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Fractures involving the proximal humeral epiphysis
Fractures
Involving
Humeral DONALD
Epiphysis
N. VIVIAN, M.D. AND .J~SEPH M. JANES, Diplomate, Rochester. Jlinnesota
From the MU,~TIFoundation and the Section oj Orthopedic Sur,eery, Mqfo Clinic, f&&ester, Minn.
Americurl
Board
ojOrthopaedic
Surgery.,
Aitken contended that open reduction and interna fixation are dangerous. He presented eIeven cases in which follow-up studies of one to five years were done; in onIy two of these cases was open reduction done, with interna fixation applied by means of a 3 inch (7.6cm.) nail, yet permanent deformity did not deveIop in any of these eleven cases. AIthough accurate reduction was not accompIished in six cases, no deformities developed in them; he stated that shortening as great as I inch (2.5 cm.) is of IittIe import. Roche presented a case in which an exceIIent functional resuIt was obtained despite a shortening of I$$ inches (2.9 cm.). Lee presented three cases in which excellent results were obtained by treatment with open reduction and interna fixation. Conwell reported three cases in which reduction without internal fixation was done in one and closed reduction was done in two; in a11 three exceIIent functiona1 resuIts were obtained. He was of the opinion, however, that interna fixation should never be used. Roberts described two cases in which open reduction was done without interna fixation with excellent resuIts. Jeffery described twenty-eight cases, in a11 but six of which reduction by cIosed methods was accomplished; open reduction was done in the six exceptions. He described a method of reduction by traction and manipulation which is appeaIing. Good functional results were obtained in a11 but three of his cases; treatment in one of these three cases was operative, whereas in the other two, it was manipulative. It is apparently a crushing type of trauma that causes gross deformities, according to Watson-Jones. This trauma may occur from the injury or in an attempt to reduce the fracture. It is conceivable that tightening of screws during interna fixation may produce enough compression on the epiphysea1 plate to cause disturbances in growth. Rough manip-
CONSIDERABLE controversy exists regarding the treatment of fractures that involve the proximal epiphysis of the humerus. Inasmuch as the proxima1 epiphysis is responsible for 81 per cent of the growth of the humerus,2 the problem of future deformities Iooms Iarge in the treatment of these fractures. REVIEW
the Proximal
OF LITERATURE
In the’ EngIish Iiterature the consensus is that an attempt at closed reduction shouId be made in fractures that invoIve this epiphysis and show displacement, and that if cIosed reduction is not accomplished, then open reduction shouId be done. A great deaI of the controversy already mentioned arises as to whether or not interna fixation shouId be applied for fear of disturbing future growth. Reduction of these fractures is frequently difficult if not impossibIe because of lack of contro1 of the humera head, because the head is frequentIy rotated or because of interposition of tendon or muscle. Lee brought to Iight a frequent compIication whose occurrence we can confirm. When the humera fracture is on a slanting Iine so that the upper outer edge of the dista1 fragment is broader than the Iower portion of this fragment, this broad edge may protrude through a sIit in the capsuIar extension of the joint and be gripped firmIy. The long head of the biceps muscle can slip between the fragments; when this takes pIace, traction only tightens the capsuIe around the fragments and the presence of the biceps tendon prevents apposition of the fragments. Open reduction is always indicated in such a condition. BIount and Aitken stated that patients who have proxima1 epiphysea1 fractures of the humerus do we11 even if reduction is not compIeted, as Iong as alignment is maintained. 211
Fractures
InvoIving
Proximal
ulation must bc avoitlctl in the process of rctluction in order to climinatc such coniprcssion. Rlost of these I‘racturcs are sustained during injuries that in\,olvc compression, hypei-cstcnsion and rotation, accorcling to Bourdillon. He presented five cases of this type of fracture; in three of these, clear-cut histories nere obtainecl that depicted this type of injur!-. It \vas unfortunate that adequate histories describing how the injuries occurred m-ere not obtained in our cases. PRESENT
Epiphysis
0rl.v. One col);llt-cI1roI~li~ii~i Witallium”) scrc\\ \\;Is pl:icc*ti through the distal l‘ragmcnt into the pro-\imal l’ragmcnt. .A Velpeau dressing \Y:IS applictl and rcmovccl in thirty-one da>-s. A sling \\.a~ then \\.orn for two lvecks. Three months later, follm\ -up discIosed a minimal range of motion. In April, 1952, the patient ~~1s seen again, at which time he had a normal range of motion with no pain at any time. Roentgenograms at this time showecl no gross ahnormaIitv. The screw \vas at least 2! 1 inches (5.7 cm.) ciistal to the upper epiphysis, tvhich apparently indicated the amount of growth experienced by this patient in five years. CASE III. A fifteen year oId boy sustained a fracture of the neck of the left humerus, involving the epiphvsis, in July, 1917, when he fell from a haylojt and struck the posterior aspect of his Ieft shoulder on the ground. He also had dislocated his shouIder, accorcling to his local physician. The dislocation was reduced and the arm placed in an abduction splint but, because of persistent posterior anguIation, the patient was referred to the clinic six days after the accident. (Fig. ra.) He \vas placed in an L frame and traction was applied 1)s means of a Kirschner lvire placed through the olecranon. After six days reduction \vas not accomplished, so open reduction \vas clone. At this titne it was found that the proximal end of the distal fragment was caught in the deltoid muscle. The fracture was reduced ancl two VitaIlium screws were placed across the oblique line of fracture. (Fig. rb.) The patient was pIaced in an airplane splint, which was removed after fifty-four days. Five months after the injury all motions of his arm were normal and painless. (Fig. IC and d.) The screws \vere removecl at this time and the function of his arm after their removal continued to be exceIlent. An eleven year old gir1 sustained CASE IV. a fracture of the surgica1 neck of the right humerus, involving the epiphysis, when she feI1 from a sled while sliding dohvn a hiI1 in December, 1947. (Fig. za.) An attempt at reduction of the fracture was made by manipulation with traction and abduction without success. She was then placed in an L frame with traction by means of moleskin. After six days, reduction was not accomplished, so open reduction was performed and a VitaIlium scren was pIaced obIiqueIy through the proximal encl of the dista1 fragment into the proxima1 fragment. A plaster spica was appIied with the arm in
STUDY
We have revierzecl the records in all cases of fractured humeri encountered at the Mayo CIinic from 1946 through 1951 and have found twelve cases in which such fractures involved the proxima1 epiphysis. Our follow-up studies consisted of examination of those patients who were abIe to return to the clinic, or personal letters to those who could not return because of distance, requesting their opinion as to the functional result obtained. CASE
Humeral
REPORTS
CASE I. A fourteen year old girI sustained a fracture dislocation of the right upper humeral epiphysis in October, 1946. She feI1 from a horse fifteen clays prior to admission at the cIinic. She was treated at home by her local physician by means of traction in a plaster spica but, because reduction was not obtained, the patient was referred to the cIinic. Open reduction was done at the cIinic, which disclosed compIete anterior dispracement of the epiphysis, with the Iong head of the biceps between the fragments. The fracture was reduced and no interna fixation was used. The patient was dismissed in a VeIpeau dressing five days postoperativeI?, in view of the fact that her father, a physlcian, couId give adequate care at home. A letter in December, 1952, reveaIed that this patient had exceIIent function in her shoulder in a11 directions, aIthough slight cIinical deformity was present. CASE II. A fourteen year old boy was struck by a car while riding on a sIed in December, 1946. He sustained a fracture dislocation of the proxima1 epiphysis of the right humerus. The patient was pIaced in an abduction splint for three days but overriding of the fragments couId not be corrected. An open reduction was then performed which discIosed over-riding of the proximal fragment anteri212
Fractures
InvoIving
Proximal
HumeraI
Epiphysis
FIG. I. Cast III. a, fracture six days after accident; at operation the proximal end of the dista1 fragment was found to be caught in the deItoid muscle. 6, appearance after open reduction was nccompIished and two VitalIium screws were inserted across the line of fracture. c and d, five months after operation. Healing is compIete; alignment and function are euceIIent.
abduction at an angIe of 90 degrees. After forty-two days the spica was removed. (Fig. 26.) Two weeks later a11 motions of the arm Iacked 13 degrees. Roentgenograms at this time showed excelIent position and heaIing. The patient was seen again in March, 1952, at which time fulI range of motion was present without pain. The right upper extremity was shortened by fi inch (0.64 cm.). However, the patient had no compIaints and had not noticed shortening. Roentgenograms at this time showed normaI configuration of the head and
neck of the humerus, with the metallic screw in place; it was the opinion of one of us (Janes) that the epiphysea1 line might be closing prematurely. (Fig. 2c and d.) CASE v. A sixteen year old boy sustained a fracture disIocation of the proxima1 epiphysis of the right humerus with upward dispIacement of the shaft in March, 1948, when he fell from a manure spreader and Ianded on the Iateral surface of his right shouIder. He was placed in an L frame for two days but reduction was not accompIished. Open reduction was done 213
Fractures
InvoIving
ProximaI
HumeraI
Epiphysis
FIG. 2. Gse Iv. (L,fritcture on admission. 0, site of frncturr forty-two days xftcr oprmtion :~nd following rm~ov:lI of plnstvr spkt. The fracture. is hcding wail :~ntl t hc p&&n is good. A loss of I 5 tlcgrccs was present in :dl motions of the shoulder. c ~\nd d, four yurs :\ftcr operation. The Iinc of fracturr is wdl hcdccl and the position is excellent. This pntient hul shortming of ‘:I inch (0.64 cm.) of thv :trm :tt this timr of which she WILSumrwnrc. Thr rpiphysed line nppwrs to lx closing prcm:tt urcly. a fracture separation of the proxima1 epiphysis of the right humerus with dispIacement of the head in May, 1948, when he was injured after being tackIed whiIe playing footbaI1. (Fig. 3a.) The fracture was reduced by manipuIation with the patient under thiopenta1 sodium (pentotha1 sodium@) anesthesia; the arm was pIaced in an airplane spIint with some traction to the arm. The splint was removed twentyfive days later and a sling was appIied, which was removed after ten days. (Fig. 3h.) FoI-
and the distal fragment was noted to he high anteriorIy and IateraIIy. The fracture was reduced and a CoIIison screw was pIaced through the fragments to maintain reduction. A VeIpeau dressing was applied and removed after two weeks, at which time a sBng was appIied and used for another two weeks. Two weeks after remova of the sIing, fuI1 range of motion was present and roentgenograms showed that the fracture had heaIed weI1. CASE VI. A sixteen year old boy sustained 214
Fractures
Involving
Proximal
Humerd
Epiphysis
FIG. 3. Case VI. CL,appearance of fracture on admission; it was reduced by manipulation. b, site of fracture fortyone days after reduction. Ilcaling is progressing well and the position remains good. c and d, site of fracture foul years Iatcr. Pain was present in the shoulder on abduction at an angle of 80 degrees; a jog was palpated in the scapulohumeral motion at this angle. Ail other motions were normal.
feI1 from a motorcycle. He was pIaced in an L frame for two days but reduction was not accomplished. Successful reduction of the fracture was then done by manipuIation with the patient under genera1 anesthesia. This reduction was accomplished when the surgeon’s heel was placed in the patient’s asiIIa and strong traction was applied to the arm in a downward direction. A Iarge Kirschner wire was inserted across the epiphysexl Iine from the proximal to the dista1 fragment and a VeIpeau dressing was applied. The pin was removed twenty-
low-up esaniination in ApriI, 1952, di.doSed pain in the right shouIder on abduction at an angIe of about 80 degrees. When he abducted his arm at this angIe, a jog in the scapuIohumeral motion couId be felt. (Fig. 3c and cl.) It was the opinion of one of us (Janes) that the patient might have damaged his musculotendinous CUR at the time of the original injury. AI1 other motions were norma and painIess. CASE ~711. A seventeen year old boy sustained a disIocation of the proxima1 epiphysis of his right humerus in August, 1949, when he 215
Fractures
I nvol\.ing
Proximal
Humeral
Epiphpis
Fi(;. 4. Gsr lx. II and 11,fracture on admission. 0pc.n iwtluction ~35 done; I hc pro\inl:il end of the clistd fragment W:LS found to bc protruding into the ckltoitl ~nuscl~~.Rduction \J;I.CI tlonc \vitbout USCof intcrn:ll Fixation. c :~ntl tl, two ywrs ztfter operation. Note rxcellc~nt position; functicrn is c\-cdlcnt.
MYIS done and it has found that the proxima1 fragment FVBSanterior. The tendon of the biceps muscle was not seen. The fracture m-as reduced and t\vo Collison screws were placed across the fragments. The patient \vas then placed in an L frame in J>ed because of a coGsting fracture of the pelvis. Three weeks later the L frame \Y;I~removed anti motion \vas begit n. FoIlow-up csarnination in t\\o months tlisrloscd excellent range of motion. C.\SE IS. A sistccn year old boy sustained a fracture of the neck of the right humerus I\-ith epiphyseal separation in April, 1950, when
seven days Iater. In April, 1950, follow-up of the patient disclosed that function was excellent in all directions. Roentgenograms at that time showed sIight dorsa1 slipping of the proximal fragment. A seventeen year old boy susCASE VIII. tained a fracture of the proxima1 cpiphysis of the left humerus with comniinution of :I portion of the metaphysis in Novemlwr, 1949, when he fell from a moving car. Closed reduction was attempted by use of an abduction splint with traction by means of moleskin Ihr twelve days without success. Open reduction 216
Fractures
Involving
Proximal
Humeral
EpiphJsis
FIG. 5. Case XI. (L and b, fractuw on admission. c and tl, open reduction was done; the long head of the biceps between the fragments. A Stuck nail W:LSinscrtetl ;~cross the line of fracture; some posterior rotation wm of the head was still present but this was accepted. muscle
he feI1 on his right shouIcIer while pole vauIting. The arm was placed in a Thomas splint by his local physician for four days but reduction was not accompIished. He was then referred to the clinic w-here an attempt was made to reduce the fracture (Fig. la and h) I,;\;: manipulation without success. Open reduction was done and it was found that the proximal end of the distal fragment was projecting through the soft tissue, which had intervened between the fragments. The fracture was reduced and no interna fixation m-as beIieved necessary to
maintain reduction. A shouIder spica was applied and removed after forty-one days. In JuIy, 1950, the patient had a norma range of motion and by March, 1952, range of motion was excellent. Koentgenograms at this time showed solid union with no deformity. (Fig. 4c and d.) CASE s. A thirteen year old boy sustained :I fracture dislocation of the proximal epiphysis 1951, when of the left humerus in February, he was injured while wrestling. The fracture was reduced by manipuIation with the patient 217
Fractures
Involving
Proximal
under general anesthesia. This was done I~!placing one hand in the axilla and exerting traction on the arm. The lateral surface of the upper arm was then struck a sharp MO\?-;on the second attempt, the fracture was reduced. The site of fracture was transfixed with a Kirschner wire and a VeIpeau dressing was applied. In forty-eight days the wire and dressing were removed. At foIIow-up in March, 1951, slight restriction was noted in motion of the Ieft shoulder but the patient had no compIaints and stated that he couId do anything. CASE XI. A ten year oId girl sustained a fracture of the neck of the humerus, with epiphysea1 separation, in September, 195 I, when she fell on her Ieft shotrIder while playing. (Fig. 5a and b.) She was pIaced in an L frame with traction for six days but reduction did not take pIace. Open reduction was then done and it was found that the Iong head of the biceps muscle was Iying between the fragments. The fracture was reduced and fixed with a stainIess stee1 screw but reduction was incomplete and the screw was removed. The fracture was reduced again and a Stuck nail was pIaced across the site of fracture. Some posterior rotation of the head was present in the axial view but this was accepted. (Fig. 5c and d.) An airpIane splint Jvas applied nncl removed after tweIve days. A pIaster spica was then applied and removed after thirty days. On foIIow-up sixty days after operation, full range of motion was present except for a 20 degree Ioss of abduction, 218
Hurneral
Epiphysis
a 20 degree loss of Ilesion and a IO degree Ioss of externa1 rotation. In Alarch, 1952, foIIow-up examination disclosed complete range ofmotion except for a 15 degree Ioss of full abduction and extension. Roentgenograms at this time showed that the fracture was dell healed and in good position. The Stuck nail traversed the epiphyseal Iine. (Fig. (ia and b.) Comparison of these films with those of the other arm discIosed no evidence of earIv closure of the epiphysis. It was the opinion of one of us (Janes) that in time the patient uould achieve absolutely fuI1 motion of the Ieft shouIder. CASE XII. A sixteen year old boy, injured his Ieft arm in an auto accident in August, 1948. He was sitting in the back seat at the time and was unable to recaI1 how he injured the arm. His local physician found a fracture of the neck of the Ieft humerus that invoIved the epiphysis. SeveraI attempts were made to reduce this fracture by manipuIation with the patient under pentotha1 sodium anesthesia without success. Nine clays after the accident he was referred to the clinic. Roentgcnograms at this time discIosed a fracture of the neck of the Ieft humerus with anguIation of the head and some over-riding. It was considered that, in view of the severa previous attempts at reduction by manipuIation, open reduction shouId be done; the Iatter was accomplished fifteen days after the injury. The deIay of six days was necessary because of the condition of the skin. A Collison screw was pIaced obIiqueIy
Fractures
InwIving
Proxind
across the site of fracture. Postreduction roentgenograms taken at the operating tabIe reveaIed the position of the fracture to be acceptable but not perfect. A prominent portion of the latera side of the proximal end of the distal fragment was Ieveled off by means of an osteotome. The arm was then placed in an airplane spIint which was removed eleven days later; a pIaster spica then was applied with the arm in abduction at an angle of 90 degrees. The patient was dismissed two days later. On foIIow-up his father stated that the patient was in the United States Marines; he stated that a IittIe more than I inch (2.5 cm.) of shortening had been experienced but no interference in the function of the arm was apparent. This patient was seen recently at the clinic. He had 134 inches (4.3 cm.) of shortening of the left upper extremity and slight limitation of extension and externa1 rotation of the left arm. COMMENT
have classified the results in our tweIve cases into the following three categories: excelIent (the patient had no limitation of motion); good (the patient had any degree of limitation of motion but no interference in the normal function of the arm), and fairIy good (limitation was present in the functiona use of the arm in the patient’s usual occupation). In our twelve cases excellent resuIts were present in nine, good results in two and fairIy good results in one (Case VI). Open reduction was necessary in nine of our cases; in seven of these, we used interna fixation by one of the many types of screws or nails avaiIabIe. In two cases no interna fixation was thought necessary. In three cases closed reduction was possible by manipulation with the patient under anesthesia; in one of these (Case x) the fracture was transfixecl with a Kirschner wire after reduction by manipuIation was accomplished. In Case III the screws used for interna fixation were removed five months postoperativeiy. With two exceptions no apparent interfercnce in epiphyseal growth was present in any of our cases in which interna fixation was used; in these two cases (Cases IV and XII), shortening of >; inch (a.64 cm.) and 19.; inches (1.3 cm.) was present, respecti\-eIy. In one of these (Case IV) the patient \vas una\vare of the shortening. No interference in function of the arm was present in either instance. In Case XII the interference in the epiphysea1 growth may we11 We
Hurneral
Epiphysis
have been caused by the several attempts at cIosed reduction or by the necessary deIay in reduction. If such interference were caused by the metaIIic fixation, it wouId appear that shortening would have occurred in more than two of seven cases. In none of the cases was there uneven growth at the epiphysis, which might have caused angulation at the site of fracture. We were unabIe to substantiate the opinions of Aitken and Conwell that open reduction of these fractures is dangerous for fear of injury to the epiphysis. In al1 of our operative cases, the results were exceIIent or good. In the one case in which onIy fairIy good resuIts were obtained, treatment incIuded manipuIation and traction. ApparentIy the amount of compression across the epiphysea1 Iine that accompanies interna fixation is not sufficient to produce interference in growth of the epiphysis. It is more conceivabIe that the trauma incurred in manipuIation of this type of fracture is much more apt to cause injury to the epiphysea1 plate. One must, therefore, use great care in manipulating this fracture. Although Jeffery reported that the fractures in most of these cases can be reduced by manipuIation and traction, we cannot agree. In four of our nine operative cases either soft tissue or the Iong head of the biceps tendon was found to be interposed between the fragments, a situation that renders cIosed reduction impossibIe. Jeffery described a method of reducing these fractures by hyperabduction and traction that may give better resuIts than other methods of closed reduction. We did not use this method in attempts at manipulation and traction in our cases, although we attempted reduction by manipuIation in al1 our cases before proceeding to open reduction. SUMMARY
AND
CONCLUSIONS
Fractures involving the proxima1 humera epiphysis are relatively rare. This study includes twelve cases encountered during a period of six years at the Mayo CIinic. CIosed reduction by manipulation should be attempted in a11 cases. In none of our cases was reduction :~ccompIished by any of the many devices that are nvnilabIe for the production of traction. If reduction is not accompIished with reasonabIe ease by manipuIation, then open reduction shouId be done. CIosed reduction is most often
219
Fractures
InvoIving
Proximal
Humeral
Epiphysis
impossibIe because of interposition of soft tissue or of the Iong head of the biceps muscIe between the fragments. Use of interna fixation across the epiphyseal line apparentIy has no influence on growth of the arm because the accompanying compression is not enough to interfere with the epiphysis. ResuIts are usuaIIy good in treatment of this type of fracture as Iong as the alignment of the fragments is good, even though reduction may be_incompIetk REFERENCES I. AITKEN, A. P. End
humera
epiphysis.
results of fractures of proxinla1 J. Bone &+ Joint Surg., 18:
1036-1041, 1936. 2. BISGARD, J. D. Fractures involving cpiphyseal cartih~ge. West. J. Surg., 46: 412-415. 1938. 3. BLOLNT, W. P. Fractures in chiIdren are different. Chicago &t. sec. Bull., 52: 5 I 1-5 16, 1949.
hurncr;s: An end-result studv \if;ich show the advantage of early active m&n. J. A. :M. A., 98: 367-372, 1932. 9. KOCHE, A. E. The ultimate result of a cast of separated upper cpiphysis of the humerus. C/in.
I o.
220
J., 55: 478-479, 1926. WATSOX-JOYES, R. Fractures
and Other Bone and Joint Injuries, 2nd ed. Baltimore, 1941. The Williams & Wilkins Company.
Involving
Humeral DONALD
Epiphysis
N. VIVIAN, M.D. AND .J~SEPH M. JANES, Diplomate, Rochester. Jlinnesota
From the MU,~TIFoundation and the Section oj Orthopedic Sur,eery, Mqfo Clinic, f&&ester, Minn.
Americurl
Board
ojOrthopaedic
Surgery.,
Aitken contended that open reduction and interna fixation are dangerous. He presented eIeven cases in which follow-up studies of one to five years were done; in onIy two of these cases was open reduction done, with interna fixation applied by means of a 3 inch (7.6cm.) nail, yet permanent deformity did not deveIop in any of these eleven cases. AIthough accurate reduction was not accompIished in six cases, no deformities developed in them; he stated that shortening as great as I inch (2.5 cm.) is of IittIe import. Roche presented a case in which an exceIIent functional resuIt was obtained despite a shortening of I$$ inches (2.9 cm.). Lee presented three cases in which excellent results were obtained by treatment with open reduction and interna fixation. Conwell reported three cases in which reduction without internal fixation was done in one and closed reduction was done in two; in a11 three exceIIent functiona1 resuIts were obtained. He was of the opinion, however, that interna fixation should never be used. Roberts described two cases in which open reduction was done without interna fixation with excellent resuIts. Jeffery described twenty-eight cases, in a11 but six of which reduction by cIosed methods was accomplished; open reduction was done in the six exceptions. He described a method of reduction by traction and manipulation which is appeaIing. Good functional results were obtained in a11 but three of his cases; treatment in one of these three cases was operative, whereas in the other two, it was manipulative. It is apparently a crushing type of trauma that causes gross deformities, according to Watson-Jones. This trauma may occur from the injury or in an attempt to reduce the fracture. It is conceivable that tightening of screws during interna fixation may produce enough compression on the epiphysea1 plate to cause disturbances in growth. Rough manip-
CONSIDERABLE controversy exists regarding the treatment of fractures that involve the proximal epiphysis of the humerus. Inasmuch as the proxima1 epiphysis is responsible for 81 per cent of the growth of the humerus,2 the problem of future deformities Iooms Iarge in the treatment of these fractures. REVIEW
the Proximal
OF LITERATURE
In the’ EngIish Iiterature the consensus is that an attempt at closed reduction shouId be made in fractures that invoIve this epiphysis and show displacement, and that if cIosed reduction is not accomplished, then open reduction shouId be done. A great deaI of the controversy already mentioned arises as to whether or not interna fixation shouId be applied for fear of disturbing future growth. Reduction of these fractures is frequently difficult if not impossibIe because of lack of contro1 of the humera head, because the head is frequentIy rotated or because of interposition of tendon or muscle. Lee brought to Iight a frequent compIication whose occurrence we can confirm. When the humera fracture is on a slanting Iine so that the upper outer edge of the dista1 fragment is broader than the Iower portion of this fragment, this broad edge may protrude through a sIit in the capsuIar extension of the joint and be gripped firmIy. The long head of the biceps muscle can slip between the fragments; when this takes pIace, traction only tightens the capsuIe around the fragments and the presence of the biceps tendon prevents apposition of the fragments. Open reduction is always indicated in such a condition. BIount and Aitken stated that patients who have proxima1 epiphysea1 fractures of the humerus do we11 even if reduction is not compIeted, as Iong as alignment is maintained. 211
Fractures
InvoIving
Proximal
ulation must bc avoitlctl in the process of rctluction in order to climinatc such coniprcssion. Rlost of these I‘racturcs are sustained during injuries that in\,olvc compression, hypei-cstcnsion and rotation, accorcling to Bourdillon. He presented five cases of this type of fracture; in three of these, clear-cut histories nere obtainecl that depicted this type of injur!-. It \vas unfortunate that adequate histories describing how the injuries occurred m-ere not obtained in our cases. PRESENT
Epiphysis
0rl.v. One col);llt-cI1roI~li~ii~i Witallium”) scrc\\ \\;Is pl:icc*ti through the distal l‘ragmcnt into the pro-\imal l’ragmcnt. .A Velpeau dressing \Y:IS applictl and rcmovccl in thirty-one da>-s. A sling \\.a~ then \\.orn for two lvecks. Three months later, follm\ -up discIosed a minimal range of motion. In April, 1952, the patient ~~1s seen again, at which time he had a normal range of motion with no pain at any time. Roentgenograms at this time showecl no gross ahnormaIitv. The screw \vas at least 2! 1 inches (5.7 cm.) ciistal to the upper epiphysis, tvhich apparently indicated the amount of growth experienced by this patient in five years. CASE III. A fifteen year oId boy sustained a fracture of the neck of the left humerus, involving the epiphvsis, in July, 1917, when he fell from a haylojt and struck the posterior aspect of his Ieft shoulder on the ground. He also had dislocated his shouIder, accorcling to his local physician. The dislocation was reduced and the arm placed in an abduction splint but, because of persistent posterior anguIation, the patient was referred to the clinic six days after the accident. (Fig. ra.) He \vas placed in an L frame and traction was applied 1)s means of a Kirschner lvire placed through the olecranon. After six days reduction \vas not accomplished, so open reduction \vas clone. At this titne it was found that the proximal end of the distal fragment was caught in the deltoid muscle. The fracture was reduced ancl two VitaIlium screws were placed across the oblique line of fracture. (Fig. rb.) The patient was pIaced in an airplane splint, which was removed after fifty-four days. Five months after the injury all motions of his arm were normal and painless. (Fig. IC and d.) The screws \vere removecl at this time and the function of his arm after their removal continued to be exceIlent. An eleven year old gir1 sustained CASE IV. a fracture of the surgica1 neck of the right humerus, involving the epiphysis, when she feI1 from a sled while sliding dohvn a hiI1 in December, 1947. (Fig. za.) An attempt at reduction of the fracture was made by manipulation with traction and abduction without success. She was then placed in an L frame with traction by means of moleskin. After six days, reduction was not accomplished, so open reduction was performed and a VitaIlium scren was pIaced obIiqueIy through the proximal encl of the dista1 fragment into the proxima1 fragment. A plaster spica was appIied with the arm in
STUDY
We have revierzecl the records in all cases of fractured humeri encountered at the Mayo CIinic from 1946 through 1951 and have found twelve cases in which such fractures involved the proxima1 epiphysis. Our follow-up studies consisted of examination of those patients who were abIe to return to the clinic, or personal letters to those who could not return because of distance, requesting their opinion as to the functional result obtained. CASE
Humeral
REPORTS
CASE I. A fourteen year old girI sustained a fracture dislocation of the right upper humeral epiphysis in October, 1946. She feI1 from a horse fifteen clays prior to admission at the cIinic. She was treated at home by her local physician by means of traction in a plaster spica but, because reduction was not obtained, the patient was referred to the cIinic. Open reduction was done at the cIinic, which disclosed compIete anterior dispracement of the epiphysis, with the Iong head of the biceps between the fragments. The fracture was reduced and no interna fixation was used. The patient was dismissed in a VeIpeau dressing five days postoperativeI?, in view of the fact that her father, a physlcian, couId give adequate care at home. A letter in December, 1952, reveaIed that this patient had exceIIent function in her shoulder in a11 directions, aIthough slight cIinical deformity was present. CASE II. A fourteen year old boy was struck by a car while riding on a sIed in December, 1946. He sustained a fracture dislocation of the proxima1 epiphysis of the right humerus. The patient was pIaced in an abduction splint for three days but overriding of the fragments couId not be corrected. An open reduction was then performed which discIosed over-riding of the proximal fragment anteri212
Fractures
InvoIving
Proximal
HumeraI
Epiphysis
FIG. I. Cast III. a, fracture six days after accident; at operation the proximal end of the dista1 fragment was found to be caught in the deItoid muscle. 6, appearance after open reduction was nccompIished and two VitalIium screws were inserted across the line of fracture. c and d, five months after operation. Healing is compIete; alignment and function are euceIIent.
abduction at an angIe of 90 degrees. After forty-two days the spica was removed. (Fig. 26.) Two weeks later a11 motions of the arm Iacked 13 degrees. Roentgenograms at this time showed excelIent position and heaIing. The patient was seen again in March, 1952, at which time fulI range of motion was present without pain. The right upper extremity was shortened by fi inch (0.64 cm.). However, the patient had no compIaints and had not noticed shortening. Roentgenograms at this time showed normaI configuration of the head and
neck of the humerus, with the metallic screw in place; it was the opinion of one of us (Janes) that the epiphysea1 line might be closing prematurely. (Fig. 2c and d.) CASE v. A sixteen year old boy sustained a fracture disIocation of the proxima1 epiphysis of the right humerus with upward dispIacement of the shaft in March, 1948, when he fell from a manure spreader and Ianded on the Iateral surface of his right shouIder. He was placed in an L frame for two days but reduction was not accompIished. Open reduction was done 213
Fractures
InvoIving
ProximaI
HumeraI
Epiphysis
FIG. 2. Gse Iv. (L,fritcture on admission. 0, site of frncturr forty-two days xftcr oprmtion :~nd following rm~ov:lI of plnstvr spkt. The fracture. is hcding wail :~ntl t hc p&&n is good. A loss of I 5 tlcgrccs was present in :dl motions of the shoulder. c ~\nd d, four yurs :\ftcr operation. The Iinc of fracturr is wdl hcdccl and the position is excellent. This pntient hul shortming of ‘:I inch (0.64 cm.) of thv :trm :tt this timr of which she WILSumrwnrc. Thr rpiphysed line nppwrs to lx closing prcm:tt urcly. a fracture separation of the proxima1 epiphysis of the right humerus with dispIacement of the head in May, 1948, when he was injured after being tackIed whiIe playing footbaI1. (Fig. 3a.) The fracture was reduced by manipuIation with the patient under thiopenta1 sodium (pentotha1 sodium@) anesthesia; the arm was pIaced in an airplane spIint with some traction to the arm. The splint was removed twentyfive days later and a sling was appIied, which was removed after ten days. (Fig. 3h.) FoI-
and the distal fragment was noted to he high anteriorIy and IateraIIy. The fracture was reduced and a CoIIison screw was pIaced through the fragments to maintain reduction. A VeIpeau dressing was applied and removed after two weeks, at which time a sBng was appIied and used for another two weeks. Two weeks after remova of the sIing, fuI1 range of motion was present and roentgenograms showed that the fracture had heaIed weI1. CASE VI. A sixteen year old boy sustained 214
Fractures
Involving
Proximal
Humerd
Epiphysis
FIG. 3. Case VI. CL,appearance of fracture on admission; it was reduced by manipulation. b, site of fracture fortyone days after reduction. Ilcaling is progressing well and the position remains good. c and d, site of fracture foul years Iatcr. Pain was present in the shoulder on abduction at an angle of 80 degrees; a jog was palpated in the scapulohumeral motion at this angle. Ail other motions were normal.
feI1 from a motorcycle. He was pIaced in an L frame for two days but reduction was not accomplished. Successful reduction of the fracture was then done by manipuIation with the patient under genera1 anesthesia. This reduction was accomplished when the surgeon’s heel was placed in the patient’s asiIIa and strong traction was applied to the arm in a downward direction. A Iarge Kirschner wire was inserted across the epiphysexl Iine from the proximal to the dista1 fragment and a VeIpeau dressing was applied. The pin was removed twenty-
low-up esaniination in ApriI, 1952, di.doSed pain in the right shouIder on abduction at an angIe of about 80 degrees. When he abducted his arm at this angIe, a jog in the scapuIohumeral motion couId be felt. (Fig. 3c and cl.) It was the opinion of one of us (Janes) that the patient might have damaged his musculotendinous CUR at the time of the original injury. AI1 other motions were norma and painIess. CASE ~711. A seventeen year old boy sustained a disIocation of the proxima1 epiphysis of his right humerus in August, 1949, when he 215
Fractures
I nvol\.ing
Proximal
Humeral
Epiphpis
Fi(;. 4. Gsr lx. II and 11,fracture on admission. 0pc.n iwtluction ~35 done; I hc pro\inl:il end of the clistd fragment W:LS found to bc protruding into the ckltoitl ~nuscl~~.Rduction \J;I.CI tlonc \vitbout USCof intcrn:ll Fixation. c :~ntl tl, two ywrs ztfter operation. Note rxcellc~nt position; functicrn is c\-cdlcnt.
MYIS done and it has found that the proxima1 fragment FVBSanterior. The tendon of the biceps muscle was not seen. The fracture m-as reduced and t\vo Collison screws were placed across the fragments. The patient \vas then placed in an L frame in J>ed because of a coGsting fracture of the pelvis. Three weeks later the L frame \Y;I~removed anti motion \vas begit n. FoIlow-up csarnination in t\\o months tlisrloscd excellent range of motion. C.\SE IS. A sistccn year old boy sustained a fracture of the neck of the right humerus I\-ith epiphyseal separation in April, 1950, when
seven days Iater. In April, 1950, follow-up of the patient disclosed that function was excellent in all directions. Roentgenograms at that time showed sIight dorsa1 slipping of the proximal fragment. A seventeen year old boy susCASE VIII. tained a fracture of the proxima1 cpiphysis of the left humerus with comniinution of :I portion of the metaphysis in Novemlwr, 1949, when he fell from a moving car. Closed reduction was attempted by use of an abduction splint with traction by means of moleskin Ihr twelve days without success. Open reduction 216
Fractures
Involving
Proximal
Humeral
EpiphJsis
FIG. 5. Case XI. (L and b, fractuw on admission. c and tl, open reduction was done; the long head of the biceps between the fragments. A Stuck nail W:LSinscrtetl ;~cross the line of fracture; some posterior rotation wm of the head was still present but this was accepted. muscle
he feI1 on his right shouIcIer while pole vauIting. The arm was placed in a Thomas splint by his local physician for four days but reduction was not accompIished. He was then referred to the clinic w-here an attempt was made to reduce the fracture (Fig. la and h) I,;\;: manipulation without success. Open reduction was done and it was found that the proximal end of the distal fragment was projecting through the soft tissue, which had intervened between the fragments. The fracture was reduced and no interna fixation m-as beIieved necessary to
maintain reduction. A shouIder spica was applied and removed after forty-one days. In JuIy, 1950, the patient had a norma range of motion and by March, 1952, range of motion was excellent. Koentgenograms at this time showed solid union with no deformity. (Fig. 4c and d.) CASE s. A thirteen year old boy sustained :I fracture dislocation of the proximal epiphysis 1951, when of the left humerus in February, he was injured while wrestling. The fracture was reduced by manipuIation with the patient 217
Fractures
Involving
Proximal
under general anesthesia. This was done I~!placing one hand in the axilla and exerting traction on the arm. The lateral surface of the upper arm was then struck a sharp MO\?-;on the second attempt, the fracture was reduced. The site of fracture was transfixed with a Kirschner wire and a VeIpeau dressing was applied. In forty-eight days the wire and dressing were removed. At foIIow-up in March, 1951, slight restriction was noted in motion of the Ieft shoulder but the patient had no compIaints and stated that he couId do anything. CASE XI. A ten year oId girl sustained a fracture of the neck of the humerus, with epiphysea1 separation, in September, 195 I, when she fell on her Ieft shotrIder while playing. (Fig. 5a and b.) She was pIaced in an L frame with traction for six days but reduction did not take pIace. Open reduction was then done and it was found that the Iong head of the biceps muscle was Iying between the fragments. The fracture was reduced and fixed with a stainIess stee1 screw but reduction was incomplete and the screw was removed. The fracture was reduced again and a Stuck nail was pIaced across the site of fracture. Some posterior rotation of the head was present in the axial view but this was accepted. (Fig. 5c and d.) An airpIane splint Jvas applied nncl removed after tweIve days. A pIaster spica was then applied and removed after thirty days. On foIIow-up sixty days after operation, full range of motion was present except for a 20 degree Ioss of abduction, 218
Hurneral
Epiphysis
a 20 degree loss of Ilesion and a IO degree Ioss of externa1 rotation. In Alarch, 1952, foIIow-up examination disclosed complete range ofmotion except for a 15 degree Ioss of full abduction and extension. Roentgenograms at this time showed that the fracture was dell healed and in good position. The Stuck nail traversed the epiphyseal Iine. (Fig. (ia and b.) Comparison of these films with those of the other arm discIosed no evidence of earIv closure of the epiphysis. It was the opinion of one of us (Janes) that in time the patient uould achieve absolutely fuI1 motion of the Ieft shouIder. CASE XII. A sixteen year old boy, injured his Ieft arm in an auto accident in August, 1948. He was sitting in the back seat at the time and was unable to recaI1 how he injured the arm. His local physician found a fracture of the neck of the Ieft humerus that invoIved the epiphysis. SeveraI attempts were made to reduce this fracture by manipuIation with the patient under pentotha1 sodium anesthesia without success. Nine clays after the accident he was referred to the clinic. Roentgcnograms at this time discIosed a fracture of the neck of the Ieft humerus with anguIation of the head and some over-riding. It was considered that, in view of the severa previous attempts at reduction by manipuIation, open reduction shouId be done; the Iatter was accomplished fifteen days after the injury. The deIay of six days was necessary because of the condition of the skin. A Collison screw was pIaced obIiqueIy
Fractures
InwIving
Proxind
across the site of fracture. Postreduction roentgenograms taken at the operating tabIe reveaIed the position of the fracture to be acceptable but not perfect. A prominent portion of the latera side of the proximal end of the distal fragment was Ieveled off by means of an osteotome. The arm was then placed in an airplane spIint which was removed eleven days later; a pIaster spica then was applied with the arm in abduction at an angle of 90 degrees. The patient was dismissed two days later. On foIIow-up his father stated that the patient was in the United States Marines; he stated that a IittIe more than I inch (2.5 cm.) of shortening had been experienced but no interference in the function of the arm was apparent. This patient was seen recently at the clinic. He had 134 inches (4.3 cm.) of shortening of the left upper extremity and slight limitation of extension and externa1 rotation of the left arm. COMMENT
have classified the results in our tweIve cases into the following three categories: excelIent (the patient had no limitation of motion); good (the patient had any degree of limitation of motion but no interference in the normal function of the arm), and fairIy good (limitation was present in the functiona use of the arm in the patient’s usual occupation). In our twelve cases excellent resuIts were present in nine, good results in two and fairIy good results in one (Case VI). Open reduction was necessary in nine of our cases; in seven of these, we used interna fixation by one of the many types of screws or nails avaiIabIe. In two cases no interna fixation was thought necessary. In three cases closed reduction was possible by manipulation with the patient under anesthesia; in one of these (Case x) the fracture was transfixecl with a Kirschner wire after reduction by manipuIation was accomplished. In Case III the screws used for interna fixation were removed five months postoperativeiy. With two exceptions no apparent interfercnce in epiphyseal growth was present in any of our cases in which interna fixation was used; in these two cases (Cases IV and XII), shortening of >; inch (a.64 cm.) and 19.; inches (1.3 cm.) was present, respecti\-eIy. In one of these (Case IV) the patient \vas una\vare of the shortening. No interference in function of the arm was present in either instance. In Case XII the interference in the epiphysea1 growth may we11 We
Hurneral
Epiphysis
have been caused by the several attempts at cIosed reduction or by the necessary deIay in reduction. If such interference were caused by the metaIIic fixation, it wouId appear that shortening would have occurred in more than two of seven cases. In none of the cases was there uneven growth at the epiphysis, which might have caused angulation at the site of fracture. We were unabIe to substantiate the opinions of Aitken and Conwell that open reduction of these fractures is dangerous for fear of injury to the epiphysis. In al1 of our operative cases, the results were exceIIent or good. In the one case in which onIy fairIy good resuIts were obtained, treatment incIuded manipuIation and traction. ApparentIy the amount of compression across the epiphysea1 Iine that accompanies interna fixation is not sufficient to produce interference in growth of the epiphysis. It is more conceivabIe that the trauma incurred in manipuIation of this type of fracture is much more apt to cause injury to the epiphysea1 plate. One must, therefore, use great care in manipulating this fracture. Although Jeffery reported that the fractures in most of these cases can be reduced by manipuIation and traction, we cannot agree. In four of our nine operative cases either soft tissue or the Iong head of the biceps tendon was found to be interposed between the fragments, a situation that renders cIosed reduction impossibIe. Jeffery described a method of reducing these fractures by hyperabduction and traction that may give better resuIts than other methods of closed reduction. We did not use this method in attempts at manipulation and traction in our cases, although we attempted reduction by manipuIation in al1 our cases before proceeding to open reduction. SUMMARY
AND
CONCLUSIONS
Fractures involving the proxima1 humera epiphysis are relatively rare. This study includes twelve cases encountered during a period of six years at the Mayo CIinic. CIosed reduction by manipulation should be attempted in a11 cases. In none of our cases was reduction :~ccompIished by any of the many devices that are nvnilabIe for the production of traction. If reduction is not accompIished with reasonabIe ease by manipuIation, then open reduction shouId be done. CIosed reduction is most often
219
Fractures
InvoIving
Proximal
Humeral
Epiphysis
impossibIe because of interposition of soft tissue or of the Iong head of the biceps muscIe between the fragments. Use of interna fixation across the epiphyseal line apparentIy has no influence on growth of the arm because the accompanying compression is not enough to interfere with the epiphysis. ResuIts are usuaIIy good in treatment of this type of fracture as Iong as the alignment of the fragments is good, even though reduction may be_incompIetk REFERENCES I. AITKEN, A. P. End
humera
epiphysis.
results of fractures of proxinla1 J. Bone &+ Joint Surg., 18:
1036-1041, 1936. 2. BISGARD, J. D. Fractures involving cpiphyseal cartih~ge. West. J. Surg., 46: 412-415. 1938. 3. BLOLNT, W. P. Fractures in chiIdren are different. Chicago &t. sec. Bull., 52: 5 I 1-5 16, 1949.
hurncr;s: An end-result studv \if;ich show the advantage of early active m&n. J. A. :M. A., 98: 367-372, 1932. 9. KOCHE, A. E. The ultimate result of a cast of separated upper cpiphysis of the humerus. C/in.
I o.
220
J., 55: 478-479, 1926. WATSOX-JOYES, R. Fractures
and Other Bone and Joint Injuries, 2nd ed. Baltimore, 1941. The Williams & Wilkins Company.