning is a useful alternative to open reduction and internal fixation for displaced four part fracture that can be reduced but unstable. Though technique appears simple is highly demanding, technically and biologically very good.

In elderly patients with osteoporotic bones with comminution with limited functional demands hemiarthroplasty is the treatment of the choice.

Satisfactory outcome of the treatment is equally dependent on reduction –fixation as well as effective postoperative rehabilitation.

Reference :

1. Jakob, R.P., Miniaci, A., Anson, P.S., Jaberg, H., Osterwalder, A., and Ganz, R.: Four-part valgus impacted fractures of the proximal humerus. J. Bone Joint Surg., 73B:295–298, 1991.

2. Jaberg, H., Warner, J.J., and Jakob, R.P.: Percutaneous stabilization of unstable fractures of the humerus. J. Bone Joint Surg. 74A:508–515, 1992.

3. Leyshon, R.L.: Closed Treatment of Fractures of the Proximal Humerus. Acta Orthop. Scand. 55:48–51, 1984.

4.  Moda open reduction and internal fixation of proximal humerus JBJS 1990-72b,1050-2

5.  Neer, C.S.: Four-Segment Classification of Displaced Proximal Humeral Fracture, C.S.: Prosthetic Replacement of the Humeral Head: Indications and Operative Technique. Surg. Clin. North Am., 43:1581–1597, 1983.

6.  Paavolainen, P., Bjorkenheim, J.-M., Slatis, P., and Paukku, P.: Operative Treatment of Severe Proximal Humeral Fractures. Acta Orthop. Scand., 54:374–379, 1983

7.  Stableforth, P.G.: Four-Part Fractures of the Neck of the Humerus. J. Bone Joint Surg., 66B:104–108, 1984.

8.  Wijgman A.J.,MD,W.Roolker open reduction and internal fixation of  three & four part fractures proximal humerus.JBJS 2002

9.  Rockwood and Green’s Fractures in adults edition IV

10.  Campbell Operative Orthopaedics , Edition 9

This is a peer reviewed paper 

Please cite as : Shirish  Shivanand Pathak:Results  Of Of Treatment Of Neer’s Four Part Fractures Of Proximal Humerus Using Different Modalities

J.Orthopaedics 2006;3(4)e9

URL: http://www.jortho.org/2006/3/4/e9

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