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Current concepts in the treatment of proximal humeral fractures
Current Orthopaedics (1997) 11, 203-214 © 1997 Pearson Professional Ltd
Trauma
Current concepts in the treatment of proximal humeral fractures
G. Schippingel, R. Szyszkowitz, E J. Seibert
INTRODUCTION
VASCULARIZATION
Proximal humeral fractures are common comprising 4-5% of all fractures, 1,2 being more common in the elderly. The classic mechanism is a fall on the outstretched arm; however, a direct blow from the side or excessive rotation on the abducted arm as well as grand real seizures may produce a fracture. In the elderly the primary predisposing factor is severe osteoporosis which can result in a comminuted fracture after a minor fall. In younger patients a dislocation of the shoulder joint is more frequently seen because the tensile strength of the shoulder capsule is weaker than the structure of bone. The most severe fracture patterns, for example, a combination of fracture and dislocation are seen in middle-aged people? Approximately 75% of proximal humeral fractures respond satisfactorily to simple conservative treatment and functional after-treatment? Failure to achieve or maintain reduction is probably due to the extent of bony injury or interposition of soft tissue such as the biceps tendon. Displaced and unstable fractures as well as comminuted fractures necessitate open reduction and internal fixation. This stabilization provides the orthopaedic surgeon with a formidable challenge. One of the key problems associated with proximal humeral fractures is the potential damage to the blood supply of the humeral head with consequent humeral head necrosis?
The knowledge of the humeral head blood supply is crucial to the understanding of the mechanism which may cause avascular necrosis after comminuted fractures. This will influence the selection of fixation techniques, or whether primary prosthetic replacement is indicated. Avascular necrosis may result in partial or total collapse of the head with subsequent articular incongruency and osteoarthritis.6 Many attempts have been made to establish whether avascular necrosis is caused by the fracture pattern or by the surgery with its extensile exposure, soft tissue damage and large implants. The main source of blood supply of the humeral head is clearly the anterior circumflex artery.7,8 Its most important anterolateral branch provides some small branches to the lesser tuberosity, crosses under the tendon of the long head of the biceps and runs proximally, adjacent to the lateral border of the biceps tendon. This artery is called the antero-lateral branch of the anterior circumflex artery (ACA). At the level of the greater tuberosity it enters the humeral head lateral to the intertubercular groove as the arcuate artery (Fig. 1A). It vascularizes almost the entire anterior and upper epiphysis. Only a small part of the posterior portion of the greater tuberosity is supplied by a branch of the posterior circumflex artery (PCA) as posteromedial arteries (Fig. 1B). No vessel other than the ACA and PCA directly enters the humeral head. Laing could not confirm that vessels from the rotator cuff directly vascularize the underlying bone. 7 It might be different under fracture conditions, because Gerber et al found an ample network of anastomosis through selective injection of the ACA, PCA, thoracoacromial or suprascapular artery. 8 This explains why the ACA can be ligated medially to the
G. Schippinger MD, R. Szyszkowitz MD, Professor of Traumatology, EJ. Seibert MD, University Clinic for Traumatology, University of Graz/Austria, Auenbruggerplatz 29, A-8036 Graz, Austria. Address correspondence to: G. Schippinger.
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Fig. 1 (A) 1, axillaryartery; 2, anterior circumflexartery (ACA); 3, antero-lateralbranch of the ACA; 4, arcuate artery; 5, lesser tuberosity; 6, greater tuberosity;7, intertuberculargroove;8, posterior circumflexartery (PCA). (B) 1, axillaryartery; 2, posterior circumflexartery; 3, postero-medialbranches; 4, anterior circumflexartery. (C) 1, axillaryartery; 2, posterior circumflexartery; 3, ventromedialbranches (ACA); 4, lesser tuberosity;5, greater tuberosity;6, medio-dorsalbranches (PCA).
intertubercular groove without risk of avascular necrosis of the head. Great emphasis should be taken not to ligate or injure the antero-lateral branch at the point of entry into the head because anastomoses at this level are very rare5 ,* In cases of compound fractures it can sometimes be observed that the medial capsule of the surgical neck is intact. These structures should also be preserved at all costs because there is blood supply from the ACA, the so-called ventro-medial branches (Fig. 1(2) and from the PCA the so-called mediodorsal branches described by Seggl and Weiglein. 9
CLASSIFICATION Many attempts have been made to classify humeral head fractures. Kocher's classification was fundamentally based on the same principles as for femoral neck fractures? ° The location of the fracture played the most important role, whether the injury was through the surgical neck, the anatomical neck or through the tubercle region. B6hler extended the classification with the introduction of X-rays considering fractures of the tubercle and the epiphysis? Codman was the first who observed the importance of four fracture segments. 11 The segments are the head, the lesser tuberosity, the greater tuberosity and the shaft. A classification merely based upon the level of the fracture permits a non-displaced lesion to be grouped together with a serious displacement. A milestone in the classification system was laid down by Neer where he considered the same four segments as important but with additional attention to the presence or absence of displacement of one or
more of the four segments. 12He noted the significance of more than 10ram separation between fracture fragments or greater than 45 ° fragment angulation (Fig. 2). With these considerations, Neer was the first who encountered the problem of vascularity, the more fragments being displaced the worse the prognosis, with respect to the high risk of avascular necrosisY 3 Habermeyer modified the original version of Neer. He considered not only the number of segments and displacement, but also the level of the fracture as important. Fracture dislocations are only classified after reduction, in contrast to Neer's scheme? The comprehensive ABC classification, a widely used system and recommended by SICOT was introduced in 1984. It is based on the clinical study of 730 surgically treated proximal humeral fractures documented at the AO centre in Bern, Switzerland (Fig. 3)24,15 This scheme distinguishes three alphanumerical groups, A, B and C. Type A is an extraarticular fracture with two main fragments where the likelihood of partial avascular necrosis is very low. Type B is a fracture partially intra- and partially extracapsular. Two or three segments are involved and the risk of avascular necrosis is somewhat higher. Type C comprises fractures with intracapsular involvement with two, three or four fragments. There is a high risk of total avascular necrosis of the humeral head. Within each of these main groups there are three subgroups with increasing severity. These subgroups are again divided into three further subgroups depicting the degree of displacement, for example, varus/valgus. Fractures can be broken down to 27 types. Over the years, this classification has been modified to the most recent version? 6 The subgroups are necessary for scientific comparison of results and quality control.
Treatment of proximal humeral fractures Displaced
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The complexity of the widely used Neer and AO classification systems implies the risk of intra- and inter-observer error particularly with poor X-ray quality such as projections in only one plane. Therefore the 'trauma series' advocated by Neer is required in every fracture.Z7 Gerber has shown that in 95 humeral fractures, agreement over the type of fractures occurred in only 26% with the Neer classification, and 15% with the AO classification. TM Other investigations have shown similar results. 19,2° Thus, there is a potential for a wide variety of treatment recommendations and prediction of the prognosis becomes less accurate. Further work must be done to standardize the comprehensive classification of proximal humerus fractures with the aid of CT-scan and 3-D reconstruction techniquesY
TREATMENT )i~oca~on
The management decisions in the treatment of proximal humeral fractures are dependent on the fracture morphology on the one hand and on the age and needs of the patients on the other. Obviously the operative experience in the different techniques is important. Therefore the consideration whether to treat operatively or conservatively is still an individual decision; however, there is also some general agreement.
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Fig. 2 Neer'sclassificationsystem.
Type A fractures Non-displaced fractures of the proximal humerus are treated conservatively with good results. The incidence
A- F r a c t u r e s A1
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Fig. 3 ABC classificationsystem.
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Fig. 4 Undisplaced proximal humeral fracture.
of this type of fracture is between 60 and 85% (Fig. 4). The fragments are held together by the periosteum and the rotator cuff muscles and are therefore considered stable?2 Closed reduction is indicated in A2 and A3 fractures if the displacement of the main fragment is more than 5-10 mm and/or angulation is greater than 30-45 ° . Reduction is obtained by the manoeuvre advocated by Neer. 23Following i.v. analgesia, traction on the arm corrects the shortening and medialization of the shaft caused by the pull of the pectoralis major muscle. The arm is then flexed and adducted. The pectoralis is now relaxed and impaction in the correct position is then possible. Another method of reduction is described by B6hler24(Fig. 5). After reduction, immobilization is achieved with a sling or bandage dressing for at least 7 days?5 Rarely are abduction splints necessary to prevent redisplacement. Functional treatment may be commenced some days after the injury in impacted or non-displaced fractures, and after 14 days in stable reduced fractures. Prior to mobilization, one must prove the stability of the fracture. The surgeon stands behind the patient and palpates the humeral head with one hand. The other hand flexes the elbow and rotates the shaft internally and externally very cautiously. An 'abnormal movement' of the humeral head indicates an unstable condition. 22 Some authors question the value of manipulation alone after displaced humeral neck fractures. 26 If fracture reduction is achieved by manipulation but cannot be maintained, percutaneous K-wire fixation is performed?2'27~9 An alternative method of fixation after closed reduction is the use of intramedullary pins. These pins are elastic and usually made of steel. The design is such that the last 20 mm of the tip is angulated at 15 degrees. They are inserted 3 cm proximal to the olecranon tip and passed into the shaft and up to the humeral head. 3°,31A similar
Fig. 5 Reduction technique of Type A2 and A3 fractures.
technique can be carried out with Rush pins. 32 In rare cases an external fixator can be applied after transcutaneous reduction33,34with a Steinmann-pin as described by Kristiansen.23,3538 Usually, three to four terminally threaded Kirschner-wires 2.5 mm in diameter are inserted with a power drill and are directed superiorly from the lateral and the anterior cortex. Correct placement of the pins should be checked with an image intensifer. Maintenance of reduction after manipulation is achieved by placing a K-wire from the top into the medial cortex. After placement of the other K-wires and gaining enough stability this pin can be removed (Fig. 6). All K-wires should be placed into the subchondral bone of the humeral head and are left in a subcutaneous position. Sling immobilization is necessary for 3-4 weeks after surgery. In osteoporotic bone the shoulder is immobilized for 5-6 weeks, especially if there is pin loosening. Inability to reduce the fracture is usually due to interposition of the biceps tendon or the deltoid muscle or from the pull of the pectoralis, supra and infraspinatus muscles (Fig. 7). Open reduction through a delto-pectoral approach is advocated under these conditions. After creating a valgus impaction, tension band techniques by means of trans-osseous sutures, cerclage wires, screws or plates may be used to stabilize the fracture. 39'4° In greater tuberosity fractures the objective is to avoid prominence in order to reduce the chance of impingement. Patients younger than 50 years of age are allowed up to 5 mm displacement before open reduction is indicated. Whereas patients older than 50 are permitted 10 mm displacement.41,42The displacement is best verified with a so-called 'sulcus view' (Fig. 8). The greater tuberosity is usually retracted superiorly and posteriorly through the pull of the supraand infraspinatus muscles. In superiorly displaced tuberosities, the fragment overlaps the articular
Treatment of proximal humeral fractures
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Fig. 8 (A) X-ray technique to assess the displacement of the greater tuberosity; (B) 56-year-oldman with nearly undisplaced greater tuberosity fracture.
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Fig. 6 Placement of percutaneous K-wires after closed reduction. repaired to relieve tension on the tuberosity repair. 43 This is usually the best way of stabilization in osteoporotic bone with a weak trabecular pattern. In young patients with good bone stock stabilization can be achieved with screws which can be inserted percutaneously under image intensifier control (Fig. 10). Metaphyseal comminution as seen in A3/1 fractures is best treated by bridging the metaphyseal zone with a T-plate or a small fragment clover leaf plate 44 (Fig. 11). An alternative technique is the use of a semitubular or one third tubular plate bent to 90 ° and inserted into the head of the humerus or a small 90 ° angle blade-plate fixed with 3 . 5 m m screws. ~5,45,46
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B Type B fractures
Fig. 7 (A) Interposition of long biceps tendon. (B) Piercing of the humeral shaft through the deltoid. (C) Medialization of the shaft due to pectoralis major muscle pull in a 76-year-oldwoman with a typical A2/2 fracture.
surface of the humerus and thus prohibits osseous healing. Tuberosity stabilization is accomplished by resorbable bone sutures (Fig. 9). The tear in the rotator cuff which occurs in the interval is meticulously
These fractures are partially intra- and extra-articular according to the ABC classification system. They comprise either the greater or lesser tuberosity together with the surgical neck. Other characteristics are rotatory displacement and shaft displacement. It is crucial that surgery does not further jeopardize the residual blood supply to the head. Closed reduction rarely allows an anatomic reduction. Therefore usually open reduction is required. Conservative treatment is restricted to patients who are very old or non-compliant. More recently, percutaneous manipulation with bone hooks or a raspatory to achieve anatomical reduction has been introduced, after which fixation of the fracture is performed with various cannulated screw systems. Otherwise the delto-pectoral approach is used to stabilize these fractures. The main goal should be restoration of the articular segment using the biceps tendon as reference point. Elevation of the deltoid from the clavicle should be avoided under all circumstances. To gain more access to the fracture the pectoralis major can be incised at its humeral insertion. The reduction of the fragments should be carried out very cautiously in
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CurrentOrthopaedics Hemiarthroplasty remains a salvage procedure in patients, where stable fixation for functional aftertreatment cannot be achieved in older patients with osteoporotic bone and with tenuous soft tissue attachment to the head. 46,48,49With hemiarthroplasty emphasis must be placed on the necessity to tension band wire or to use non-resorbable sutures between the tuberosity fragments and the shaft with associated autogenous bone graft to allow tuberosity shaft healing. Humeral head impression fractures (Hill-Sachs) associated with dislocation may be treated with elevation and bone grafting to prevent redislocation. Fracture dislocations should be treated in the same way as mentioned previously.
Fig. 9 Transosseoussuturesto stabilizethe greatertuberosityto the shaft.
Type C fractures
order to avoid additional damage to the blood supply. Many different fixation options are available. Minimal osteosynthesis has recently shown superior results over plate f i x a t i o n . 37'38'4°'47Plate fixation may be quite tenuous in osteoporotic bone, when fractures extend into the shaft and it may increase the frequency of osteonecrosis of the head fragments. Anatomical reduction should be the aim, especially in young individuals. This is a prerequisite for achieving an optimal range of movement after bony union. After reduction and fixation of the tuberosities by cerclage wires or trans-osseous sutures the main fracture is either stabilized by cerclage wires, sutures or screws alone or with trans-osseous wires or sutures around the head of the screws'° (Fig. 12). An alternative can be the combination of percutaneous pinning of the head to the shaft suturing of the tuberosities to the head and tuberosity and head to the shaft48(Fig. 13).
In group C fractures the fracture pattern is totally intracapsular, with significant risk of avascular necrosis. The C1 fractures are extremely rare accounting for less than 1% of proximal humeral fractures?° This type of fracture is extremely prone to head necrosis, because the blood supply from the arcuate artery is interrupted. Fractures without displacement and reasonable impaction can be treated conservatively. In cases of displacement, closed reduction is hampered by rotatory displacement of the articular segment, ventro- or dorso-caudally. Due to the fact that this fracture is intracapsular, manipulation is often very difficult. Therefore open reduction with arthrotomy is indicated and fixation can usually be managed with 50 mm 4.0 mm diameter cancellous bone screws.TM Neer discusses an alternative management whereby he accepts the displacement of the head segment after closed reduction and permits osseous healing so as not to endanger the blood supply of the head. If this
Fig. 10 Percutaneoustitaniumscrewfixationof a greatertuberosityfragment.
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Fig. 11 Cloverleafplate fixationof a A3/1 fracture.
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A
C Fig. 12 (A) 75-year-oldwomanwith a A3/1 fracture;(B) After minimal osteosynthesis;(C, D) Activerange of movementafter bonyhealing.
malunion causes problems either a corrective osteotomy or hemiarthroplasty is his favoured treatment protocol. ~7In C2 fractures the blood supply of the humeral head is at high risk and this fact should influence the surgical considerations. In type C2/1 and C2/2 fractures the fracture consists of four fragments with variable displacement of the tuberosities and valgus impaction of the humeral head. Recently
Stableforth, in his review of four-part fractures, makes brief mention of an impacted and little displaced fractureY It seems that if the valgus impacted fracture maintains bony and periosteal contact, at least medially, the head fragment is more likely to retain some blood supply, than if the fragment is laterally or posteriorly displaced. 52Therefore this fracture pattern cannot be summarized under four-part fractures
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Fig. 13 (A) 80-year-oldwoman with a B2/1 fracture; (B) Situation after open reduction and K-wirefixation.Additional fixation of the tubercula with a transversecortex screw.
Fig. 14 (A) Impaction of the head fragment into the shaft. (B) X-ray of a C2/2 ice-cone type fracture. (C) Anatomical reduction is achieved by elevating the head fragments with a bone hook. An autologous or allogenic bone graft is interposed between the fragments and fixed with cancellous bone screws.
because with adequate operation management, the incidence of avascular necrosis is lower than in more displaced four-part fractures. In elderly patients with osteoporotic bone, stability is more easily achieved by impaction of the humeral head leaving the remaining periosteal connections intact. Furthermore the displaced tuberosities may be pulled distally with non-absorbable sutures and secured to the shaft or to the screw heads, because the main fragment is stabilized by titanium cortical or cancellous screws. Titanium screws are preferable because they do not interfere with M R I which is used to monitor the head necrosis. With this treatment, enough stability is achieved to allow functional after-treatment, however a limited range of motion is to be expected. In C2/2 fractures, the so called 'ice-cone' fractures, joint incongruency is usually not acceptable as the head is too low (Fig. 14 A,B). The disturbed joint mechanics may lead to osteoarthritis, malposition of the tuberosities, malfunction and consequent impingement. Through a delto-pectoral approach special care should be taken again not to denude bone fragments. Dissection should
be minimized to avoid damage to the remaining soft tissue attachments of the fracture fragments. If the tuberosities are not separated and a better orientation for reduction of the head fragment is necessary, the tuberosities can be separated by sharp dissection along the long biceps tendon. Reduction is then carried out by elevating the humeral head fragment. In young patients and sometimes in osteoporotic bone an autologous or allogenic bone graft is necessary to fill the defect and to maintain the head position? 3By elevating the humeral head with the bone hook or raspatory, reduction is achieved2 2,53Stabilization is achieved with cortical or cancellous screws through the lateral cortex sometimes through the tuberosity into the head. Additional fixation is necessary to bring down the tuberosities. This can be managed with tension band wiring or with absorbable sutures, which are secured to the shaft with a transverse cortical screw, or by means of a drill hole (Fig. 14C). Even if avascular necrosis of the head occurs function often remains good? 4 In fracture type C2/3 there is severe disruption of all fragments and there is no valgus impaction but
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Fig. 15 (A) Fracturepattern of a 90-year-oldfit man. (B) Same patient afterhemiarthroplasty. lateral displacement, and thus soft tissue attachments medially are very unlikely. In younger patients it is worthwhile to consider careful reduction of the fragments with minimal osteosynthesis. If this goal cannot be achieved primary endoprosthetic replacement particulary in older patients should be carried out (Fig. 15).
Type C3fractures Type C3 fractures are the most severe fractures of the proximal humerus, where the fragments do not show any soft tissue attachments and are severely displaced, or there is additional dislocation of the anatomical head or head splitting factors. These fractures are comparable to Neer's four-part fractures and fracture-dislocation and the rate of avascular necrosis is 80-90%. 4oAccurate reduction and fixation of these fractures is reserved for the most experienced shoulder surgeons and is only justified in a young fit patient (Fig. 16). Most surgeons prefer primary hemiarthroplasty55-58 (Fig. 17). Head replacement should be carried out within 2 weeks of injury to gain a good functional outcome. Due to muscle atrophy, scarring of the soft tissue and possible adhesive capsulitis, the results of hemiarthroplasty after more than 4 weeks have proved to yield less satisfactory results?9 Exceptions of course are those patients where relatively stable conditions can be achieved after minimal osteosynthesis, allowing an acceptable passive range of motion during the first 3 weeks and a good active range of motion during the next 3-6 weeks. If secondary head necrosis later occurs in these active patients, an implanted head endoprosthesis can also give good functional results. Several salient features of prosthetic replacement in fracture situations should be emphasized. The stem must be cemented to ensure rotational stability and to
guarantee appropriate height of the stem. This is assessed by mobilizing the rotator cuff distal to the prosthetic head. Removal of fracture fragments should be kept to a minimum. For good rotator cuff function it is important to restore the appropriate musculo-tendinous tension and it is necessary to leave the prosthesis with its fins above the level of the resected bone. The tuberosities must be mobilized distally beyond the prosthesis to allow fixation to each other and to the shaft. Autogenous bone graft from the removed head fragment should be used to ensure union of the tuberosities to the shaft, because realpositioned tuberosities would cause loss of muscle function and loss of head depressing function with uprising of the humeral head and consequent impingement. An alternative to prosthetic replacement is resection of the humeral head, but results from such a procedure have not been good 6°,6I(Fig. 18). Absence of the head leaves the patient with a flat shoulder, short limb and a weak arm, and pain particularly in abduction and flexion. Furthermore resection of the head usually does not give satisfactory pain relief especially during the night. 62
SUMMARY
Treatment considerations should be based on the age, bone stock and lifestyle requirements of the patient and the surgeon's operative experience. Conservative management yields good results if there is no major displacement and angulation and if humeral head blood supply is not endangered. On the other hand one should not hesitate to consider open reduction and internal fixation if major joint incongruency or displacement of fracture fragment exists. Several methods of stabilization have been used in the past. Plate fixation in these fractures is a very demanding
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Fig. 16 (A) C2/3 fracturein a youngpatient. (B) Patient after minimalosteosynthesis.(C) Patient after bone healing. (D, E) Activerange of motion 4 months after injury. technique associated with multiple pitfalls, such as: (a) too proximal placement of the plate; (b) screw and plate loosening due to poor bone stock: (c) excessive denudation of the humerus to gain enough access to fit the plate; and (d) damage to the ascending branch of the ACA, with possible head necrosis. Technical errors associated with incorrect positioning of the plate may cause compression and devascularization. The Cloverleaf plate has advantages over the T-plate, because it can be more easily contoured to the surface of the bone and adjusted to the fragments. Our own results and those of other authors show that minimal osteosynthesis with careful exposure leads to a better functional outcome of severely displaced fractures. Through minimal use of implants it is possible to minimize the risk of further vascular damage even in cases
of four-part or C2 and C3 fractures. Plate osteosynthesis is mainly indicated in unstable fractures extending into the proximal shaft or with large fragments of the metaphyseal area. These fractures occur in relatively young patients after indirect trauma. The trend towards reconstruction of the humeral head by careful soft tissue handling and osteosynthesis shows encouraging results and has advantages over primary hemiarthroplasty in our and others' opinions. The long-term results of endoprosthetic replacement in three and four-part fractures are not satisfying but can be accepted as long as endoprosthetic replacement is reserved as a salvage procedure. It is appropriate in the more complex type C2/3 and C3 fractures and also in other C fractures in elderly patients with poor bone stock and limited goal expectations. Considering all
Treatment of proximal humeral fractures
Fig. 17
Fig. 18
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(A) 43-year-old man with a C3/3 fracture. (B) After hemiarthroplasty. (C, D) Functional outcome 5 months after operation.
Situation after head resection in a 75-year-old woman.
the technical details of prosthetic replacement, reasonable shoulder function and pain relief can be achieved in experienced hands even in the worst fracture situations. REFERENCES 1. Habermeyer P, Schweiberer L. Frakturen des proximalen Humerus. Orthop/ide 1989; 18:200-207 2. Schweiberer L, Betz A, Eitel F, Krueger P, Wilker D, Bilanz der konservativen und operativen Knochenbruchbehandlung Obere Extremit/it. Chirurg 1982; 54:226-233 3. Neer CS II. Shoulder Reconstruction. Saunders, Philadelphia. 1991
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16. Miiller ME, Nazarian S, Koch R Schatzker J. The comprehensive classification of fractures of long bones. Springer, Berlin 1990; p 54 17. Neer CS II. Fractures. In: Shoulder Reconstruction. Saunders, Philadelphia 1990; p 363 18. Siebenrock KA, Gerber C. The reproducibility of classification of the proximal end of the humerus. J Bone Joint Surg 1993; 75A: 1751-1755 19. Kristiansen B, Andersen ULS, Olsen CA, Varmarken JE. The Neer classification of fractures of the proximal humerus. Skeletal Radiol 1988; 17:420-422 20. Sidor M, Zuckerman JD, Lyon T, Koval K, Cuomo F, Schoenberg N. The Neer classification system for proximal humeral fractures. J Bone Joint Surg 1993; 75A: 1745-1749 21. Siebler G, Walz H, Kuner EH. Minimalosteosynthese von Oberarmkopffrakturen. Unfallchirurg 1989; 92:169-174 22. Habermeyer P, Schweiberer L. Oberarmkopffrakturen. Unfallchirurg 1991; 94:438-446 23. Resch H, Th6ni H. Luxationsfrakturen der Schulter. Sonderstellung and Therapiekonzepte. Orthop/idie 1992; 21: 131-139 24. B6hler L. Die Technik der Knochenbruchbehandlung. Bdq 12,12 Aufi. Maudrich, Wien 1963; 625 25. B6hler L. Die Behandlung yon Verrenkungsbrtichen der Schulter. Dtsch Z Chir 219:238-245 26. Young B Th, Wallace AW. Conservative treatment of fractures and fracture dislocations of the upper end of the humerus. J Bone Joint Surg 1985; 67B: 373-377 27. Jaberg H, Warner J, Jakob RE Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg 1992; 74A: 508-515 28. Kocialkowski A, Wallace A. Closed percutaneous K-wire stabilization of displaced fractures of the surgical neck of the humerus. Injury 1990; 21:209~12 29. Wiedemann E, Schweiberer L. Die geschlossene Behandlung bei Humeruskopffrakturen. Orthopfide 1992; 21:106 114 30. Zifko B, Poigenffirst J. Die Behandlung unstabiler Frakturen am proximalen Humerusende durch elastische vorgebogene Markdr/ihte. Unfallchirurgie 1987; 13:72 81 31. Zifko B, Poigenf/irst J, Pezzei Ch. Die Markdrahtung unstabiler proximaler Humerusfrakturen. Orthopfide 1992; 21:115 120 32. Robinson CM, Christie J. The two part proximal humeral fracture: a review of operative treatment using two techniques. Injury 1993; 24:123-125 33. Kristiansen B, Kofoed H. Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. J Bone Joint Surg 1988; 70B: 821-824 34. Miinst P, Kuner EH. Osteosynthesen bei dislozierten Humeruskopffrakturen. Orthop/ide 1992; 21:121 130 35. Brooks CH, Carvell JE. External fixation for fracturedislocations of the proximal humerus. J Bone Joint Surg 1989; 71B: 864-865 36. Kristiansen B, Kofoed H. External fixation of displaced fractures of the proximal humerus. J Bone Joint Surg 1987; 69B: 643-646 37. Kuner EH, Siebler G. Luxationsfrakturen des proximalen humerus - Ergebnisse nach operativer Behandlung. Unfallchirurgie 1987; 13:64-71 38. Siebenrock KA, Gerber C. Frakturklassifikation und problematik bei proximalen humerusfrakturen. Orthop/idie 1992; 21:98-105 39. Cornell CN, Levine D, Pagnini MJ. Internal fixation of proximal humerus fractures using the screw tension band technique. J Orth Trauma 1994; 8:22-27
40. Hawkins R J, Kiefer GN. Internal fixation techniques for proximal humeral fractures. Clin Orthop 1987; 223:77 85 41. McLaughlin HL. Dislocation of the shoulder with tuberosity fracture. Surg Clin N Am 1963; 43:1615-1620 42. Resch H, Beck E. Praktische Chirurgie des Schultergelenkes. Innsbruck Frohnweiler Druck Ges.m.b.H. 1988 43. Flatow E, Cuomo F, Maday M, Miller S, McIlveen St, Bigliani L. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg 1991; 73A: 1213-1218 44. Esser R. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clin Orthop 1994; 299:244-251 45. Paavolainen P, Bj6rkenheim JM, S1/ifis P, Paukku R Operative treatment of severe proximal humeral fractures. Acta Orthop Scandinavica 1983; 54:374-379 46. Szyszkowitz R, Schleifer P, Lottersberger E. Bruchformen, Technik der operativen Behandlnng und Ergebnisse bei Verrenkungsbrtichen des Oberarmkopfes. Hefte zur Unfallheilkunde 1987; Heft 186:165-171 47. Cofield HR. Comminuted fractures of the proximal humerus. Clin Orthop 1988; 230:49-57 48. Hawkins R, Bell RH, Gurr K. The three-part fractures of the proximal part of the humerus. J Bone Joint Surg 1986; 68-A: 1410-1414 49. Moeckel B, Dines D, Russel F, Waren MD, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg 1992; 74A: 884-889 50. Poigenfiirst J. Der Oberarmbruch im Collum anatomicum. Unfallheilkunde 1977; 80:537 51. Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg 1984; 66B: 104-108 52. Jakob RP, Miniaci A, Anson Ph, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractm-es of the proximal humerus. J Bone Joint Surg 1991; 73B: 295-298 53. Kasperczyk WJ, Engel M, Tscherne H. Die 4-fragment fraktur des proximalen oberarms. Unfallchirurg 1993; 96: 422-426 54. B6hler J. Les fractures recentes de L6paule. Acta Orth Belg 1964; 30:235-242 55. Esser R. Treatment of three- and four-part fractures of the proximal humerus with a modified cloverleaf plate. J Orthop Trauma 1994; 8:15-22 56. Healy W, Jupiter JB, Kristiansen K, White R. Non-union of the proximal humerus. J Orthop Trauma 1990; 4:424-431 57. Neer SC, Watson K, Stanton J. Recent experience in total shoulder replacement. J Bone Joint Surg 1982; 64A: 319-337 58. Neer CS II, Rockwood CA. Fractures and dislocations of the shoulder. In: Rockwood CA and Green DP (eds): Fractures in Adults, 2nd edu, vol 1. Philadelphia, J.B. Lippincott, 1984; pp 684, 688-696 59. Neumann K, Muhr G, Breitful3 H. Prim~irer kopfersatz der dislozierten oberarmkopffraktur. Orthop~de 1992; 21: 140-147 60. Neviaser J. Complicated fractures and dislocations about the shoulder joint. J Bone Joint Surg 1962; 44A: 984-998 61. J~ger M, Wirth Ch. Luxationstriimmerfrakturen des humeruskopfes - resektion oder refixation der fragmente? Unfallheilkunde 84:26 62. Svend-Hansen H. Displaced proximal humeral fractures results of non-prosthetic treatment. In: Bayley I, Kessel L (eds) Shoulder Surgery. Springer, Berlin, pp 205-206
Trauma
Current concepts in the treatment of proximal humeral fractures
G. Schippingel, R. Szyszkowitz, E J. Seibert
INTRODUCTION
VASCULARIZATION
Proximal humeral fractures are common comprising 4-5% of all fractures, 1,2 being more common in the elderly. The classic mechanism is a fall on the outstretched arm; however, a direct blow from the side or excessive rotation on the abducted arm as well as grand real seizures may produce a fracture. In the elderly the primary predisposing factor is severe osteoporosis which can result in a comminuted fracture after a minor fall. In younger patients a dislocation of the shoulder joint is more frequently seen because the tensile strength of the shoulder capsule is weaker than the structure of bone. The most severe fracture patterns, for example, a combination of fracture and dislocation are seen in middle-aged people? Approximately 75% of proximal humeral fractures respond satisfactorily to simple conservative treatment and functional after-treatment? Failure to achieve or maintain reduction is probably due to the extent of bony injury or interposition of soft tissue such as the biceps tendon. Displaced and unstable fractures as well as comminuted fractures necessitate open reduction and internal fixation. This stabilization provides the orthopaedic surgeon with a formidable challenge. One of the key problems associated with proximal humeral fractures is the potential damage to the blood supply of the humeral head with consequent humeral head necrosis?
The knowledge of the humeral head blood supply is crucial to the understanding of the mechanism which may cause avascular necrosis after comminuted fractures. This will influence the selection of fixation techniques, or whether primary prosthetic replacement is indicated. Avascular necrosis may result in partial or total collapse of the head with subsequent articular incongruency and osteoarthritis.6 Many attempts have been made to establish whether avascular necrosis is caused by the fracture pattern or by the surgery with its extensile exposure, soft tissue damage and large implants. The main source of blood supply of the humeral head is clearly the anterior circumflex artery.7,8 Its most important anterolateral branch provides some small branches to the lesser tuberosity, crosses under the tendon of the long head of the biceps and runs proximally, adjacent to the lateral border of the biceps tendon. This artery is called the antero-lateral branch of the anterior circumflex artery (ACA). At the level of the greater tuberosity it enters the humeral head lateral to the intertubercular groove as the arcuate artery (Fig. 1A). It vascularizes almost the entire anterior and upper epiphysis. Only a small part of the posterior portion of the greater tuberosity is supplied by a branch of the posterior circumflex artery (PCA) as posteromedial arteries (Fig. 1B). No vessel other than the ACA and PCA directly enters the humeral head. Laing could not confirm that vessels from the rotator cuff directly vascularize the underlying bone. 7 It might be different under fracture conditions, because Gerber et al found an ample network of anastomosis through selective injection of the ACA, PCA, thoracoacromial or suprascapular artery. 8 This explains why the ACA can be ligated medially to the
G. Schippinger MD, R. Szyszkowitz MD, Professor of Traumatology, EJ. Seibert MD, University Clinic for Traumatology, University of Graz/Austria, Auenbruggerplatz 29, A-8036 Graz, Austria. Address correspondence to: G. Schippinger.
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Fig. 1 (A) 1, axillaryartery; 2, anterior circumflexartery (ACA); 3, antero-lateralbranch of the ACA; 4, arcuate artery; 5, lesser tuberosity; 6, greater tuberosity;7, intertuberculargroove;8, posterior circumflexartery (PCA). (B) 1, axillaryartery; 2, posterior circumflexartery; 3, postero-medialbranches; 4, anterior circumflexartery. (C) 1, axillaryartery; 2, posterior circumflexartery; 3, ventromedialbranches (ACA); 4, lesser tuberosity;5, greater tuberosity;6, medio-dorsalbranches (PCA).
intertubercular groove without risk of avascular necrosis of the head. Great emphasis should be taken not to ligate or injure the antero-lateral branch at the point of entry into the head because anastomoses at this level are very rare5 ,* In cases of compound fractures it can sometimes be observed that the medial capsule of the surgical neck is intact. These structures should also be preserved at all costs because there is blood supply from the ACA, the so-called ventro-medial branches (Fig. 1(2) and from the PCA the so-called mediodorsal branches described by Seggl and Weiglein. 9
CLASSIFICATION Many attempts have been made to classify humeral head fractures. Kocher's classification was fundamentally based on the same principles as for femoral neck fractures? ° The location of the fracture played the most important role, whether the injury was through the surgical neck, the anatomical neck or through the tubercle region. B6hler extended the classification with the introduction of X-rays considering fractures of the tubercle and the epiphysis? Codman was the first who observed the importance of four fracture segments. 11 The segments are the head, the lesser tuberosity, the greater tuberosity and the shaft. A classification merely based upon the level of the fracture permits a non-displaced lesion to be grouped together with a serious displacement. A milestone in the classification system was laid down by Neer where he considered the same four segments as important but with additional attention to the presence or absence of displacement of one or
more of the four segments. 12He noted the significance of more than 10ram separation between fracture fragments or greater than 45 ° fragment angulation (Fig. 2). With these considerations, Neer was the first who encountered the problem of vascularity, the more fragments being displaced the worse the prognosis, with respect to the high risk of avascular necrosisY 3 Habermeyer modified the original version of Neer. He considered not only the number of segments and displacement, but also the level of the fracture as important. Fracture dislocations are only classified after reduction, in contrast to Neer's scheme? The comprehensive ABC classification, a widely used system and recommended by SICOT was introduced in 1984. It is based on the clinical study of 730 surgically treated proximal humeral fractures documented at the AO centre in Bern, Switzerland (Fig. 3)24,15 This scheme distinguishes three alphanumerical groups, A, B and C. Type A is an extraarticular fracture with two main fragments where the likelihood of partial avascular necrosis is very low. Type B is a fracture partially intra- and partially extracapsular. Two or three segments are involved and the risk of avascular necrosis is somewhat higher. Type C comprises fractures with intracapsular involvement with two, three or four fragments. There is a high risk of total avascular necrosis of the humeral head. Within each of these main groups there are three subgroups with increasing severity. These subgroups are again divided into three further subgroups depicting the degree of displacement, for example, varus/valgus. Fractures can be broken down to 27 types. Over the years, this classification has been modified to the most recent version? 6 The subgroups are necessary for scientific comparison of results and quality control.
Treatment of proximal humeral fractures Displaced
Fractures Articular Surface "
~el ck~nat°mcia?l Surgical ~leck
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The complexity of the widely used Neer and AO classification systems implies the risk of intra- and inter-observer error particularly with poor X-ray quality such as projections in only one plane. Therefore the 'trauma series' advocated by Neer is required in every fracture.Z7 Gerber has shown that in 95 humeral fractures, agreement over the type of fractures occurred in only 26% with the Neer classification, and 15% with the AO classification. TM Other investigations have shown similar results. 19,2° Thus, there is a potential for a wide variety of treatment recommendations and prediction of the prognosis becomes less accurate. Further work must be done to standardize the comprehensive classification of proximal humerus fractures with the aid of CT-scan and 3-D reconstruction techniquesY
TREATMENT )i~oca~on
The management decisions in the treatment of proximal humeral fractures are dependent on the fracture morphology on the one hand and on the age and needs of the patients on the other. Obviously the operative experience in the different techniques is important. Therefore the consideration whether to treat operatively or conservatively is still an individual decision; however, there is also some general agreement.
;pliffing tead-
Fig. 2 Neer'sclassificationsystem.
Type A fractures Non-displaced fractures of the proximal humerus are treated conservatively with good results. The incidence
A- F r a c t u r e s A1
A2
A3
B2
B3
C2
C3
B - Fractures B1
C- F r a c t u r e s C1
Fig. 3 ABC classificationsystem.
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Fig. 4 Undisplaced proximal humeral fracture.
of this type of fracture is between 60 and 85% (Fig. 4). The fragments are held together by the periosteum and the rotator cuff muscles and are therefore considered stable?2 Closed reduction is indicated in A2 and A3 fractures if the displacement of the main fragment is more than 5-10 mm and/or angulation is greater than 30-45 ° . Reduction is obtained by the manoeuvre advocated by Neer. 23Following i.v. analgesia, traction on the arm corrects the shortening and medialization of the shaft caused by the pull of the pectoralis major muscle. The arm is then flexed and adducted. The pectoralis is now relaxed and impaction in the correct position is then possible. Another method of reduction is described by B6hler24(Fig. 5). After reduction, immobilization is achieved with a sling or bandage dressing for at least 7 days?5 Rarely are abduction splints necessary to prevent redisplacement. Functional treatment may be commenced some days after the injury in impacted or non-displaced fractures, and after 14 days in stable reduced fractures. Prior to mobilization, one must prove the stability of the fracture. The surgeon stands behind the patient and palpates the humeral head with one hand. The other hand flexes the elbow and rotates the shaft internally and externally very cautiously. An 'abnormal movement' of the humeral head indicates an unstable condition. 22 Some authors question the value of manipulation alone after displaced humeral neck fractures. 26 If fracture reduction is achieved by manipulation but cannot be maintained, percutaneous K-wire fixation is performed?2'27~9 An alternative method of fixation after closed reduction is the use of intramedullary pins. These pins are elastic and usually made of steel. The design is such that the last 20 mm of the tip is angulated at 15 degrees. They are inserted 3 cm proximal to the olecranon tip and passed into the shaft and up to the humeral head. 3°,31A similar
Fig. 5 Reduction technique of Type A2 and A3 fractures.
technique can be carried out with Rush pins. 32 In rare cases an external fixator can be applied after transcutaneous reduction33,34with a Steinmann-pin as described by Kristiansen.23,3538 Usually, three to four terminally threaded Kirschner-wires 2.5 mm in diameter are inserted with a power drill and are directed superiorly from the lateral and the anterior cortex. Correct placement of the pins should be checked with an image intensifer. Maintenance of reduction after manipulation is achieved by placing a K-wire from the top into the medial cortex. After placement of the other K-wires and gaining enough stability this pin can be removed (Fig. 6). All K-wires should be placed into the subchondral bone of the humeral head and are left in a subcutaneous position. Sling immobilization is necessary for 3-4 weeks after surgery. In osteoporotic bone the shoulder is immobilized for 5-6 weeks, especially if there is pin loosening. Inability to reduce the fracture is usually due to interposition of the biceps tendon or the deltoid muscle or from the pull of the pectoralis, supra and infraspinatus muscles (Fig. 7). Open reduction through a delto-pectoral approach is advocated under these conditions. After creating a valgus impaction, tension band techniques by means of trans-osseous sutures, cerclage wires, screws or plates may be used to stabilize the fracture. 39'4° In greater tuberosity fractures the objective is to avoid prominence in order to reduce the chance of impingement. Patients younger than 50 years of age are allowed up to 5 mm displacement before open reduction is indicated. Whereas patients older than 50 are permitted 10 mm displacement.41,42The displacement is best verified with a so-called 'sulcus view' (Fig. 8). The greater tuberosity is usually retracted superiorly and posteriorly through the pull of the supraand infraspinatus muscles. In superiorly displaced tuberosities, the fragment overlaps the articular
Treatment of proximal humeral fractures
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Fig. 8 (A) X-ray technique to assess the displacement of the greater tuberosity; (B) 56-year-oldman with nearly undisplaced greater tuberosity fracture.
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Fig. 6 Placement of percutaneous K-wires after closed reduction. repaired to relieve tension on the tuberosity repair. 43 This is usually the best way of stabilization in osteoporotic bone with a weak trabecular pattern. In young patients with good bone stock stabilization can be achieved with screws which can be inserted percutaneously under image intensifier control (Fig. 10). Metaphyseal comminution as seen in A3/1 fractures is best treated by bridging the metaphyseal zone with a T-plate or a small fragment clover leaf plate 44 (Fig. 11). An alternative technique is the use of a semitubular or one third tubular plate bent to 90 ° and inserted into the head of the humerus or a small 90 ° angle blade-plate fixed with 3 . 5 m m screws. ~5,45,46
/i
A
B Type B fractures
Fig. 7 (A) Interposition of long biceps tendon. (B) Piercing of the humeral shaft through the deltoid. (C) Medialization of the shaft due to pectoralis major muscle pull in a 76-year-oldwoman with a typical A2/2 fracture.
surface of the humerus and thus prohibits osseous healing. Tuberosity stabilization is accomplished by resorbable bone sutures (Fig. 9). The tear in the rotator cuff which occurs in the interval is meticulously
These fractures are partially intra- and extra-articular according to the ABC classification system. They comprise either the greater or lesser tuberosity together with the surgical neck. Other characteristics are rotatory displacement and shaft displacement. It is crucial that surgery does not further jeopardize the residual blood supply to the head. Closed reduction rarely allows an anatomic reduction. Therefore usually open reduction is required. Conservative treatment is restricted to patients who are very old or non-compliant. More recently, percutaneous manipulation with bone hooks or a raspatory to achieve anatomical reduction has been introduced, after which fixation of the fracture is performed with various cannulated screw systems. Otherwise the delto-pectoral approach is used to stabilize these fractures. The main goal should be restoration of the articular segment using the biceps tendon as reference point. Elevation of the deltoid from the clavicle should be avoided under all circumstances. To gain more access to the fracture the pectoralis major can be incised at its humeral insertion. The reduction of the fragments should be carried out very cautiously in
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CurrentOrthopaedics Hemiarthroplasty remains a salvage procedure in patients, where stable fixation for functional aftertreatment cannot be achieved in older patients with osteoporotic bone and with tenuous soft tissue attachment to the head. 46,48,49With hemiarthroplasty emphasis must be placed on the necessity to tension band wire or to use non-resorbable sutures between the tuberosity fragments and the shaft with associated autogenous bone graft to allow tuberosity shaft healing. Humeral head impression fractures (Hill-Sachs) associated with dislocation may be treated with elevation and bone grafting to prevent redislocation. Fracture dislocations should be treated in the same way as mentioned previously.
Fig. 9 Transosseoussuturesto stabilizethe greatertuberosityto the shaft.
Type C fractures
order to avoid additional damage to the blood supply. Many different fixation options are available. Minimal osteosynthesis has recently shown superior results over plate f i x a t i o n . 37'38'4°'47Plate fixation may be quite tenuous in osteoporotic bone, when fractures extend into the shaft and it may increase the frequency of osteonecrosis of the head fragments. Anatomical reduction should be the aim, especially in young individuals. This is a prerequisite for achieving an optimal range of movement after bony union. After reduction and fixation of the tuberosities by cerclage wires or trans-osseous sutures the main fracture is either stabilized by cerclage wires, sutures or screws alone or with trans-osseous wires or sutures around the head of the screws'° (Fig. 12). An alternative can be the combination of percutaneous pinning of the head to the shaft suturing of the tuberosities to the head and tuberosity and head to the shaft48(Fig. 13).
In group C fractures the fracture pattern is totally intracapsular, with significant risk of avascular necrosis. The C1 fractures are extremely rare accounting for less than 1% of proximal humeral fractures?° This type of fracture is extremely prone to head necrosis, because the blood supply from the arcuate artery is interrupted. Fractures without displacement and reasonable impaction can be treated conservatively. In cases of displacement, closed reduction is hampered by rotatory displacement of the articular segment, ventro- or dorso-caudally. Due to the fact that this fracture is intracapsular, manipulation is often very difficult. Therefore open reduction with arthrotomy is indicated and fixation can usually be managed with 50 mm 4.0 mm diameter cancellous bone screws.TM Neer discusses an alternative management whereby he accepts the displacement of the head segment after closed reduction and permits osseous healing so as not to endanger the blood supply of the head. If this
Fig. 10 Percutaneoustitaniumscrewfixationof a greatertuberosityfragment.
Treatment of proximal humeral fractures
209
Fig. 11 Cloverleafplate fixationof a A3/1 fracture.
B
A
C Fig. 12 (A) 75-year-oldwomanwith a A3/1 fracture;(B) After minimal osteosynthesis;(C, D) Activerange of movementafter bonyhealing.
malunion causes problems either a corrective osteotomy or hemiarthroplasty is his favoured treatment protocol. ~7In C2 fractures the blood supply of the humeral head is at high risk and this fact should influence the surgical considerations. In type C2/1 and C2/2 fractures the fracture consists of four fragments with variable displacement of the tuberosities and valgus impaction of the humeral head. Recently
Stableforth, in his review of four-part fractures, makes brief mention of an impacted and little displaced fractureY It seems that if the valgus impacted fracture maintains bony and periosteal contact, at least medially, the head fragment is more likely to retain some blood supply, than if the fragment is laterally or posteriorly displaced. 52Therefore this fracture pattern cannot be summarized under four-part fractures
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Fig. 13 (A) 80-year-oldwoman with a B2/1 fracture; (B) Situation after open reduction and K-wirefixation.Additional fixation of the tubercula with a transversecortex screw.
Fig. 14 (A) Impaction of the head fragment into the shaft. (B) X-ray of a C2/2 ice-cone type fracture. (C) Anatomical reduction is achieved by elevating the head fragments with a bone hook. An autologous or allogenic bone graft is interposed between the fragments and fixed with cancellous bone screws.
because with adequate operation management, the incidence of avascular necrosis is lower than in more displaced four-part fractures. In elderly patients with osteoporotic bone, stability is more easily achieved by impaction of the humeral head leaving the remaining periosteal connections intact. Furthermore the displaced tuberosities may be pulled distally with non-absorbable sutures and secured to the shaft or to the screw heads, because the main fragment is stabilized by titanium cortical or cancellous screws. Titanium screws are preferable because they do not interfere with M R I which is used to monitor the head necrosis. With this treatment, enough stability is achieved to allow functional after-treatment, however a limited range of motion is to be expected. In C2/2 fractures, the so called 'ice-cone' fractures, joint incongruency is usually not acceptable as the head is too low (Fig. 14 A,B). The disturbed joint mechanics may lead to osteoarthritis, malposition of the tuberosities, malfunction and consequent impingement. Through a delto-pectoral approach special care should be taken again not to denude bone fragments. Dissection should
be minimized to avoid damage to the remaining soft tissue attachments of the fracture fragments. If the tuberosities are not separated and a better orientation for reduction of the head fragment is necessary, the tuberosities can be separated by sharp dissection along the long biceps tendon. Reduction is then carried out by elevating the humeral head fragment. In young patients and sometimes in osteoporotic bone an autologous or allogenic bone graft is necessary to fill the defect and to maintain the head position? 3By elevating the humeral head with the bone hook or raspatory, reduction is achieved2 2,53Stabilization is achieved with cortical or cancellous screws through the lateral cortex sometimes through the tuberosity into the head. Additional fixation is necessary to bring down the tuberosities. This can be managed with tension band wiring or with absorbable sutures, which are secured to the shaft with a transverse cortical screw, or by means of a drill hole (Fig. 14C). Even if avascular necrosis of the head occurs function often remains good? 4 In fracture type C2/3 there is severe disruption of all fragments and there is no valgus impaction but
Treatment of proximal humeral fractures
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Fig. 15 (A) Fracturepattern of a 90-year-oldfit man. (B) Same patient afterhemiarthroplasty. lateral displacement, and thus soft tissue attachments medially are very unlikely. In younger patients it is worthwhile to consider careful reduction of the fragments with minimal osteosynthesis. If this goal cannot be achieved primary endoprosthetic replacement particulary in older patients should be carried out (Fig. 15).
Type C3fractures Type C3 fractures are the most severe fractures of the proximal humerus, where the fragments do not show any soft tissue attachments and are severely displaced, or there is additional dislocation of the anatomical head or head splitting factors. These fractures are comparable to Neer's four-part fractures and fracture-dislocation and the rate of avascular necrosis is 80-90%. 4oAccurate reduction and fixation of these fractures is reserved for the most experienced shoulder surgeons and is only justified in a young fit patient (Fig. 16). Most surgeons prefer primary hemiarthroplasty55-58 (Fig. 17). Head replacement should be carried out within 2 weeks of injury to gain a good functional outcome. Due to muscle atrophy, scarring of the soft tissue and possible adhesive capsulitis, the results of hemiarthroplasty after more than 4 weeks have proved to yield less satisfactory results?9 Exceptions of course are those patients where relatively stable conditions can be achieved after minimal osteosynthesis, allowing an acceptable passive range of motion during the first 3 weeks and a good active range of motion during the next 3-6 weeks. If secondary head necrosis later occurs in these active patients, an implanted head endoprosthesis can also give good functional results. Several salient features of prosthetic replacement in fracture situations should be emphasized. The stem must be cemented to ensure rotational stability and to
guarantee appropriate height of the stem. This is assessed by mobilizing the rotator cuff distal to the prosthetic head. Removal of fracture fragments should be kept to a minimum. For good rotator cuff function it is important to restore the appropriate musculo-tendinous tension and it is necessary to leave the prosthesis with its fins above the level of the resected bone. The tuberosities must be mobilized distally beyond the prosthesis to allow fixation to each other and to the shaft. Autogenous bone graft from the removed head fragment should be used to ensure union of the tuberosities to the shaft, because realpositioned tuberosities would cause loss of muscle function and loss of head depressing function with uprising of the humeral head and consequent impingement. An alternative to prosthetic replacement is resection of the humeral head, but results from such a procedure have not been good 6°,6I(Fig. 18). Absence of the head leaves the patient with a flat shoulder, short limb and a weak arm, and pain particularly in abduction and flexion. Furthermore resection of the head usually does not give satisfactory pain relief especially during the night. 62
SUMMARY
Treatment considerations should be based on the age, bone stock and lifestyle requirements of the patient and the surgeon's operative experience. Conservative management yields good results if there is no major displacement and angulation and if humeral head blood supply is not endangered. On the other hand one should not hesitate to consider open reduction and internal fixation if major joint incongruency or displacement of fracture fragment exists. Several methods of stabilization have been used in the past. Plate fixation in these fractures is a very demanding
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CurrentOrthopaedics
Fig. 16 (A) C2/3 fracturein a youngpatient. (B) Patient after minimalosteosynthesis.(C) Patient after bone healing. (D, E) Activerange of motion 4 months after injury. technique associated with multiple pitfalls, such as: (a) too proximal placement of the plate; (b) screw and plate loosening due to poor bone stock: (c) excessive denudation of the humerus to gain enough access to fit the plate; and (d) damage to the ascending branch of the ACA, with possible head necrosis. Technical errors associated with incorrect positioning of the plate may cause compression and devascularization. The Cloverleaf plate has advantages over the T-plate, because it can be more easily contoured to the surface of the bone and adjusted to the fragments. Our own results and those of other authors show that minimal osteosynthesis with careful exposure leads to a better functional outcome of severely displaced fractures. Through minimal use of implants it is possible to minimize the risk of further vascular damage even in cases
of four-part or C2 and C3 fractures. Plate osteosynthesis is mainly indicated in unstable fractures extending into the proximal shaft or with large fragments of the metaphyseal area. These fractures occur in relatively young patients after indirect trauma. The trend towards reconstruction of the humeral head by careful soft tissue handling and osteosynthesis shows encouraging results and has advantages over primary hemiarthroplasty in our and others' opinions. The long-term results of endoprosthetic replacement in three and four-part fractures are not satisfying but can be accepted as long as endoprosthetic replacement is reserved as a salvage procedure. It is appropriate in the more complex type C2/3 and C3 fractures and also in other C fractures in elderly patients with poor bone stock and limited goal expectations. Considering all
Treatment of proximal humeral fractures
Fig. 17
Fig. 18
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(A) 43-year-old man with a C3/3 fracture. (B) After hemiarthroplasty. (C, D) Functional outcome 5 months after operation.
Situation after head resection in a 75-year-old woman.
the technical details of prosthetic replacement, reasonable shoulder function and pain relief can be achieved in experienced hands even in the worst fracture situations. REFERENCES 1. Habermeyer P, Schweiberer L. Frakturen des proximalen Humerus. Orthop/ide 1989; 18:200-207 2. Schweiberer L, Betz A, Eitel F, Krueger P, Wilker D, Bilanz der konservativen und operativen Knochenbruchbehandlung Obere Extremit/it. Chirurg 1982; 54:226-233 3. Neer CS II. Shoulder Reconstruction. Saunders, Philadelphia. 1991
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