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Fracture-separation of the proximal humeral epiphysis
Fracture-Separation A STUDY
OF CASES SEEN
of the Proximal Epiphysis AT THE
PRESBYTERIAN
HOSPITAL
Humeral FROM
1929-1953
FREDERICK M. SMITH, M.D., New York, New York From the Fracture Service of tbe Presbyterian Hospital, and tbe Department of Ortbopaedic Surgery, College of Physicians and Surgeons, Columbia University, New York, New York.
and then spIitting off a variabIe-sized trianguIar-shaped fragment of the diaphysis, the same type of trianguIar diaphysea1 fragment as seen in epiphysea1 separations of the radius, Iower tibia or Iower femur. From a review of x-ray fiIms of these patients it becomes quickIy evident how difKcuIt it is to make a proper diagnosis, IargeIy because of troubIe in obtaining two-position views. The anteroposterior view in interna rotation (Figs. I and 2A) is readily obtainabIe, but to get a IateraI or anteroposterior view in externa1 rotation (Fig. 2B) is often impossibIe in the
HIS study of forty-three cases has been carefuIIy seIected to represent a very specific type of injury, i.e., fracture-separation of the proxima1 humera epiphysis. No injury to this epiphysis without visible x-ray evidence of separation is included in order to avoid confusion as to accuracy of the diagnosis. I have been unable to find-in the Iiterature a reaIIy adequate description of this injury accompanied with late x-ray foIIow-up and cIinica1 evaluation of the patients. OriginaIIy it seemed to us very important to obtain correction of the bad1y dispIaced proxima1 humera epiphyses, so much so that we made numerous attempts both bv cIosed and open reduction to effect anatoGic reduction and hoId this with interna fixation if necessary. This present study extends over a period of twenty-five years, from 1929 to 1953. The proxima1 extremity of the humerus develops from three centers of ossification, one for the head and one for each tuberosity. These unite when a person is approximately seven years of age ant1 form a cap-Iike bony mass which rests upon the conicaI-shaped upper end of the shaft (diaphysis). On x-ray examination with the humerus internaIIy rotated the epiph>-sea1 line appears to cross in a transverse direction ; with the humerus in external rotation the inn& half of the epiphysea1 Iine runs paraIIe1 to the anatomic neck from its media1 border to the center, and then courses downward and IateraIward to just beIow the greater tuberosity. Ossification becomes complete at about a person’s eighteenth to twentieth year. The common fracture-separation of the proximal humeral epiphysis is with the fracture Iine extending from the IateraI side mediaIIy
T
FIG. I. October 24, 1939. An anteroposterior view of the upper humerus in a five year old girI showing sIight anguIation of the shaft upon the epiphysis with a trianguIar diaphyseal fragment remaining attached to the epiphysis. The child was treated using sling and swathe for two weeks and made an exceIIent recovery without deformity.
627
American
Journal
of Surgery.
Volume
pr,
April,
IOjO
Smith
FIG. zA. Patient was a sixteen year oId boy. Anteroposterior view; arm in internal rotation showing miId deformity.
FIG. zB. Same patient The arm is in externa1 rotation and more marked deformity may be noted between the diaphysis and the epiphysis. This child was treated using sling and swathe for eight days and made an uneventfu1 recovery; however, there was a 2.0 cm. shortening of the humerus.
early stages because of pain on positioning the patient’s arm. An oblique or transthoracic view therefore must be made if the straight anteroposterior view f&Is to reveaI displacement or anguIation. (Figs. 3 and. 6B.) The common dispIacement of the dista1 fragment is in an upward, forward and inward direction due to the coracobrachiaIis and biceps muscIe puI1, whereas the proxima1 fragment rotates outward and forward. In severa of our cases the upper end of the diaphysis has been shown projecting into the deItoid muscIe; in one this end was originaIIy caught in the deep surface of the skin, a11 but making this an open (compound) fracture. In some cases the Iower fragment is shifted mediaIIy. OccasionaIIy the fracture Iine runs the entire Iength of the epiphysea1 Iine between cartiIage pIate and diaphysis without breaking off the trianguIar fragment usuaIIy seen. (Fig. 4.) The common type of dispIacement with head rotated outward and the shaft riding upward and inward is caIIed the adduction type by most authors who describe a type, but it wouId seem to me to represent more cIoseIy the true varus type of fracture seen so commonIy in femora1 necks. The periosteum covering the upper diaphysis splits IongitudinaIIy to permit escape of this fragment and is dispIaced mediaIIy with the epiphysea1 (head) fragment. (Fig. 3.) In
chiIdren the periosteum is extremeIy tough; for this reason it often tightens and cIoses under the extruded shaft end on attempts to reduce the fracture and thus renders cIosed reduction diffIcuIt or impossibIe. If reduction is not achieved, new bone is then formed within the periosteum in the trianguIar space formed by the dispIaced epiphysis, the shaft and the periosteum itseIf. A bowing of the head and upper shaft thus resuIts in the fn-st few months of heaIing; however, with time, growth and physica activity this bowing becomes partiaIIy corrected and the originaIIy dispIaced shaft becomes absorbed. (Fig. 8A to E.) AIthougfl we have known this for years, it was Aitkenl who first recorded this fact in 1936. In genera1 most authors believe that where there is IittIe or no displacement there need be no reduction. The patient’s arm is kept quiet in a sIing and swathe or VeIpeau dressing for two weeks; progressive exercises and activity are then started. Regarding moderate dispIacement or more, there are many suggestions in the Iiterature as to the necessity for anatomic reduction, how to accompIish this and how to immobilize the arm after reduction. Key and ConweIP in their
628
Fracture-Separation
of Proximal
Humeral
Epiphysis
FIG. 4. P:ttient was :S liftwn year old boy. S-IW,V film shows an example of complrtc separation of thr proximal humeral epiphysis without any trianguktr fragment remaining attached to the epiphysis. The patient was treated using sling and swathe for elevrn days; howwcr, 3 cm. of shortening developed although full functi
FIG. 3. This patient was a six year old girl. A tangential view of the upper humeral cpiphysis showing slight separation which did not show in the regular antrroposterior view. The chiId ~vas treated using sling and swathe for eleven days and made an cvccllcnt recovery without deformit:.
F --
state that their routine treatment is reduction by manipulation folIowed with application of a hanging cast. As ahernate methods of treatment they suggest manipulative reduction followed with immobilization with the arm elevated 60 to 90 degrees and either in forward flexion or external rotation. On the same page they state that “If satisfactory reduction cannot be accompIished and if the fragments are not impacted, the lesion is best treated with recumbency and IateraI Also on the same page they say traction.” that if impaction cannot be broken up, if it is impossible to secure approximate anatomic reduction or if the fragments have united with deformity, open reduction is indicated. They also state that they are incIined to perform open reduction in chiIdren for this Iesion more frequentIy than for fractures in the same region in aduIts because they believe “It is important that anatomic reduction be secured.” After open reduction they immobiIize
textbook
EDC
FIG. 5. This semi-diagrammatic sketch of the upper humerus showing a fracture separation of the proximal epiphysis reveaIs: A, the denuded upper end of the shaft which has become extruded through a tear in the periosteum at (B); C, the periosteum on the inner side, stripped away from the shaft; D, the triangular fragment of diaphysis remaining attached to the epiphysis; E, the epiphyseai plate; F, the articular head of the humerus. Compare this sketch with Figure 8A, C. I> and E.
629
Smith the arm in a VeIpeau dressing or with Kirschner wires passed through the skin, humera head and into the shaft. At the other extreme is Blount,3 who states, “The greatest faIlacy is to think that accurate reduction of an epiphysea1 fracture at the proxima1 end of the humerus is important enough to require open reduction.” He says this can be reduced usuaIIy (if seen earIy) by traction and hanging cast, but occasionally it is diffIcuIt to reduce it and maintain reduction unless the arm is pIaced over the head in the pivota position and fixed there in a Iight pIaster spica for four to five weeks. Stewart and HundIey13 mention the injury to say that the adduction type is the most common seen in the upper humerus in chiIdren, that it must be reduced accurateIy and that the biceps tendon is often interposed between the fragments. The authors believe open reduction is necessary if manipuIation faiIs. They do not state how much dispIacement makes manipuIation necessary or how accurate open reduction and interna fixation must be. Their one iIIustration with a five-week foIIow-up shows far from perfect reaIignment and not enough eIapsed time to show if this might have been corrected by growth or deveIoped a growth disturbance. ANALYSIS
Our forty-three cases have been divided into four groups according to the degree of dispIacement seen on x-ray fiIms, i.e., 1 pIus to 4 pIus. This cIassification must, of course, be rather arbitrary due to inabiIity to catch the humerus aIways in the same amount of rotation which in itseIf may aIter the apparent displacement. The study therefore can be divided into sixteen cases with I pIus dispIacement, ten with z PIUS, six with 3 plus, and eIeven with 4 plus dispIacement. The sex and age incidence is as foIIows: maIes to femaIes 3 : I; maIes averaged thirteen years of age and femaIes averaged eIeven years of age. The right side was invoIved seventeen times, the left side twenty-six times. The etioIogy consisted of three main groups: (I) faIIs (in generaI), (2) sports (footbaI1, wrestIing, etc.), and (3) traffic accidents. Twenty-eight patients stated definiteIy on admission that they had faIIen 071 the arm or shoulder or had been hit there; this cause differs from the usua1 given textbook 630
etioIogy of a faI1 on the outstretched hand. The height of the faIIs (where stated) ranged from IO to 13 feet, and four other patients feI1 from trees of unstated height. As for age incidence, our youngest patient was five years oId and the oIdest was seventeen years of age. Eight patients were in the age group of five to nine years, whereas thirty-five patients were in the age group of ten to seventeen years. The injury therefore occurs chiefly in oIder chiIdren who are prone to undertake the rougher types of sports or who in genera1 faI1 from greater heights than those sustaining one of the more common wrist or eIbow fractures. ASSOCIATED
LESIONS
Associated Iesions are uncommon and in this group there were onIy three in which there was any significance from the standpoint of treatment or eventua1 outcome. One patient, J. G., a six year oId boy, sustained an injury in traffic. This boy had a fracture of the shaft of the humerus which was pIated, but the epiphysis with 2 pIus dispIacement was treated with cIosed reduction and pIaster; he also had a fracture of the jaw and paraIysis of the radia1 nerve. This boy remained in the hospita1 two and a half months because of his associated Iesions. The second case (P. F., a ten year oId boy), was an oId “polio” case with fIai1 shouIder joint previously fused for stabiiization and with permanent shortening; a spica was used for two months to get bony union and restiffening of the shouIder. The third patient (J. F., a tweIve year oId boy) had an extensive, severe poison ivy rash covering his entire shouIder; this rash precIuded open reduction. (See case history of this patient.) TREATMENT
Twenty-four patients were treated with ambuIatory measures, ten additiona with hospita1 admission and conservative measures, and nine with hospita1 admission, conservative measures and open reduction. Conservative treatment consisted of attempted reduction under anesthesia in twenty-two patients; traction and suspension by means of Kirschner wire with the arm heId over the body in fourteen patients; and pIaster spIints or casts in sixteen patients; or by sIing and swathe onIy. Exercises in the non-operative cases were
Fracture-Separation
of Proximal
HumeraI
Epiphysis
SC
6B
6A
OA, 13 and C. Patient was a fourteen year old boy. A, the original anteroposterior x-ray taken on the day of . . . . _y. Thrrc does not appear to be any deformity in this view. The fracture was missed clinically as well as by s-ray and the boy was sent home with his arm in a sIing. He returned the foIiowing day. B, an x-ray was taken in the transthoracic view showing the position of the humcral head and the shaft, and marked displacement at the epiphyseal line. lie was operated upon the same day; open reduction was performed and the shaft was fastened to the tri;lnguI:lr fragmrnt with two screws. The screws were too short and fixation was lost. C, an anteroposterior view in external rotation taken five weeks after the origina operation shows the fracture healing with recurrent deformity tollc,\cing loss of fiu:rtion.
6D
6E
FIG. 6D and E. Same patient. D, a similar view, shows the same humerus seventeen months after the original injury. Note the correction of the deformity. Also note that the screws are projecting from the shaft. It would seem at first that these screws had worked themseIves Ioose; however, on studying the x-ray fiIms more carefuIIy it is seen that the origina upper end of the shaft which had been dispIaced, and in which the screws were placed, has become absorbed beneath the heads of the screws and the space between the periosteum and shaft has fiIIed in with new bone. These screws became prominent beneath the deItoid, caused irritation and formed an adventitious bursa, giving discomfort and crepitation on motion. They were therefore removed. E, the same humerus two weeks after removal of the screws. This patient has fuI1 return of function ancl no visibIe deformity but there is a shortening of I .$ cm. in the humerus.
631
Smith
FIG. 7A. Patient was an eight year old boy. Anteroposterior view of the original fracture with marked comminution of the upper shaft and diaphyseal fragment attached to the epiphysis. This boy was treated with manipulation, traction and suspension; subsequentIy a sling was used. No better position could be
FIG. 7B. Same patient. X-ray shows the same humerus twenty-two months after the original injury. Note the marked correction of the original deformity.
suture of periosteum after open reduction. Two patients were operated upon as earIy as one day after injury, the other patients mostIy at three to five days, and one as Iate as tweIve days after injury. Four patients were kept in Kirschner wire traction-suspension after operation; three were put in pIaster and two were given a sIing and body swathe. Loss of fixation or reduction occurred in four of the nine patients operated upon; two of these four had no internal fixation empIoyed, and two had internal screw fixation (the screws being too short). (Fig. 6A to E.) Four patients subsequentIy had secondary operations for removal of the screws.
obtained from the x-ray standpoint. started at 12 plus days on the average, 19 days in the operative cases.
and at
OPERATION
Open reduction was performed in nine patients mainIy because attempted closed reduction was unsatisfactory in eight of these. The outstanding pathoIogic conditions noted at operation were: (I) marked soft tissue dam(2) “buttonage and periostea1 stripping; hoIing” of the shaft through periosteum necessitating spIitting of the Iatter to obtain reduction; (3) biceps tendon caught. between fragments in three cases; and (4) portions of deItoid and SubscapuIaris muscIe interposed between fragments. In three cases no pathoIogic condition was described. Interna fixation (in the nine operative cases) consisted of the use of one to three screws in six cases (and in one, an additional wire Ioop). In attempting to obtain interna fixation with screws, these were passed from the upper end of the shaft mediaIIy into the trianguIar diaphyseal fragment attached to the epiphysis. No attempt was made in any case to pass the screw across or through the epiphysea1 pIate. Chromic sutures were used in one case. In two cases no interna fixation was empIoyed except
RESULTS
The resuIts in genera1 have a11 been exceIIent from the standpoint of function and use. As for the anatomic result, two main deformities have been noted, namely, (I) sIight angulation or prominence of the upper humera shaft and (2) measurabIe shortening. AIthough actua1 measurements were not recorded in a11 on foIIow-up visits, ten patients of the forty-three had definite shortening. Two of these patients had had operation and the shortening was 7.4 and 1.3 cm., respectiveIy; the remaining eight patients showed shortening varying from 1.0 to 3.0 cm. Therefore, some shortening resuIted in at Ieast 20 per cent of a11 the pa632
Fracture-Separation
of Proximal
HumeraI
Epiphysis
tients. The patient with the greatest shortening was the youngest patient operated upon (age seven years). Of’ the severely dispIaced 4 pIus fractures not operated upon, two were in a five and a half and an eight year old child, both with marked comminution (7A and B); a third was in the previously mentioned tweIve year old boy with the parson ivy rash which prevented operation. This latter patient is so interesting from the standpoint of his history, lack of reduction, correction of his earIy deformity and recovery of function, that I believe his case history should be incIuded. J. F., a tweIve year old schoolboy, feI1 15 feet from a tree on September 2, 1943. This accident deformity, pain, swelling resulted in immediate and disability in his Ieft arm and shoulder. In another city two forceful attempts at cIosed manipulative reduction were made after x-ray examination on the day of injury and three days Iater, both without success. The parents were informed that a tendon lying between the fragments prevented reduction and that an open reduction must be performed. He was therefore referred to us on September 6th and was admitted to the Presbyterian HospitaI. When the boy was examined, the Ieft arm and shoulder were supported in a sIing and body swathe. The left humerus was about 2.5 cm. short
FIG;. 8A. Patient
.I. F., i, twelve year old boy. ,X-ray of view that could be obtained upon
best antcropostcrior
admission.
deformity. The situation and why operation almost certainly insured disaster were explained carefulIy to the parents, and with much reluctance they agreed to the conservative program advised. The patient was then put to bed and his arm was suspended at his side in 60 degrees of abduction with the humerus in neutral rotation. Low intensity heat was applied and he was encouraged to practice eIbow, wrist and finger exercises. The swelling at the shoulder sIowIy decreased. Two weeks after admission it was possibIe to test rotation of the humerus with paIpation and without pain, and it was found that the head of the humerus rotated with the shaft. With bony union thus becoming evident, the suspension in abduction was discontinued. The arm was placed in a sling and the patient was made ambuIatory and encouraged to practice pendulum exercises every two hours. The rash had now cIeared and x-ray examination revealed beginning union of the fracture. He was discharged from the hospita1 sixteen days after admission (September 23rd) and folIowed up in the office. Four weeks after admission (September 30th) it was possibIe for the boy to abduct the left arm to go degrees without pain. Three weeks later he couId actively abduct it to 160 degrees; interna rotation of the humerus was possibIe to 70 degrees and external rotation was 60 degrees. The upper end of the humera shaft showed a visible and palpable prominence. At this time (October 22nd) it was possibIe to get an x-ray fiIm with the humerus in some external rotation. (Fig. SB.) By the end of I I th) the three and a quarter months (December patient was pIaying basketbalI and using the
and the upper end of the shaft was displaced forward and upward. There was marked swelling and ecchymosis over the entire shoulder region, at motion upper arm and chest. Any attempt caused severe pain. The skin of this entire area was covered with a rash, bullae and scratch marks. This boy had had a rather extensive poison ivy rash in this region before he was injured. The radial pulse was good and the axiilary, radial, median and ulnar nerves showed no impairment in function or sensation. The patient had no other symptoms or signs pertinent to his injury. X-ray examination on September 7th showed a fracture-separation of the proximal humeral epiphysis with marked displacement of the fragments. (Fig. 8A.) However desirable it seemed to obtain reduction, it was obvious that open reduction (for which the boy had been referred) should not be undertaken in view of the extensive skin rash and the great risk of wound infection, with possible subsequent proIonged suppuration, non-union, growth disturbance or other deformity. It was therefore thought best and safest to treat this particuIar fracture in this patient by a11 possibIe conservative means and to trust in “nature” to correct the
633
Smith
FIG. 8B. Patient J. F. FiIm shows same humerus seven weeks after injury, at which time it was possibIe to obtain a view with the humerus in external rotation. Note the marked deformity and bony healing.
FIG. 8C. Patient J. F. Film shows the humerus three months after injury. Note beginning resorption of the prominent upper end of the shaft. (Because of incompIete externa1 rotation, this view is not entirely comparabIe to the previous view.)
FIG. 8D. Patient J. F. Anteroposterior view six months after the injury. This discloses marked absorption of the upper end of the diaphysis.
FIG. 8E. Patient J. F. Same humerus thirteen months foIlowing the initia1 injury Note the marked correction of the deformity and the sIight residua1 bowing of the upper humera shaft.
horizonta1
This patient subsequentIy pIayed coIIege football and tennis, and enjoyed swimming without any discomfort or handicap whatsoever. When the patient was*Iast examined eIeven years and three months after injury (December 4, Ig54), a 2 cm.
bar in the schoo1 gymnasium. (Fig. 8C.) after injury (March 4, 1944) he was enjoying fuII use of the arm and shouIder without pain. His total abduction was Iimited to 165 degrees. The projecting end of the upper shaft was no longer prominent. (Fig. 8D.) One year foIIowing injury (September 27, 1944) the onIy cIinica1
shortening of the Ieft humerus was found by measmotion urement, but there was no Ioss in strength,
deformity to be detected was slight anterior convex bowing of the upper humera shaft. (Fig. 8E.)
range or function and he carried on ful1 physica activity without compIaint or pain.
By six months
634
Fracture-Separation
of Proximal
CONCLUSIONS I. The results (functional and anatomic) have been so excellent in the mild to moderately displaced cases (twenty-six) that the recommended treatment need be no more than rest, in a sling and swathe for two weeks, followed with early active exercises and use. Two patients only in this group showed shortening of more than 1.0 cm. These were the two patients whose epiphyses were displaced from an intact diaphysis without a triangular fragment remaining attached. 2. The results in the moderate to severeIy displaced cases (seventeen) were excelIent from the standpoint of function. Of this seventeen, five showed shortening (one of 7.5 cm. in a seven year old girl who underwent surgery). Three others showed mild anterior prominence or bowing of the upper humera shaft. 3. As for operative treatment, it would seem from our findings that Iittle or nothing has been accomplished when we compare reductions or those patients successfully operated upon with those receiving no reduction or those operated upon and in whom loss of reduction and internal fixation resuItec1. One might we11 pose the question: In patients under fifteen years of age with marked displacement should we keep them comfortable and let “nature” correct the deformity or should we try to find a more satisfactory tvpe of internal fixation such as two or three E;irschner wire implants pIaced at different angles? This might be reserved for the older patients jtweIve to seventeen years of age) in whom attempted cIosed reduction or tiaction and suspension has failed and in whom interposition of the biceps tendon is strongly suspected. It might perhaps be better to treat the markedly displaced fractures simply by attempted closed reduction and foIlow this by suspension of the arm in 70 to 80 degrees of abduction for two weeks. Early pendulum exercises would be started after this. From our study of these patients, their x-ray fihns and their individual long-term follow-up observations, severa points become very obvious and shouId be emphasized: (I) The injury appears on its face far more serious than it actualIy is. (2) Bony healing occurs rapidIy. (3) EssentiaIIy full recovery of shoulder and arm function results. (4) By subsequent growth
HumeraI
Epiphysis
the greater part of the original angular deformity corrects itself. This fortunately is true regardless of the fracture being left uncorrected, or after loss of correction foIIowing closed or open reduction. Shortening occurs in approximately 20 per cent of these humeri regardless of their treatment. SUMMARI-
In our hands the foregoing examples demonstrate all too cIearIy how overconscientious we have been in handling this “much overtreated fracture.” In the future I hope we may be able to adopt a routine course of treatment bordering on a laissez-faire policy, and I suspect the next generation of fracture surgeons will find the Iate follow-up resuIts quite as good or better than those in our study. REl=ERENCES
2.
3. 4.
5.
6.
8. 9. 0.
I I. 12.
13.
r4.
AITKEN, A. P. End resuIts of fractures of the proxima1 humera epiphysis. J. Bone @ Joint Surg., 18: 1036, 1936. BANCROFT, F. W. and MARBLE, H. C. Surgery of the Motor SkeIetaI System, 2nd ed. Philadelphia, 1951. J. B. Lippincott Co. BLOC.NT, W. P. Fractures in Children. Baltimore, 1954. Williams & WiIkins Co. BBHLER, L. The Treatment of Fractures, 4th English ed. TransIated by Hey-Groves, E. W. Baltimore, 1935. Wm. Wood 8r Co. BONNIN, J. G. A Complete Outline of Fractures. London, I 94 I. William Heineman (Medical Books Ltd.). BOURDILLON, J. F. Fracture-separation of the proxima1 epiphysis of the humerus. J. &me Ed Joint .%g.: jz-IB: 35, 1950. KEY. J. A. and CONWELL. H. E. The Rlanaeement of’Fractures, DisIocatibns and Sprains, $h ed. St. Louis, 1951. C. V. Mosby Co. LORENZO, F. T. Osteosynthesis with Blount’s staples in fractures of the proxima1 end of the humerus. J. Bone 4~ Joint Surg., 37-A: 4q. 1955. MACNUSON, P. B. and STACK, J. K. Fractures, 5th ed. PhiIadeIphia, 1949. J. B. Lippincott Co. SCUDDER,C. L. The Treatment of Fractures, I I th ed. Philadelphia, 1938. W. B. Saunders Co. SPEED. K. Fractures and DisIocations. dth ed. PhiIadeIphia, 1942. Lea ti Febiger. ’ ’ STEINDLER, A. The Traumatic Deformities and Disabilities of the Upper Extremity. SpringfieId, Illinois, 1946. Charles C Thomas. STEWART, M. J. and HUNDLEY, J. M. Fractures of the humerus (a comparative study in methods of treatment). J. Bone @Y Joint Surg., 37-A: 681, ‘955. STIMSON, B. B. A ManuaI of Fractures and Dislocations, 2nd ed. PhiIadeIphia, 1947. Lea & Febiger.
OF CASES SEEN
of the Proximal Epiphysis AT THE
PRESBYTERIAN
HOSPITAL
Humeral FROM
1929-1953
FREDERICK M. SMITH, M.D., New York, New York From the Fracture Service of tbe Presbyterian Hospital, and tbe Department of Ortbopaedic Surgery, College of Physicians and Surgeons, Columbia University, New York, New York.
and then spIitting off a variabIe-sized trianguIar-shaped fragment of the diaphysis, the same type of trianguIar diaphysea1 fragment as seen in epiphysea1 separations of the radius, Iower tibia or Iower femur. From a review of x-ray fiIms of these patients it becomes quickIy evident how difKcuIt it is to make a proper diagnosis, IargeIy because of troubIe in obtaining two-position views. The anteroposterior view in interna rotation (Figs. I and 2A) is readily obtainabIe, but to get a IateraI or anteroposterior view in externa1 rotation (Fig. 2B) is often impossibIe in the
HIS study of forty-three cases has been carefuIIy seIected to represent a very specific type of injury, i.e., fracture-separation of the proxima1 humera epiphysis. No injury to this epiphysis without visible x-ray evidence of separation is included in order to avoid confusion as to accuracy of the diagnosis. I have been unable to find-in the Iiterature a reaIIy adequate description of this injury accompanied with late x-ray foIIow-up and cIinica1 evaluation of the patients. OriginaIIy it seemed to us very important to obtain correction of the bad1y dispIaced proxima1 humera epiphyses, so much so that we made numerous attempts both bv cIosed and open reduction to effect anatoGic reduction and hoId this with interna fixation if necessary. This present study extends over a period of twenty-five years, from 1929 to 1953. The proxima1 extremity of the humerus develops from three centers of ossification, one for the head and one for each tuberosity. These unite when a person is approximately seven years of age ant1 form a cap-Iike bony mass which rests upon the conicaI-shaped upper end of the shaft (diaphysis). On x-ray examination with the humerus internaIIy rotated the epiph>-sea1 line appears to cross in a transverse direction ; with the humerus in external rotation the inn& half of the epiphysea1 Iine runs paraIIe1 to the anatomic neck from its media1 border to the center, and then courses downward and IateraIward to just beIow the greater tuberosity. Ossification becomes complete at about a person’s eighteenth to twentieth year. The common fracture-separation of the proximal humeral epiphysis is with the fracture Iine extending from the IateraI side mediaIIy
T
FIG. I. October 24, 1939. An anteroposterior view of the upper humerus in a five year old girI showing sIight anguIation of the shaft upon the epiphysis with a trianguIar diaphyseal fragment remaining attached to the epiphysis. The child was treated using sling and swathe for two weeks and made an exceIIent recovery without deformity.
627
American
Journal
of Surgery.
Volume
pr,
April,
IOjO
Smith
FIG. zA. Patient was a sixteen year oId boy. Anteroposterior view; arm in internal rotation showing miId deformity.
FIG. zB. Same patient The arm is in externa1 rotation and more marked deformity may be noted between the diaphysis and the epiphysis. This child was treated using sling and swathe for eight days and made an uneventfu1 recovery; however, there was a 2.0 cm. shortening of the humerus.
early stages because of pain on positioning the patient’s arm. An oblique or transthoracic view therefore must be made if the straight anteroposterior view f&Is to reveaI displacement or anguIation. (Figs. 3 and. 6B.) The common dispIacement of the dista1 fragment is in an upward, forward and inward direction due to the coracobrachiaIis and biceps muscIe puI1, whereas the proxima1 fragment rotates outward and forward. In severa of our cases the upper end of the diaphysis has been shown projecting into the deItoid muscIe; in one this end was originaIIy caught in the deep surface of the skin, a11 but making this an open (compound) fracture. In some cases the Iower fragment is shifted mediaIIy. OccasionaIIy the fracture Iine runs the entire Iength of the epiphysea1 Iine between cartiIage pIate and diaphysis without breaking off the trianguIar fragment usuaIIy seen. (Fig. 4.) The common type of dispIacement with head rotated outward and the shaft riding upward and inward is caIIed the adduction type by most authors who describe a type, but it wouId seem to me to represent more cIoseIy the true varus type of fracture seen so commonIy in femora1 necks. The periosteum covering the upper diaphysis splits IongitudinaIIy to permit escape of this fragment and is dispIaced mediaIIy with the epiphysea1 (head) fragment. (Fig. 3.) In
chiIdren the periosteum is extremeIy tough; for this reason it often tightens and cIoses under the extruded shaft end on attempts to reduce the fracture and thus renders cIosed reduction diffIcuIt or impossibIe. If reduction is not achieved, new bone is then formed within the periosteum in the trianguIar space formed by the dispIaced epiphysis, the shaft and the periosteum itseIf. A bowing of the head and upper shaft thus resuIts in the fn-st few months of heaIing; however, with time, growth and physica activity this bowing becomes partiaIIy corrected and the originaIIy dispIaced shaft becomes absorbed. (Fig. 8A to E.) AIthougfl we have known this for years, it was Aitkenl who first recorded this fact in 1936. In genera1 most authors believe that where there is IittIe or no displacement there need be no reduction. The patient’s arm is kept quiet in a sIing and swathe or VeIpeau dressing for two weeks; progressive exercises and activity are then started. Regarding moderate dispIacement or more, there are many suggestions in the Iiterature as to the necessity for anatomic reduction, how to accompIish this and how to immobilize the arm after reduction. Key and ConweIP in their
628
Fracture-Separation
of Proximal
Humeral
Epiphysis
FIG. 4. P:ttient was :S liftwn year old boy. S-IW,V film shows an example of complrtc separation of thr proximal humeral epiphysis without any trianguktr fragment remaining attached to the epiphysis. The patient was treated using sling and swathe for elevrn days; howwcr, 3 cm. of shortening developed although full functi
FIG. 3. This patient was a six year old girl. A tangential view of the upper humeral cpiphysis showing slight separation which did not show in the regular antrroposterior view. The chiId ~vas treated using sling and swathe for eleven days and made an cvccllcnt recovery without deformit:.
F --
state that their routine treatment is reduction by manipulation folIowed with application of a hanging cast. As ahernate methods of treatment they suggest manipulative reduction followed with immobilization with the arm elevated 60 to 90 degrees and either in forward flexion or external rotation. On the same page they state that “If satisfactory reduction cannot be accompIished and if the fragments are not impacted, the lesion is best treated with recumbency and IateraI Also on the same page they say traction.” that if impaction cannot be broken up, if it is impossible to secure approximate anatomic reduction or if the fragments have united with deformity, open reduction is indicated. They also state that they are incIined to perform open reduction in chiIdren for this Iesion more frequentIy than for fractures in the same region in aduIts because they believe “It is important that anatomic reduction be secured.” After open reduction they immobiIize
textbook
EDC
FIG. 5. This semi-diagrammatic sketch of the upper humerus showing a fracture separation of the proximal epiphysis reveaIs: A, the denuded upper end of the shaft which has become extruded through a tear in the periosteum at (B); C, the periosteum on the inner side, stripped away from the shaft; D, the triangular fragment of diaphysis remaining attached to the epiphysis; E, the epiphyseai plate; F, the articular head of the humerus. Compare this sketch with Figure 8A, C. I> and E.
629
Smith the arm in a VeIpeau dressing or with Kirschner wires passed through the skin, humera head and into the shaft. At the other extreme is Blount,3 who states, “The greatest faIlacy is to think that accurate reduction of an epiphysea1 fracture at the proxima1 end of the humerus is important enough to require open reduction.” He says this can be reduced usuaIIy (if seen earIy) by traction and hanging cast, but occasionally it is diffIcuIt to reduce it and maintain reduction unless the arm is pIaced over the head in the pivota position and fixed there in a Iight pIaster spica for four to five weeks. Stewart and HundIey13 mention the injury to say that the adduction type is the most common seen in the upper humerus in chiIdren, that it must be reduced accurateIy and that the biceps tendon is often interposed between the fragments. The authors believe open reduction is necessary if manipuIation faiIs. They do not state how much dispIacement makes manipuIation necessary or how accurate open reduction and interna fixation must be. Their one iIIustration with a five-week foIIow-up shows far from perfect reaIignment and not enough eIapsed time to show if this might have been corrected by growth or deveIoped a growth disturbance. ANALYSIS
Our forty-three cases have been divided into four groups according to the degree of dispIacement seen on x-ray fiIms, i.e., 1 pIus to 4 pIus. This cIassification must, of course, be rather arbitrary due to inabiIity to catch the humerus aIways in the same amount of rotation which in itseIf may aIter the apparent displacement. The study therefore can be divided into sixteen cases with I pIus dispIacement, ten with z PIUS, six with 3 plus, and eIeven with 4 plus dispIacement. The sex and age incidence is as foIIows: maIes to femaIes 3 : I; maIes averaged thirteen years of age and femaIes averaged eIeven years of age. The right side was invoIved seventeen times, the left side twenty-six times. The etioIogy consisted of three main groups: (I) faIIs (in generaI), (2) sports (footbaI1, wrestIing, etc.), and (3) traffic accidents. Twenty-eight patients stated definiteIy on admission that they had faIIen 071 the arm or shoulder or had been hit there; this cause differs from the usua1 given textbook 630
etioIogy of a faI1 on the outstretched hand. The height of the faIIs (where stated) ranged from IO to 13 feet, and four other patients feI1 from trees of unstated height. As for age incidence, our youngest patient was five years oId and the oIdest was seventeen years of age. Eight patients were in the age group of five to nine years, whereas thirty-five patients were in the age group of ten to seventeen years. The injury therefore occurs chiefly in oIder chiIdren who are prone to undertake the rougher types of sports or who in genera1 faI1 from greater heights than those sustaining one of the more common wrist or eIbow fractures. ASSOCIATED
LESIONS
Associated Iesions are uncommon and in this group there were onIy three in which there was any significance from the standpoint of treatment or eventua1 outcome. One patient, J. G., a six year oId boy, sustained an injury in traffic. This boy had a fracture of the shaft of the humerus which was pIated, but the epiphysis with 2 pIus dispIacement was treated with cIosed reduction and pIaster; he also had a fracture of the jaw and paraIysis of the radia1 nerve. This boy remained in the hospita1 two and a half months because of his associated Iesions. The second case (P. F., a ten year oId boy), was an oId “polio” case with fIai1 shouIder joint previously fused for stabiiization and with permanent shortening; a spica was used for two months to get bony union and restiffening of the shouIder. The third patient (J. F., a tweIve year oId boy) had an extensive, severe poison ivy rash covering his entire shouIder; this rash precIuded open reduction. (See case history of this patient.) TREATMENT
Twenty-four patients were treated with ambuIatory measures, ten additiona with hospita1 admission and conservative measures, and nine with hospita1 admission, conservative measures and open reduction. Conservative treatment consisted of attempted reduction under anesthesia in twenty-two patients; traction and suspension by means of Kirschner wire with the arm heId over the body in fourteen patients; and pIaster spIints or casts in sixteen patients; or by sIing and swathe onIy. Exercises in the non-operative cases were
Fracture-Separation
of Proximal
HumeraI
Epiphysis
SC
6B
6A
OA, 13 and C. Patient was a fourteen year old boy. A, the original anteroposterior x-ray taken on the day of . . . . _y. Thrrc does not appear to be any deformity in this view. The fracture was missed clinically as well as by s-ray and the boy was sent home with his arm in a sIing. He returned the foIiowing day. B, an x-ray was taken in the transthoracic view showing the position of the humcral head and the shaft, and marked displacement at the epiphyseal line. lie was operated upon the same day; open reduction was performed and the shaft was fastened to the tri;lnguI:lr fragmrnt with two screws. The screws were too short and fixation was lost. C, an anteroposterior view in external rotation taken five weeks after the origina operation shows the fracture healing with recurrent deformity tollc,\cing loss of fiu:rtion.
6D
6E
FIG. 6D and E. Same patient. D, a similar view, shows the same humerus seventeen months after the original injury. Note the correction of the deformity. Also note that the screws are projecting from the shaft. It would seem at first that these screws had worked themseIves Ioose; however, on studying the x-ray fiIms more carefuIIy it is seen that the origina upper end of the shaft which had been dispIaced, and in which the screws were placed, has become absorbed beneath the heads of the screws and the space between the periosteum and shaft has fiIIed in with new bone. These screws became prominent beneath the deItoid, caused irritation and formed an adventitious bursa, giving discomfort and crepitation on motion. They were therefore removed. E, the same humerus two weeks after removal of the screws. This patient has fuI1 return of function ancl no visibIe deformity but there is a shortening of I .$ cm. in the humerus.
631
Smith
FIG. 7A. Patient was an eight year old boy. Anteroposterior view of the original fracture with marked comminution of the upper shaft and diaphyseal fragment attached to the epiphysis. This boy was treated with manipulation, traction and suspension; subsequentIy a sling was used. No better position could be
FIG. 7B. Same patient. X-ray shows the same humerus twenty-two months after the original injury. Note the marked correction of the original deformity.
suture of periosteum after open reduction. Two patients were operated upon as earIy as one day after injury, the other patients mostIy at three to five days, and one as Iate as tweIve days after injury. Four patients were kept in Kirschner wire traction-suspension after operation; three were put in pIaster and two were given a sIing and body swathe. Loss of fixation or reduction occurred in four of the nine patients operated upon; two of these four had no internal fixation empIoyed, and two had internal screw fixation (the screws being too short). (Fig. 6A to E.) Four patients subsequentIy had secondary operations for removal of the screws.
obtained from the x-ray standpoint. started at 12 plus days on the average, 19 days in the operative cases.
and at
OPERATION
Open reduction was performed in nine patients mainIy because attempted closed reduction was unsatisfactory in eight of these. The outstanding pathoIogic conditions noted at operation were: (I) marked soft tissue dam(2) “buttonage and periostea1 stripping; hoIing” of the shaft through periosteum necessitating spIitting of the Iatter to obtain reduction; (3) biceps tendon caught. between fragments in three cases; and (4) portions of deItoid and SubscapuIaris muscIe interposed between fragments. In three cases no pathoIogic condition was described. Interna fixation (in the nine operative cases) consisted of the use of one to three screws in six cases (and in one, an additional wire Ioop). In attempting to obtain interna fixation with screws, these were passed from the upper end of the shaft mediaIIy into the trianguIar diaphyseal fragment attached to the epiphysis. No attempt was made in any case to pass the screw across or through the epiphysea1 pIate. Chromic sutures were used in one case. In two cases no interna fixation was empIoyed except
RESULTS
The resuIts in genera1 have a11 been exceIIent from the standpoint of function and use. As for the anatomic result, two main deformities have been noted, namely, (I) sIight angulation or prominence of the upper humera shaft and (2) measurabIe shortening. AIthough actua1 measurements were not recorded in a11 on foIIow-up visits, ten patients of the forty-three had definite shortening. Two of these patients had had operation and the shortening was 7.4 and 1.3 cm., respectiveIy; the remaining eight patients showed shortening varying from 1.0 to 3.0 cm. Therefore, some shortening resuIted in at Ieast 20 per cent of a11 the pa632
Fracture-Separation
of Proximal
HumeraI
Epiphysis
tients. The patient with the greatest shortening was the youngest patient operated upon (age seven years). Of’ the severely dispIaced 4 pIus fractures not operated upon, two were in a five and a half and an eight year old child, both with marked comminution (7A and B); a third was in the previously mentioned tweIve year old boy with the parson ivy rash which prevented operation. This latter patient is so interesting from the standpoint of his history, lack of reduction, correction of his earIy deformity and recovery of function, that I believe his case history should be incIuded. J. F., a tweIve year old schoolboy, feI1 15 feet from a tree on September 2, 1943. This accident deformity, pain, swelling resulted in immediate and disability in his Ieft arm and shoulder. In another city two forceful attempts at cIosed manipulative reduction were made after x-ray examination on the day of injury and three days Iater, both without success. The parents were informed that a tendon lying between the fragments prevented reduction and that an open reduction must be performed. He was therefore referred to us on September 6th and was admitted to the Presbyterian HospitaI. When the boy was examined, the Ieft arm and shoulder were supported in a sIing and body swathe. The left humerus was about 2.5 cm. short
FIG;. 8A. Patient
.I. F., i, twelve year old boy. ,X-ray of view that could be obtained upon
best antcropostcrior
admission.
deformity. The situation and why operation almost certainly insured disaster were explained carefulIy to the parents, and with much reluctance they agreed to the conservative program advised. The patient was then put to bed and his arm was suspended at his side in 60 degrees of abduction with the humerus in neutral rotation. Low intensity heat was applied and he was encouraged to practice eIbow, wrist and finger exercises. The swelling at the shoulder sIowIy decreased. Two weeks after admission it was possibIe to test rotation of the humerus with paIpation and without pain, and it was found that the head of the humerus rotated with the shaft. With bony union thus becoming evident, the suspension in abduction was discontinued. The arm was placed in a sling and the patient was made ambuIatory and encouraged to practice pendulum exercises every two hours. The rash had now cIeared and x-ray examination revealed beginning union of the fracture. He was discharged from the hospita1 sixteen days after admission (September 23rd) and folIowed up in the office. Four weeks after admission (September 30th) it was possibIe for the boy to abduct the left arm to go degrees without pain. Three weeks later he couId actively abduct it to 160 degrees; interna rotation of the humerus was possibIe to 70 degrees and external rotation was 60 degrees. The upper end of the humera shaft showed a visible and palpable prominence. At this time (October 22nd) it was possibIe to get an x-ray fiIm with the humerus in some external rotation. (Fig. SB.) By the end of I I th) the three and a quarter months (December patient was pIaying basketbalI and using the
and the upper end of the shaft was displaced forward and upward. There was marked swelling and ecchymosis over the entire shoulder region, at motion upper arm and chest. Any attempt caused severe pain. The skin of this entire area was covered with a rash, bullae and scratch marks. This boy had had a rather extensive poison ivy rash in this region before he was injured. The radial pulse was good and the axiilary, radial, median and ulnar nerves showed no impairment in function or sensation. The patient had no other symptoms or signs pertinent to his injury. X-ray examination on September 7th showed a fracture-separation of the proximal humeral epiphysis with marked displacement of the fragments. (Fig. 8A.) However desirable it seemed to obtain reduction, it was obvious that open reduction (for which the boy had been referred) should not be undertaken in view of the extensive skin rash and the great risk of wound infection, with possible subsequent proIonged suppuration, non-union, growth disturbance or other deformity. It was therefore thought best and safest to treat this particuIar fracture in this patient by a11 possibIe conservative means and to trust in “nature” to correct the
633
Smith
FIG. 8B. Patient J. F. FiIm shows same humerus seven weeks after injury, at which time it was possibIe to obtain a view with the humerus in external rotation. Note the marked deformity and bony healing.
FIG. 8C. Patient J. F. Film shows the humerus three months after injury. Note beginning resorption of the prominent upper end of the shaft. (Because of incompIete externa1 rotation, this view is not entirely comparabIe to the previous view.)
FIG. 8D. Patient J. F. Anteroposterior view six months after the injury. This discloses marked absorption of the upper end of the diaphysis.
FIG. 8E. Patient J. F. Same humerus thirteen months foIlowing the initia1 injury Note the marked correction of the deformity and the sIight residua1 bowing of the upper humera shaft.
horizonta1
This patient subsequentIy pIayed coIIege football and tennis, and enjoyed swimming without any discomfort or handicap whatsoever. When the patient was*Iast examined eIeven years and three months after injury (December 4, Ig54), a 2 cm.
bar in the schoo1 gymnasium. (Fig. 8C.) after injury (March 4, 1944) he was enjoying fuII use of the arm and shouIder without pain. His total abduction was Iimited to 165 degrees. The projecting end of the upper shaft was no longer prominent. (Fig. 8D.) One year foIIowing injury (September 27, 1944) the onIy cIinica1
shortening of the Ieft humerus was found by measmotion urement, but there was no Ioss in strength,
deformity to be detected was slight anterior convex bowing of the upper humera shaft. (Fig. 8E.)
range or function and he carried on ful1 physica activity without compIaint or pain.
By six months
634
Fracture-Separation
of Proximal
CONCLUSIONS I. The results (functional and anatomic) have been so excellent in the mild to moderately displaced cases (twenty-six) that the recommended treatment need be no more than rest, in a sling and swathe for two weeks, followed with early active exercises and use. Two patients only in this group showed shortening of more than 1.0 cm. These were the two patients whose epiphyses were displaced from an intact diaphysis without a triangular fragment remaining attached. 2. The results in the moderate to severeIy displaced cases (seventeen) were excelIent from the standpoint of function. Of this seventeen, five showed shortening (one of 7.5 cm. in a seven year old girl who underwent surgery). Three others showed mild anterior prominence or bowing of the upper humera shaft. 3. As for operative treatment, it would seem from our findings that Iittle or nothing has been accomplished when we compare reductions or those patients successfully operated upon with those receiving no reduction or those operated upon and in whom loss of reduction and internal fixation resuItec1. One might we11 pose the question: In patients under fifteen years of age with marked displacement should we keep them comfortable and let “nature” correct the deformity or should we try to find a more satisfactory tvpe of internal fixation such as two or three E;irschner wire implants pIaced at different angles? This might be reserved for the older patients jtweIve to seventeen years of age) in whom attempted cIosed reduction or tiaction and suspension has failed and in whom interposition of the biceps tendon is strongly suspected. It might perhaps be better to treat the markedly displaced fractures simply by attempted closed reduction and foIlow this by suspension of the arm in 70 to 80 degrees of abduction for two weeks. Early pendulum exercises would be started after this. From our study of these patients, their x-ray fihns and their individual long-term follow-up observations, severa points become very obvious and shouId be emphasized: (I) The injury appears on its face far more serious than it actualIy is. (2) Bony healing occurs rapidIy. (3) EssentiaIIy full recovery of shoulder and arm function results. (4) By subsequent growth
HumeraI
Epiphysis
the greater part of the original angular deformity corrects itself. This fortunately is true regardless of the fracture being left uncorrected, or after loss of correction foIIowing closed or open reduction. Shortening occurs in approximately 20 per cent of these humeri regardless of their treatment. SUMMARI-
In our hands the foregoing examples demonstrate all too cIearIy how overconscientious we have been in handling this “much overtreated fracture.” In the future I hope we may be able to adopt a routine course of treatment bordering on a laissez-faire policy, and I suspect the next generation of fracture surgeons will find the Iate follow-up resuIts quite as good or better than those in our study. REl=ERENCES
2.
3. 4.
5.
6.
8. 9. 0.
I I. 12.
13.
r4.
AITKEN, A. P. End resuIts of fractures of the proxima1 humera epiphysis. J. Bone @ Joint Surg., 18: 1036, 1936. BANCROFT, F. W. and MARBLE, H. C. Surgery of the Motor SkeIetaI System, 2nd ed. Philadelphia, 1951. J. B. Lippincott Co. BLOC.NT, W. P. Fractures in Children. Baltimore, 1954. Williams & WiIkins Co. BBHLER, L. The Treatment of Fractures, 4th English ed. TransIated by Hey-Groves, E. W. Baltimore, 1935. Wm. Wood 8r Co. BONNIN, J. G. A Complete Outline of Fractures. London, I 94 I. William Heineman (Medical Books Ltd.). BOURDILLON, J. F. Fracture-separation of the proxima1 epiphysis of the humerus. J. &me Ed Joint .%g.: jz-IB: 35, 1950. KEY. J. A. and CONWELL. H. E. The Rlanaeement of’Fractures, DisIocatibns and Sprains, $h ed. St. Louis, 1951. C. V. Mosby Co. LORENZO, F. T. Osteosynthesis with Blount’s staples in fractures of the proxima1 end of the humerus. J. Bone 4~ Joint Surg., 37-A: 4q. 1955. MACNUSON, P. B. and STACK, J. K. Fractures, 5th ed. PhiIadeIphia, 1949. J. B. Lippincott Co. SCUDDER,C. L. The Treatment of Fractures, I I th ed. Philadelphia, 1938. W. B. Saunders Co. SPEED. K. Fractures and DisIocations. dth ed. PhiIadeIphia, 1942. Lea ti Febiger. ’ ’ STEINDLER, A. The Traumatic Deformities and Disabilities of the Upper Extremity. SpringfieId, Illinois, 1946. Charles C Thomas. STEWART, M. J. and HUNDLEY, J. M. Fractures of the humerus (a comparative study in methods of treatment). J. Bone @Y Joint Surg., 37-A: 681, ‘955. STIMSON, B. B. A ManuaI of Fractures and Dislocations, 2nd ed. PhiIadeIphia, 1947. Lea & Febiger.