Recurrent Anterior Shoulder Dislocation After Trauma with Coracoid Apophysis Fracture - A Rare Association / Luxação anterior recorrente do ombro após traumatismo com fratura apófise coracoide - Uma associação rara

Abstract Anterior dislocations represent about 96% of total shoulder dislocations, with recurrence/instability being more common in young patients. Injury of other shoulder structures is frequent, namely bony Bankart lesion. However, the association with coracoid apophysis fracture is very rare. The present article describes the clinical case of a 67-year-old man who presented to the emergency department with complaints of persistent omalgia, with acute episodes, beginning after a fall from his own height. The patient also presented history of shoulder trauma 3 months earlier, which was evaluated at another hospital. Shoulder anterior dislocation was observed radiographically, and the computed tomography (CT) confirmed bone erosion of the anteroinferior part of the glenoid (bone loss of about 50% of the anteroposterior diameter in the lower region of the glenoid), with almost complete resorption of the bony Bankart lesion (apparent in later analysis of the radiography of the initial traumatic episode). Connectedly, a transverse fracture of the coracoid apophysis (type II in the Ogawa classification) was diagnosed. The patient was submitted to surgical treatment, with anterior bone stop confection using the remnant of the fractured fragment of the coracoid supplemented by tricortical autologous iliac graft, fixed with cannulated screws (according to the Bristow-Latarjet and Eden-Hybinett techniques). In the postoperative follow-up, a good functional result was observed, with no new episodes of dislocation and no significant pain complaints. A rare association of shoulder lesions is described, and the challenge of their treatment is highlighted, given the late diagnosis, as in the case presented.

Resumo As luxações anteriores representam cerca de 96% do total de luxações do ombro, sendo a recidiva/instabilidade mais comum em pacientes jovens. A lesão de outras estruturas do ombro é frequente, nomeadamente a lesão óssea de Bankart. Contudo, a associação com a fratura da apófise coracoide é muito rara. Este artigo descreve o caso clínico de um homem de 67 anos que recorreu ao serviço de urgência com queixas de omalgia persistente, com episódios de agudização, iniciados após queda da própria altura. O paciente apresentava ainda histórico de trauma do ombro 3 meses antes, avaliado em outro hospital. A luxação anterior do ombro foi constatada radiograficamente, e a tomografia computorizada (TC) do ombro confirmou erosão óssea da vertente anteroinferior da glenoide (perda óssea de cerca de 50% do diâmetro anteroposterior na região inferior da glenoide), com reabsorção quase completa de lesão óssea de Bankart (aparente em análise a posteriori da radiografia do episódio traumático inicial). Associadamente, foi diagnosticada uma fratura transversa da apófise coracoide (tipo II da classificação de Ogawa). O paciente foi submetido ao tratamento cirúrgico, com confecção do batente ósseo anterior utilizando remanescente do fragmento fraturado do coracoide suplementado por enxerto autólogo tricortical do ilíaco, fixados com parafusos canulados (de acordo com as técnicas de Bristow-Latarjet e Eden-Hybinett). No seguimento pós-operatório, foi observado um bom resultado funcional, sem novos episódios de luxação e sem queixas álgicas significativas. Descreve-se uma associação rara de lesões do ombro, e salienta-se o desafio do tratamento das mesmas dado o seu diagnóstico tardio, como no caso apresentado.

Tratamiento quirúrgico para fracturas bifocales de húmero Maresca tipo A2 / Surgical treatment in Maresca type A2 bifocal humeral fractures

Las fracturas bifocales de húmero son lesiones infrecuentes, más aun las que ocurren asociadas con fracturas en el húmero proximal y diáfisis. Presentamos a cuatro pacientes con fracturas bifocales de húmero proximal y diafisario (Maresca A2), la planificación quirúrgica, los detalles técnicos y sus resultados funcionales. Nivel de Evidencia: IV

Bifocal humeral fractures are infrequent injuries, and fractures involving the proximal and diaphyseal humerus are even rarer. We present four patients with bifocal humeral fractures of the Maresca type A2 classification. We detail the surgical plan, technical pearls, and functional outcomes. Level of Evidence: IV

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures / 中华创伤杂志(英文版)

PURPOSE@#Unsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.@*METHODS@#We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.@*RESULTS@#Of 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 - 79 years) and mean follow-up was 58.7 months (range 18 - 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).@*CONCLUSION@#Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.

Finite element analysis of PMMA bone cement reinforced screw plate fixation for osteoporotic proximal humeral fracture / 中国骨伤

OBJECTIVE@#With the help of finite element analysis, to explore the effect of proximal humeral bone cement enhanced screw plate fixation on the stability of internal fixation of osteoporotic proximal humeral fracture.@*METHODS@#The digital model of unstable proximal humeral fracture with metaphyseal bone defect was made, and the finite element models of proximal humeral fracture bone cement enhanced screw plate fixation and common screw plate fixation were established respectively. The stress of cancellous bone around the screw, the overall stiffness, the maximum stress of the plate and the maximum stress of the screw were analyzed.@*RESULTS@#The maximum stresses of cancellous bone around 6 screws at the head of proximal humeral with bone cement enhanced screw plate fixation were 1.07 MPa for No.1 nail, 0.43 MPa for No.2 nail, 1.16 MPa for No.3 nail, 0.34 MPa for No.4 nail, 1.99 MPa for No.5 nail and 1.57 MPa for No.6 nail. These with common screw plate fixation were:2.68 MPa for No.1 nail, 0.67 MPa for No.2 nail, 4.37 MPa for No.3 nail, 0.75 MPa for No.4 nail, 3.30 MPa for No.5 nail and 2.47 MPa for No.6 nail. Overall stiffness of the two models is 448 N/mm for bone cement structure and 434 N/mm for common structure. The maximum stress of plate appears in the joint hole:701MPa for bone cement structure and 42 0MPa for common structure. The maximum stress of screws appeared at the tail end of No.4 nail:284 MPa for bone cement structure and 240.8 MPa for common structure.@*CONCLUSION@#Through finite element analysis, it is proved that the proximal humerus bone cement enhanced screw plate fixation of osteoporotic proximal humeral fracture can effectively reduce the stress of cancellous bone around the screw and enhance the initial stability after fracture operation, thus preventing from penetrating out and humeral head collapsing.

Treatment of four-part proximal humerus fractures with depressed humeral head collapse using strut allograft with locking plates / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of allogeneic femoral head as strut allograft combined with proximal humeral internal locking system (PHILOS) in the treatment of proximal humeral Neer grade Ⅳ fracture with humeral head collapse.@*METHODS@#From January 2018 to November 2020, 18 patients with Neer grade Ⅳ fracture with humeral head collapse were treated with strut allograft with PHILOS, including 4 males and 14 females, aged from 55 to 78 years old, with an average of (68.11±7.20) years old. The operation time, intraoperative bleeding, postoperative drainage volume, fracture healing time, neck-shaft angle and the height of the humeral head, failure of internal fixation the shoulder function at the last follow-up was assessed using Neer's scoring system.@*RESULTS@#All 18 patients were followed up, and the duration ranged from 10 to 12 months, with an average of (11.08±0.65) months. The operation time was (66.44±5.06) min, the intraoperative bleeding volume was (206.67±36.14) ml, the postoperative drainage volume was (76.11±9.63) ml, and the fracture healing time was (17.28±3.92) weeks. At the last follow-up, the degree of loss of neck-shaft angle was (5.44±0.86) ° and the loss of the height of humeral head was (1.43±0.27) mm. All 18 patients had healing without complications such as fracture, withdrawal, penetration of internal fixation and necrosis of humeral head. According to Neer's evaluation standard, the total score was (89.61±5.60), 10 cases got an excellent result, 6 good, 2 fair.@*CONCLUSION@#Allogeneic femoral head combined with PHILOS is an appropriate treatment for the four-part proximal humerus fractures with humeral head collapse, exhibiting good clinic outcome.

Clinical outcomes of reverse shoulder arthroplasty for the treatment of failed fixation of proximal humeral fracrtures in the elderly patients / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of reverse total shoulder arthroplasty as a revision procedure for the failed fixation of proximal humeral fractures in the elderly patients.@*METHODS@#A retrospective analysis was performed on 8 patients with failed internal fixation of proximal humeral fractures from May 2014 to March 2020, including 3 males and 5 females, aged from 65 to 75 years old. All 8 patients underwent reverse total shoulder arthroplasty, and the mean time between initial fixation and reverse total shoulder arthroplasty ranged from 8 to 16 months. Range of motion(ROM), University of California at Los Angeles(UCLA) shoulder score, visual analogue scale (VAS), self-rating anxiety scale(SAS), and Constant-Murley score of shoulder function were assessed pre-operatively and at the last follow-up. Complications relating to the surgery were recorded.@*RESULTS@#All 8 patients successfully followed up. The mean follow-up after reverse total shoulder arhroplasty ranged from 16 to 28 months. The range of motion (forward flexion, external rotation, abduction and internal rotation) of the affected shoulder was significantly improved after surgery, and the post-operative VAS, SAS and UCLA scores were also significantly improved. For the Constant-Murley score of shoulder joint function, the total scores and the subscores of pain, daily activities, range of motion and strength test at the last follow-up were all significantly improved. Scapular glenoid notch was observed in patient, which was evaluated as grade 1 on imaging. All the other patients did not develop specific or non-specific complications.@*CONCLUSION@#Reverse total shoulder arhroplasty is an appropriate treatment as a revision surgery for failed fixation of proximal humeral fractures. It has shown satisfactory clinical outcomes, accelerating the rehabilitation of shoulder function and improving the quality of life.

Clinical study of double plate system in the treatment of complex proximal humeral fractures in the elderly / 中国骨伤

OBJECTIVE@#To explore the clinical outcomes of anteromedial combined with lateral locking plate for complex proximal humeral fractures in the eldery.@*METHODS@#From June 2018 to October 2020, 30 patients who underwent surgical treatment for Neer grade 3 to 4 proximal humeral fractures, including 8 males and 22 females, aged from 51 to 78 years old with an average of (61.5±7.5) years old. Of them, 15 patients had fractures fixed with anteromedial combined with lateral locking plate(ALLP group), whereas 15 received internal fixation with proximal humerus locking plate only(PHLP group). The clinical data, simple shoulder test (SST), humeral head height loss, varus angle and shoulder range of motion were compared between the two groups.@*RESULTS@#All fractures were healed. The follow-up time ranged from 12 to 24 months, with an average of(14.3±2.9) months. The operation time of ALLP group was longer than that of PHLP group (P<0.05). There was no significant difference in intraoperative blood loss between the two groups (P>0.05). There was no significant difference in SST score between the two groups at 1, 3 and 12 months after operation (P>0.05). In terms of radiographic measurement, there was no significant difference in humeral head height loss and varus angle between the two groups at 1 and 3 months after operation (P>0.05). At 12 months after operation, the height loss and varus angle of humeral head in ALLP group were lower than those in PHLP group (P<0.05). In shoulder range of motion, the range of forward elevation in ALLP group was larger than that in PHLP group 1 year after operation(P<0.05). There was no significant difference in external rotation between the two groups.@*CONCLUSION@#Anteromedial combined with lateral locking plate in the treatment of complex proximal humeral fractures in the elderly can increase the stability of the medial column and obtain a good fracture prognosis. But there are also disadvantages such as longer operation time, so it should be individualized according to the fracture type of the patient.

Conceptos actuales: ventajas del clavo endomedular para fracturas del húmero proximal / Current concepts: advantages of intramedullary nail for proximal humerus fractures

Las fracturas de húmero proximal (FHP) son una de las fracturas más frecuentes en la población anciana. La reducción abierta y fijación interna (RAFI) generalmente está indicada para pacientes con una FHP desplazada en jóvenes o pacientes mayores con alta demanda funcional y buena calidad ósea. No se ha llegado a un consenso sobre la técnica de fijación ideal. La RAFI con placas ha sido la más utilizada, pero se han reportado altas tasas de reintervenciones y complicaciones globales en la literatura. La necesidad de agregar técnicas de aumentación a la RAFI con placas bloqueadas en fracturas complejas puede resultar en un tiempo quirúrgico más largo, abordajes extensos y mayores costos. Debido a esto, se hace necesario considerar otras opciones para la osteosíntesis de FHP. Con una mayor comprensión de los mecanismos de falla de la osteosíntesis, la fijación intramedular se ha convertido en una opción de tratamiento aceptada para las FHP con ventajas biomecánicas y biológicas. La fijación intramedular para las FHP ha demostrado menor tiempo quirúrgico, sangrado intraoperatorio, tiempo hasta la unión ósea y menores tasas de infecciones, que las placas bloqueadas. La fijación intramedular es una opción válida para que las fracturas complejas se resuelvan con un implante que por sí solo puede satisfacer en gran medida todas las necesidades de aumento requeridas por una placa bloqueada

Proximal humeral fractures are one of the most frequent fractures in the elderly population. Open reduction and internal fixation (ORIF) is generally indicated for young patients and older patients with high functional demands and good bone quality. No consensus has been reached regarding the ideal fixation technique. Although ORIF with plates is the most widely used technique, high re-intervention rates and global complications with locked plate fixation have been reported in the literature. Addition of augmentation techniques to locked plate fixation in complex fractures may result in longer surgical times, extensive approaches, and higher costs. Therefore, considering other options for ORIF is necessary. With a greater understanding of the mechanisms of fixation failure, intramedullary fixation has become the accepted treatment option for proximal humeral fractures considering the specific biomechanical and biological advantages. Compared with ORIF with locked plates, intramedullary fixation for proximal humeral fractures has low surgical time, intraoperative bleeding, time to bone union, and rate of infections. Intramedullary fixation is a valid option to resolve complex fractures with an implant that may largely supply all the augmentation requirements of a locked plate.

Aumento con injerto estructural endomedular en la osteosíntesis de fracturas de húmero proximal / Endosteal strut allograft augmentation in the osteosynthesis of proximal humerus fractures

Introducción: Las fracturas de húmero proximal son frecuentes, particularmente en la población mayor. Los resultados de la fijación con placa bloqueada siguen siendo impredecibles. El soporte de la columna medial jugaría un rol significativo. Nuestro pro-pósito fue evaluar los resultados de la osteosíntesis de húmero proximal con aloinjerto óseo estructural. Materiales y métodos: Se evaluaron los resultados clínico-radiológicos en 12 pacientes con fractura de húmero proximal tratados con placa bloqueada e injerto estructural endostal. Se definió como pérdida de reducción a un cambio del ángulo cervicodiafisario >5° o en la altura de la cabeza humeral >3 mm. La evaluación clínica incluyó rango de movilidad, puntaje de Constant-Murley, valor subjetivo del hombro, escala analógica visual para dolor y retorno a la actividad habitual. Resultados: Doce pacientes completaron el seguimiento (edad promedio 62.8 años). Diez mantuvieron la reducción. El puntaje promedio de Constant-Murley fue de 82,1; el del valor subjetivo del hombro, del 80%, y el de la escala analógica visual, de 1,9. La elevación anterior fue de 138,3°; la rotación externa, de 49,5°, y la rotación interna a nivel de la vértebra de L3. La diferencia de la altura de la cabeza humeral y el ángulo cervicodiafisario fue de 2,3 mm y 4,92°. No hubo complicaciones. Conclusiones: La osteosíntesis con placa bloqueada y aumento con injerto estructural endomedular es una técnica fiable para tratar fracturas de cuello quirúrgico del húmero. Proporciona soporte al cuello humeral y mantiene la reducción en la fractura de húmero proximal con rotura de la bisagra medial. Nivel de Evidencia: IV

Introduction: Proximal humeral fractures (PHF) are common, particularly in the elderly. To date, locking plate fixation continues to provide unpredictable outcomes. Medial hinge support plays a significant role in stability until the bone heals. We aim to evaluate the outcomes of plate fixation with endosteal strut allograft augmentation in the treatment of PHF. Materials and methods: We evaluated clinical and radiological outcomes in the medium-term follow-up of 12 patients with PHF who were treated with plate fixation and strut allograft augmentation. The strut allograft was introduced into the humeral shaft to add support to the medial hinge. We compared the final follow-up radiographs to those taken immediately after surgery. We defined a loss of reduction if the change in Humeral Head Height or the Neck-Shaft Angle measured over 3 mm or 5°, respectively. The clinical evaluation included range of motion, Constant-Murley (CM) score, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), and return to daily activities. Results: Twelve patients completed follow-up. The patients' average age was 62.8. Ten patients healed without loss of reduction. Average CM and SSV scores were 82.1 and 80%, respectively, and average VAS was 1.9. Anterior elevation averaged 138.3°, external rotation 49.5°, and internal rotation at L3 level. The mean differences in HHH and NSA were 2.3 mm and 4.92°, respectively. We recorded no complications associated to the procedure. Conclusion: Locking plate fixation with endosteal strut allograft augmentation is a reliable technique for the treatment of PHF. It provides support to the humeral neck and maintains reduction in fractures with disruption of the medial hinge. Level of Evidence: IV

Progress in the research of medial column reconstruction of proximal humerus fractures in the elderly / 中国骨伤

The proximal medial column of the humerus is a continuous cortical region in the inner and lower part of the humerus head, which has attracted more and more attention in clinical and scientific research since it was proposed. It has been shown to increase the stability of internal fixation, maintain the height of the humeral head to prevent varus, and reduce the risk of screw penetration. Biomechanical studies have also shown that the medial column has an outstanding performance in increasing the stiffness, torsion resistance, and shear resistance of the locking plate. Although it has many benefits, there is no unified definition of its concept and specific region, and the existing classification does not include the medial column, therefore more researches are required to provide supporting information. The methods of medial column reconstruction mainly include locking plate combined with talus screw, locking plate combined with bone grafting, internal and external double plate combined support, locking plate combined with bone cement, and humeral cage. These methods have their own characteristics, however they will increase the cost of surgery and bring new complications. How to determine the best way of reconstruction is one of the focuses of future research. In this review, the concept of the proximal medial humerus column, the role of maintaining internal fixation, the role of biomechanics and the reconstruction methods are reviewed.

Locking plate fixation with fibular strut allograft versus locking plate fixation alone for the treatment of proximal humeral fractures in adults:a Meta-analysis / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy of locking plate fixation with a fibular strut allograft (FA group) and locking plate fixation alone (LP group) in the treatment of proximal humeral fractures in adults by Meta-analysis.@*METHODS@#Databases including PubMed, The Cochrane Library, Embase, Chinese BioMedical Literature Database(CBM), China National Knowledge Infrastructure(CNKI), WanFang Data, and China Science and Technology Journal Database (cpvip Database) were searched by computer from establishing to March 2020 to collect studies about locking plate fixation with fibular strut allograft versus locking plate fixation alone for proximal humeral fractures in adults. Two reviewers independently screened literature, extracted data, and assessed the risk of bias of included studies. The postoperative humeral head height changes, neck-shaft angle changes, Constant-Murley score, American Shoulder and Elbow Surgeons(ASES)score, visual analogue scale(VAS), varus malunion rate, and screw penetration rate were compared by RevMan 5.3 software for Meta-analysis.@*RESULTS@#Ten cohort studies were enrolled in a total of 749 patients, 300 patients in the FA group and 449 patients in the LP group. The results of Meta-analysis showed that locking plate with fibular strut allograft was superior to locking plate fixation alone in the changes in humeral head height [MD=-2.69, 95%CI(-3.24, -2.13), P<0.000 01], the changes in neck-shaft angle [MD=-5.65, 95%CI(-7.18, -4.12), P<0.000 01], Constant-Murley score [MD=9.00, 95%CI(4.26, 13.73), P=0.000 2], the ASES score [MD=5.56, 95%CI(4.29, 6.84), P=0.000 01], VAS score [MD=-0.23, 95%CI(-0.37, -0.09), P=0.001], the varus malunion rate [RR=0.22, 95%CI(0.09, 0.53), P=0.000 7] and the screw penetration rate [RR=0.26, 95%CI(0.13, 0.55), P=0.000 3], respectively.While there was no significant difference in the rate of osteonecrosis of the humeral head [RR=1.18, 95%CI(0.57, 2.45), P=0.65].@*CONCLUSION@#For proximal humeral fractures in adults, current evidence shows that locking plate fixation with fibular strut allograft is superior to single locking plate fixation in improving postoperative radiological outcomes and shoulder function, relieving postoperative pain, reducing varus malunion rate and screw penetration rate. However, the efficacy in decreasing the osteonecrosis rate is not clear. Due to limited quality and quantity of the included studies, more high-quality studies are required to verify the above conclusion.

Locking compression plate combined with medial buttress plate for the treatment of osteoporotic comminuted proximal humerus fractures / 中国骨伤

OBJECTIVE@#To explore clinical effect of lateral locking compression plate combined with medial buttress plate in treating osteoporotic comminuted fractures of proximal humerus.@*METHODS@#From May 2017 to December 2021, 12 patients with osteoporotic comminution of proximal humerus were treated by lateral locking compression plates combined with medial buttress plates, including 5 males and 7 females, aged from 55 to 78 years old, bone mineral density(BMD) less than -2.5 g/cm3, the time from injury to operation was from 2 to 6 days. According to Neer classification, 7 patients were type Ⅲ, 4 patients were type Ⅳ and 1 patient was type Ⅵ. Postoperative complications, fracture healing and internal fixation were observed and Constant-Murley score of shoulder joint was used to evaluate clinical effects at 6 months after operation.@*RESULTS@#Postoperative wound healed well at stage I. All patients were followed up from 6 to 18 months. Humeral head collapse and necrosis occurred in 1 patient and humeral head varus in 1 patient. No impact of shoulder joint, internal fixation loosening occurred. Constant-Murley score at 6 months ranged from 45 to 90 points, and 6 patients got excellent result, 3 good, and 3 poor.@*CONCLUSION@#Locking compression plate combined with medial buttress plate could effectively reconstruct medial humeral column support and enhance fracture stability, and receive satisfactory clinical results. However, no control group was established in this study, and function of shoulder joint has not been evaluated many times after operation, so it cannot dynamically reflect changes of shoulder joint function.

Double plate technique and tendon fixation of long head of biceps brachii in treating Neer 3 to 4 partial fractures of proximal humerus / 中国骨伤

OBJECTIVE@#To explore clinical effect of double plate technique in treating Neer 3 to 4 partial fractures of proximal humerus.@*METHODS@#From May 2018 to December 2020, 38 patients with proximal humeral classified to Neer 3 to 4 partial fractures were treated with double plate technique and long head tendon fixation of biceps brachii, including 23 males and 15 females, aged from 41 to 89 years old with an average of (67.00 ± 9.76) years old;23 patients classified to Neer 3 fracture, 15 classified to Neer 4 fracture;the time from injury to operation ranged from 5 to 12 days with an average of (8.00±2.86) days. Degree of pain was evaluated by numerical rating scale(NRS) on the third day after operation; change of height of humeral head and angle of humeral neck stem were measured and compared between 2 days and 1 year after operation. Neer score was used to evaluate recovery of shoulder joint after operation at 1 year after operation.@*RESULTS@#All 38 patients were followed up for 12 to 19 months with an average of (14.00±1.59) months. NRS score at 3 days after operation was (1.95±0.73) points. Fracture healing time ranged from 2.2 to 3.2 months with an average of(2.60±0.27) months. There were no significant difference in the height of humeral head and angle of humeral neck trunk between two days and 1 year after operation(P>0.05). Four Neer 4 fracture patients occurred absorption of greater tubercle of humerus and partial cystic change of humeral head, but the activity function of shoulder joint was good. Postoperative Neer score at 1 year was 89.50±5.19, and 20 patients got excellent results, 16 good, and 2 moderate.@*CONCLUSION@#Double plate technique and long head tendon fixation of biceps brachii were used to treat Neer 3 to 4 fractures of proximal humerus has good clinical effect, and postoperative pain was mild, without special instruments.

Bilateral fracture of the shoulders following epileptic seizures: a case report / Fratura bilateral de ombros após convulsões epilépticas: relato de caso

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Convulsive seizures caused by hyponatremia occur when this condition is severe and develops quickly, resulting in a brain's adaptive inability to contain brain swelling. Seizures are rarely the cause of shoulder fractures. This is a case report of bilateral humerus fracture following a single epileptic seizure caused by drug hyponatremia, an unconventional event in medical practice. A 69-year-old woman was admitted to the emergency room after a single tonic-clonic seizure with spontaneously ceased sphincter relaxation, showing Glasgow 6. No falls or restraint were reported by observers. When alert, the patient reported pain and difficulty moving both arms. During examination, the movement was li- mited to the right and left. Anteroposterior radiographs revealed bilateral fracture at the neck of humerus. To complement inves- tigation for further lesions, a computed tomography confirmed bilateral fracture-dislocation with impaction of the humeral head with the glenoid. Atraumatic bilateral fracture-dislocation of the humerus after epileptic seizure is a very rare event. It is believed that some of these diagnoses have been neglected due to the difficulty of characterizing the patient's pain in a postictal state. The importance of a detailed physical examination shall be emphasized in risk groups such as the polymedicated elderly.

Resultados funcionales y radiográficos de la prótesis reversa y la reinserción del troquíter en pacientes con fracturas de húmero proximal / Functional and radiologic outcomes of reverse shoulder arthroplasty and greater tuberosity reattachment in proximal humerus fractures

Objetivo: Comunicar los resultados funcionales y radiográficos de pacientes tratados con prótesis reversa por fracturas complejas. El objetivo secundario fue determinar la relación entre rangos de movilidad y puntaje ASES con la evolución radiográfica del troquíter. Materiales y Métodos: Se incluyeron 16 pacientes >65 años, tratados con prótesis reversa y reinserción del troquíter, entre 2013 y 2017, operados antes de las 4 semanas del trauma y con un seguimiento mínimo de 2 años. Se consignaron el puntaje ASES y el rango de movilidad activa. En las radiografías, se evaluaron la posición y la consolidación del troquíter, y se registraron las complicaciones y su tratamiento. Resultados: La media de la edad fue 74.5 años (RIC 66-78.5), 11 (69%) eran mujeres. Once fracturas (69%) eran a 4 fragmentos y 5, luxofracturas a 4 fragmentos. La media entre el trauma y la cirugía fue 9.4 días y el seguimiento, 29.5 meses. En 9 casos (56%), el troquíter presentó consolidación. Rotación interna: 5 pacientes alcanzaron la región glútea con el pulgar; 4, la vértebra T12; 4, la vértebra L3; 3, la T7. Las medianas de rotación externa y flexión anterior fueron 30° (RIC 17,5-40) y 100° (RIC 87,5-160). El puntaje ASES promedio fue 78,3 (RIC 63,3-87,4). No hubo una asociación estadísticamente significativa entre la evolución del troquíter y la flexión anterior y el puntaje (p = 0,24 y 0,52, respectivamente). Conclusión: La prótesis reversa en fracturas agudas con reinserción de las tuberosidades puede llevar a buenos resultados funcionales. No se encontró relación entre la consolidación del troquíter y el puntaje ASES. Nivel de Evidencia: IV

Objective: To report functional and radiologic outcomes of reverse shoulder arthroplasty (RSA) in patients with complex proximal humeral fractures. A second objective was to assess the relation between the greater tuberosity healing and the range of motion (ROM) and the American Shoulder and Elbow Surgeons (ASES) score. Materials and Methods: Sixteen patients treated between 2013 and 2017, older than 65 years old, operated before 4 weeks after the trauma, and with a minimum of 2-year follow-up were included. ASES scores and active ROMs were recorded. Greater tuberosity and the prosthesis position and healing were radiologically evaluated, and the complications and treatment were recorded. Results: The median age was of 74.5 years (IQR 66-78.5), 11 patients were females (69%). According to Neer classification, 11 cases were four-part fractures and 5 were four-part fracture-dislocations. The average time between trauma and surgery was 9.4 days, and the average follow-up was of 29.5 months. The greater tuberosity was healed in 9 cases (56%). Internal rotation: 5 patients (31.25%) were able to reach up with their thumbs to gluteal level, 4 (25%) to T12, 3 (18.75%) to T7, and 4 (25%) to L3. The medians for external rotation and forward flexion were 30° (IQR 17.5°-40°) and 100° (IQR 87.5°-160°). The average ASES score was of 78.3 (IQR 63.3-87.4). There was no significant statistical relation between greater tuberosity healing and forward flexion or ASES score (P=0.24 and P=0.52, respectively). Conclusion: The use of reverse prostheses for complex fractures with greater tuberosity reattachment could lead to good functional outcomes, low complication rates and reoperations. There was no significant statistical relation between ASES score and greater tuberosity healing or failure to heal. Level of Evidence: IV

Ultrasound-guided multiple peripheral nerve blocks, a way out for anesthesia in morbidly obese patients for bone marrow aspiration / Múltiplos bloqueios de nervos periféricos guiados por ultrassom, uma saída para anestesia em pacientes com obesidade mórbida para aspiração de medula óssea

Abstract Morbid obesity is associated with various pathophysiological changes which affect the outcome of anaesthesia and surgery. So it's challenging to give anaesthesia to such patients. We present a 59-year-old adult morbidly obese, hypertensive, diabetic female with hypothyroidism operated for proximal humerus fracture and now presented with non-union of fracture, requiring percutaneous injection of bone marrow aspirate from the iliac crest to the site of non-union. The patient was extremely anxious and refused to undergo the procedure under local anaesthesia or sedation and demanded anaesthesia. Given her comorbidities general anaesthesia (GA) was avoided and the procedure was accomplished using Ultrasound (USG) guided Transversus abdominis plane (TAP) block and Lateral Femoral Cutaneous Nerve (LFCN) block for the bone marrow aspirate from the iliac crest and Intercostobrachial nerve block (T2) was given to prevent pain while injecting the aspirate into the non-union site. Dexmedetomidine and ketamine were given for deep level sedation and analgesia. TAP block and LFCN block is generally used for post-op analgesia but can be also used for surgical anaesthesia instead of General anaesthesia in specific scenarios. Its perioperative application and its potential use instead of GA have been discussed.

Resumo A obesidade mórbida se associa a várias alterações fisiopatológicas que afetam o desfecho da anestesia e cirurgia. É, portanto, um desafio anestesiar tais pacientes. Apresentamos uma mulher adulta de 59 anos, obesa mórbida, hipertensa, diabética, com hipotiroidismo, submetida a cirurgia devido a fratura proximal do úmero e que compareceu ao serviço com fratura não consolidada, e com indicação de injeção percutânea de aspirado de medula óssea da crista ilíaca na fratura não consolidada. A paciente estava extremamente ansiosa e recusou o procedimento sob anestesia local ou sedação e exigiu anestesia. Em função de suas comorbidades, Anestesia Geral (AG) foi evitada e o procedimento foi realizado usando bloqueio do Plano Transverso Abdominal (PTA) guiado por Ultrassonografia (USG) e bloqueio do Nervo Cutâneo Femoral Lateral (NCFL) para aspiração de medula óssea da crista ilíaca. O bloqueio do nervo Intercostobraqueal (T2) foi realizado para evitar dor durante a injeção do aspirado. Dexmedetomidina e ketamina foram dadas para sedação profunda e analgesia. O Bloqueio PTA e bloqueio NCFL geralmente são usados para analgesia pós-operatória, mas também podem ser usados para anestesia cirúrgica substituindo a anestesia geral em condições clínicas específicas. O emprego desses bloqueios no perioperatório e seu uso potencial no lugar de AG têm sido discutidos.

Alteración de mediciones radiográficas en osteosíntesis de húmero proximal con clavo centromedular / Alteration of X-ray measurements in proximal humerus osteosynthesis with intramedullary nail

Resumen: Introducción: La calidad de reducción en las fracturas de húmero proximal es posible valorarla a través de criterios radiográficos (ACD = ángulo cervicodiafisario; OM = offset medial; DTC = distancia tuberosidad-cabeza y ES = espacio subacromial), los cuales predicen la funcionalidad. Sin embargo, estos criterios establecidos para otros implantes no están descritos para el clavo centromedular. Material y métodos: Estudio de cohorte observacional y retrospectivo en pacientes > 18 años con osteosíntesis con clavo centromedular (durante el período de 2014 a 2017), en donde se evaluaron las características demográficas, severidad de lesión (clasificación de Neer) y las mediciones radiográficas progresivas y complicaciones. Resultados: Se analizaron 84 casos, cuya edad en promedio fue de 65 ± 2 años y la media de seguimiento de 13.9 meses. Por clasificación de Neer: 40.4% fueron grado II; 29.7%, grado III y 29.7%, grado IV. La consolidación en varo aumenta 10.7% al final del seguimiento, siendo aquellos pacientes Neer grado III y IV los más frecuentes. La deformidad > 140o predomina para Neer grado II (n = 15/34). En 30.9%, se presenta un cambio de ACD (ΔACD) ≥ 10o. En general, 86.9% tiene cambios de DTC < 5 mm. En los casos Neer grado III/IV, 32% tiene una alteración de ES > 5 mm. La complicación más frecuentemente es la necrosis avascular (NAV) con 44% de los casos. Conclusiones: Las mediciones radiográficas presentan cambios en valoraciones a largo plazo. Las alteraciones en ACD (> 10o) y ES (> 5 mm) se dan en mayor proporción en aquellos pacientes Neer grado III/IV (acorde con la severidad de la fractura), lo que favorece consolidaciones viciosas en varo o valgo y una mayor presencia de NAV.

Abstract: Introduction: The quality of reduction in proximal humerus fractures is valuable with radiographic criteria (Neck-shaft angle [NSA]; medial offset [MO]; distance head tuberosity [DHT] and subacromial space [SS]) that predict functionality. These criteria set for other implants are not described for the intramedullary nail. Material and methods: Observational cohort study, retrospective, with patients > 18 years, with osteosynthesis with intramedullary nail (2014 to 2017), evaluating demographic characteristics, severity of injury (Neer classification), progressive radiographic measurements and complications. Results: 84 cases with an average age of 65 ± 2 years and an average follow-up of 13.9 months were analyzed. By Neer rating 40.4% were grade II, 29.7% grade III and 29.7% grade IV. Consolidation in varus increases to 10.7% at the end of follow-up, with Neer III and IV patients. The >140o deformity is prevalent for Neer II (n = 15/34). 30.9% have a change of neck-shaft angle of ≥ 10o. Overall 86.9% has HTD changes < 5 mm. Cases Neer III/IV 32% has alteration of SS > 5 mm. The most common complication is avascular necrosis (AVN) with 44% of cases. Conclusions: Radiographic measurements have changes in long-term follow-up. Alterations in NSA (> 10o) and SS (> 5 mm) occur in higher proportion of Neer III/IV patients, according to the severity of the fracture, favoring vicious consolidations in varus or valgus and increased presence of AVN.

Treatment progress on proximal humerus fracture with proximal humerus cage / 中国骨伤

Proximal humerus fracture is one of the common shoulder fractures. With the increase in incidence, the proportion of surgical intervention is increasing. This paper explores the traditional and new treatment methods for proximal humerus fracture. Locking plate technology is the most commonly used method in the clinic, but its complication rate of intra-articular screw penetration and reoperation is too high.Fibular strut allografts can provide adequate support, but it is a significant trauma surgery and has a high incidence of potential disruption to necessary vascular.Arthroplasty is one of the treatments for complex proximal humerus fractures, but it has a long learning curve and high cost.In recent years, the proximal humerus cage's intervention model has emerged, which has the inherent advantagesof a three dimensional structure, which can provide adequate load bearing support for the humeral head and provide flexible screw placement Angle. The cage offers a new technical option to reduce postoperative complications and improve patients' rehabilitation safety. A comprehensive grasp of the treatments of proximal humerus fracture and rational choice of intervention measures will benefit patients.

Manejo quirúrgico de fracturas extraarticulares de la escápula. Reporte de caso y revisión de literatura / Surgical treatment of an extraarticular scapula fracture. Case report and literature review

Resumen: Introducción: Las fracturas escapulares comprenden 1% del total de las fracturas en general y de 3 a 5% del hombro, las cuales se presentan por alta energía en pacientes jóvenes. Sólo 10% tiene indicación quirúrgica al tomarse como base la alteración de complejo suspensorio del hombro. El objetivo es valorar el resultado de pacientes con indicación quirúrgica así como una revisión de la literatura. Reporte de casos: Presentamos dos pacientes con fractura del cuerpo escapular derecho Bartonicek D con desplazamiento mediolateral, deformidad angular anteroposterior y alteración del ángulo glenopolar. Se realizó el manejo quirúrgico con osteosíntesis y placas convencionales y anatómicas. Se realizó valoración funcional y seguimiento radiográfico de ambos casos a los seis meses y se obtuvo arcos de movilidad flexión 180o/170o en ambos casos, así como escalas funcionales DASH 22/25, Constant 90/89 y Simple Shoulder Test 11/11 respectivamente; se obtuvo una consolidación ósea grado III-IV de Montoya. Discusión: Se considera importante realizar una adecuada reducción y estabilización del trazo de fractura debido al bajo grado de satisfacción con tratamiento conservador en pacientes con alta demanda funcional, que consiste en dolor residual, pinzamiento y disquinesia escapular. Se recomienda la cirugía para estas fracturas ya que comprometen la cadena cinética del hombro e impactan en el resultado funcional a corto y mediano plazo.

Abstract: Introduction: Scapular fractures comprise 1% of all fractures and 3 to 5% of the shoulder, they occur in young patients by high energy trauma. Only 10% have surgical indication based on the alteration of the shoulder's suspensory complex. The objective is to assess the outcome of patients with surgical indication as well as a review of the literature. Case report: We present two patients with Bartonicek D fracture of the right scapular body with mediolateral displacement, anteroposterior angular deformity and alteration of the glenopolar angle. Surgery was performed on both cases with conventional and special anatomical plates. Functional assessment and radiographic follow-up of both cases were performed at 6 months, obtaining flexion mobility of 180º/170º in both cases, as well as functional scales DASH 22/25, Constant 90/89 and Simple Shoulder Test 11/11 respectively; with bone consolidation grade III-IV of Montoya. Discussion: Due to the low degree of satisfaction with conservative treatment in patients with high functional demand, and multiple complications consisting in residual pain, impingement and scapular dyskinesia; it is important to perform an adequate reduction and stabilization of the fracture. We recommend surgical management for this type of fractures since they compromise the kinetic chain of the shoulder and impact the functional outcome in the short and medium term.

Application of the modified internal fixation method of minimally invasive percutaneous plate osteosynthesis in treatment of proximal humeral fracture / 北京大学学报(医学版)

OBJECTIVE@#To study the clinical outcomes and characteristics of fracture healing of a modified internal fixation method, which was implemented by placing four and two screws respectively at the proximal and distal end of the locking plate in the minimally invasive percutaneous plate osteosynthesis (MIPPO) for patients with proximal humeral fractures.@*METHODS@#Patients in Peking University Third Hospital from February 2010 to December 2016 were brought into this retrospective study. Based on different operation methods, they were divided into minimally invasive (MI) group and non-minimally invasive (non-MI) group, and the patients in MI group were performed with the modified internal fixation. In order to observe the varying efficacy for different fracture types between the two groups, we further investigated the patients with Neer two-part and three-part fracture, respectively. The follow-up parameters included general physical examination, X-ray, visual analogue scale (VAS) and Constant-Murley score.@*RESULTS@#A total of 117 patients with an average age of (61.5±16.2) years met the inclusion criteria, and MI group included 45 patients, non-MI group included 72 patients. According to the Neer classification, there were 46 cases of two-part fracture, 63 cases of three-part fracture and 8 cases of four-part fracture. In MI group, there were 17 males and 28 males with an average age of (62.2±17.1) years, including 18 cases of two-part fracture, 23 cases of three-part fracture and 4 cases of four-part fracture. In non-MI group, there were 27 males and 45 females with an average age of (60.1±17.7) years, including 28 cases of two-part fracture, 40 cases of three-part fracture and 4 cases of four-part fracture. There were no significant differences between the two groups in terms of gender (P=0.975), age (P=0.545) and fracture type (P=0.756). The average hospital-stay in MI group and non-MI group was (2.8±1.1) days and (4.3±1.3) days (P=0.023), the operation time was (67.8±14.9) min and (102.3±34.1) min (P<0.001), the blood loss was (21.3±6.5) mL and (181.5±55.6) mL (P<0.001), the Constant-Murley score was 6.1±0.9 and 6.5±0.8 (P=0.032) one week after surgery, and the Constant-Murley score was 66.1±4.3 and 63.4±4.9 (P=0.006) three months after surgery, MI group had significant advantages in these aspects. In terms of Neer two-part and three-part fracture, the VAS score (5.9±0.8) one week postoperatively and the Constant-Murley score (66.6±3.7) three months postoperatively were significantly superior in MI group (P<0.05). In MI group, delayed fracture healing occurred in 1 case (2.2%) and abduction was restricted in 1 case (2.2%). In non-MI group, delayed fracture healing occurred in 3 cases (4.2%) and abduction was restricted in 2 cases (2.8%). There were no internal fixation complications and humeral head necrosis in both groups.@*CONCLUSION@#Applying the modified internal fixation in MIPPO to cure proximal humeral fractures is effective clinically with thick callus formation occurring at the fracture site. The fracture can achieve normal healing and the shoulder functions can restore well, indicating the modified surgical method is a good treatment option.