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.
Phone :
+91-9876188160
E-mail :
drdaljitortho@gmail.com |
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 fractures1,2.
85% of these fractures are minimally displaced or undisplaced
and are effectively treated symptomatically with immobilization
followed by early motion3, 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 necrosis8, 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 procedure12, 13. Disadvantages include the
potential of pin migration, loss of reduction, and pin site
infection12, 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 Neer15,16,17,18,19.
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.
Reference:
-
Horak J,
Nilsson BE. Epidemiology of fracture of the upper end
of the humerus. Clin Orthop 1975; 112:250-3.
-
Rose SH,
Melton LJ, Morey BF et al: Epidemiologic features of humeral
fractures. Clin Orthop 1982;168: 24.
-
Jacob RP,
Kristiansen T, Mayo K, Ganz R, Muller ME.
Classification and aspects of treatment of fractures of the
proximal humerus. In: Bateman JE, Welsh RP. Surgery of
the shoulder. Philadelphia: BC Decker Inc, 1984:330-43.
-
Koval
KJ, Gallagher MA, Marsicano JG, et al. Functional outcome
after minimally displaced fractures of the proximal part of
the humerus.
J Bone
Joint Surg Am
1997;79:203-207.
-
Neer CS :
Displaced proximal humeral fractures. Part 1. Classification
and evaluation. J Bone Joint Surg. Am. 1970;52: 1077-1089.
-
Cofield
RH. Comminuted fractures of the proximal humerus. Clin Orthop
1988;230:49-57
-
Neer CS
II. Displaced proximal humeral fractures. Part II Treatment
of three-part and four-part displacement. J Bone Joint Surg.
Am. 1970; 52: 1090-103.
-
Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal
humeral fractures: management techniques and expected results.
Clin Orthop1993;292:13-25.
-
Hagg O,
Lundberg BJ. Aspects of prognostic factors in
comminuted and dislocated proximal humerus fractures. In:
Bateman JE, Welsh RP, eds. Surgery of the shoulder.
Philadelphia, Decker, 1984.
-
Munst P,
Kuner EH. Osteosynthesis in dislocated fractures of the
humerus head. Orthop¨ade 1992;21:121-30.
-
Habermeyer P, Schweiberer L. Fractures of the proximal
humerus. Orthop¨ade 1989;18:200-7.
-
Ebrain N,
Wong F Y, Biyani A. Percutaneous pinning of the proximal
humerus, J Orthop. Am. 1996; 25:500-1,506.
-
Jaberg H,
Warner JJ and Jakob RP. Percutaneous stabilization of
unstable fractures of the humerus. J Bone Joint Surg Am.
1992;74:508-515.
-
Constant
CR, Murley AHG. A clinical method of functional
assessment of the shoulder. Clin Orthop 1987;214:160-4.
-
Sehr JR,
Szabo RM. Semitubular blade plate for fixation in the
proximal humerus. J Orthop Trauma 1988;2:327-32.
-
Moda SK,
Chada NS, Sangwan SS, et al. Open reduction and
fixation of proximal humeral fractures and fracture
dislocations. J Bone Joint Surg [Br] 1990;72-B:1050-2.
-
Kay SP,
Amstutz HC. Shoulder hemiarthroplasty at UCLA. Clin orthop
1988; 228: 42-48.
-
Kraulis
J, Hunter G. The results of prosthetic replacement in
fracture-displacements of upper end of the humerus. Injury
1976; 8: 129-31.
-
Cofield
RH. Total shoulder arthroplasty with the Neer
prosthesis. J Bone Joint Surg [Am] 1984;66-A:899-906.
-
Chen CY,
Chao EK, Tu YK, Ueng SW, Shih CH. Closed management and
percutaneous fixation of unstable proximal humerus fractures.
J Trauma. 1998 Dec;45(6):1039-45.
-
Resch H,
Povacz, Frohlich R, Wambacher M. Percutaneous fixation of
three-and four-part fractures of the proximal humerus. J Bone
Joint Surg Br. 1997 Mar;79(2);295-300.
-
Darder A,
Darder A Jr. Sanchis V, Fastaldi E, Gomar F. Four-part
displaced proximal humeral fractures: Operative treatment
using Kirschner wires and a tension band. J Orthop Trauma
1993;7(6):497-505.
-
Zyto K,
Ahrengart L, Sperberg A, Tornkvist H: Treatment of displaced
proximal humeral fractures in elderly patients. J Bone Joint
Surg. Br. 1997;79(3): 412-417.
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