Open Reduction and Long Locking Plate Fixation of Complex Proximal Humeral Metadiaphyseal Fractures.

BACKGROUND: A minority of proximal humeral fractures extend into the diaphysis and their optimal treatment remains controversial. We evaluated the outcomes and risk of complications in patients with these injuries, treated by a protocol of open reduction and long locking plate fixation (LPF). METHODS: Between 2007 and 2014, all locally resident patients with a proximal humeral fracture extending into the diaphysis were referred to a specialist shoulder clinic. Operative treatment using a protocol of open reduction and LPF was offered to medically fit patients. Those with 2-year radiographic follow-up were included in the study, and standardized assessments of clinical and radiographic outcomes were performed during the first 2 years postoperatively. At a mean of 8.8 years (range, 5 to 12 years) after LPF, the functional outcomes and satisfaction of surviving, cognitively intact patients were assessed with a questionnaire study. RESULTS: One hundred and two patients met the inclusion criteria; the majority were older women who had incurred the injury during a simple fall. Fractures were divided into 2 types depending on the pattern of diaphyseal extension. The pain levels, functional scores, and satisfaction with treatment were satisfactory both at the 2-year follow-up and at the longer-term follow-up at a mean of 8.8 years postsurgery. Complications were predominantly due to postsurgical stiffness (in 7 patients, with 3 undergoing additional surgery) and nonunion or fixation failure (in 7 patients, with 6 undergoing additional surgery). CONCLUSIONS: Proximal humeral fractures with diaphyseal extension are rare. The results of our study support the use of LPF in medically stable patients in centers with the expertise to perform these procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bilateral posterior fracture-dislocation of the shoulders: Two rare case reports and literature review.

RATIONALE: Bilateral posterior fracture-dislocation of the shoulders occurs rarely and the diagnosis is often challenging. This injury is often missed or delayed on initial presentation, leading to continuous pain, disability, and rising medical costs. Timely diagnosis and proper treatment are very important to restore shoulder function. PATIENT CONCERNS: Here we report 2 rare cases. Case 1 was a 53-year-old physical worker with severe pain and limited shoulder movement after an unexpected fall. Case 2 was a 55-year-old man with pain in upper limbs and shoulders after an electric shock. DIAGNOSIS: Both of them were diagnosed as bilateral posterior fracture-dislocation of the shoulders by computed tomography (CT) scan. INTERVENTION: After systematic preoperative evaluation, both of them were treated with open reduction and internal fixation. OUTCOMES: After 16 months follow-up, case 1 was pain-free in both shoulders. He had returned to full activity and was satisfied with his level of function. At 24 months follow-up, both shoulders of case 2 were painless and stable with acceptable range of motion and he was able to carry out daily activities. LESSONS: Our case reports highlight that bilateral posterior fracture-dislocation of the shoulders is easy to be missed; one way to prevent missing diagnosis is to suspect cases with pain and limited external rotation, especially those with a history of seizures, electric shock, or severe trauma; appropriate history inquiry, physical examination, proper shoulder images are the key to correct diagnosis.

Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures.

BACKGROUND: Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. METHODS: The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. RESULTS: The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). CONCLUSIONS: The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients' prognosis than the conventional Neer classification.

Continuous Paravertebral Nerve Block for Scapula Fracture Analgesia: A Case Report.

A 46-year-old man presented with severe refractory posterior shoulder pain due to a left scapular fracture sustained during a motor vehicle collision. Despite multimodal oral and intravenous analgesics, the patient's pain remained difficult to control. A continuous paravertebral nerve block was performed between the second and third thoracic vertebrae resulting in excellent analgesia of the scapular pain. This case suggests that a continuous thoracic paravertebral block placed between the second and third vertebrae may be considered as part of multimodal analgesia in patients with scapular fractures.

Predictive value of valgus head-shaft angle in identifying Neer 4-part proximal humerus fractures. A radiographic and CT-scan analysis of 120 cases.

BACKGROUND AND AIM OF THE WORK: Understanding the fracture morphology and its relation to the expected outcome and risk of complications is fundamental for proximal humerus fractures (PHFs) management. Most Neer 3- and 4-part fractures may deserve surgical treatment. Unfortunately, plain x-rays may not be able to differentiate between a 3- or 4-part fractures unless an axillary or analogue projection is carried out. Aim of the present study is to evaluate whether a high valgus head-shaft angle degree is predictive of a Neer 4-part rather than a 3-part fracture. METHODS: The study included 120 3-(75 cases) and 4-(45 cases) part PHFs (valgus displaced in 98 cases), M:F ratio = 1:2.6, mean age 65.7 years, classified on CT scan images. The humeral head shaft angle was calculated on AP x-rays and statistically correlated with 3 and 4-part fractures to identify values predictive of 4-part fracture. RESULTS: Valgus head/shaft angle was significantly higher in 4-part fractures, especially in the valgus displaced group (p < 0.001). A cutoff value of 168.5° was identified as predictive of a 4-part fracture with a sensibility of 74% and specificity of 78%. Increasing by 1 degree the humeral head-shaft angle, the chance to have a 4-part fracture increases of 3% in the whole population and of 11% in the valgus sub-group. CONCLUSION: The severity of PHF can be predicted analysing valgus head shaft angle on AP x-rays with a sensibility of 74% and specificity of 78% in identifying a 4-part fracture with a cutoff value of 168.5°.

Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients.

BACKGROUND: Reverse shoulder arthroplasty (RSA) in complex shoulder fractures is ever more frequently. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures (PHFs) treated with RSA, with and without tuberosities grafting. METHODS: Between January 2009 and June 2014, 55 patients aged ≥65 years with 3- and 4-part PHFs were treated surgically. Patients' files and the hospital's digital database were reviewed retrospectively with at least 5-year of follow up. We constituted three groups according to the tuberosity consolidation: patients in whom the tuberosities showed anatomic consolidation (Group I) and patients either with secondary displacement of the tuberosities (Group II) or without tuberosity repair (Group III). RESULTS: The 74% of the repaired tuberosities consolidated in anatomic position. Among range of motion (ROM), we reported that forward elevation, abduction and external rotation were significantly better in Group I than those in Group II-III. Furthermore, quick Dash score and Constant score showed more satisfied results in Group I. Regarding complications, not infection or instability were found in group I. On the other hand, in group II, we reported one patient with deep infection, leading to two steps surgery. In group III, we recorded two patients with instability required implant revision and one with deep infection treated by revision. CONCLUSION: RSA showed satisfied results even at 5 year follow up. Preservation of the tuberosities in anatomic position improves active forward elevation and external rotation as well as patient satisfaction with less complications.

Intramedullary nailing of displaced four-part fractures of the proximal humerus.

BACKGROUND: Intramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail. DESIGN: prospective monocentric cohort study. SETTING: single level 1 traumacenter. MATERIALS AND METHODS: From February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study. RESULTS: After mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity. CONCLUSIONS: Intramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result. LEVEL OF EVIDENCE: Level 2b - monocentric prospective cohort study.

Surgical and Non-Surgical Treatment for 3-Part and 4-Part Fractures of the Proximal Humerus: A Systematic Review of Overlapping Meta-Analyses.

This systematic review of overlapping meta-analyses was conducted to propose a principle to make decisions for comparing clinical safety and efficacy of surgical and non-surgical treatment for displaced 3-part and 4-part fractures of the proximal humerus. Three electronic databases (PubMed, EMBASE, and the Cochrane Library) were systematically searched to retrieve available published systematic reviews and meta-analyses comparing surgical versus non-surgical treatment for displaced 3-part and 4-part fractures of the proximal humerus. Ten meta-analyses were identified for this investigation. Based on the application of selection with the Jadad algorithm, a meta-analysis including 6 randomized clinical trials was selected for this systematic review, which demonstrated the best available evidence that no statistically significant differences were found in the Constant score, health-related quality of life, and mortality between surgical and non-surgical treatments for displaced 3-part and 4-part fractures of the proximal humerus; however, surgical treatment was associated with a significant increase in the incidence of reoperation. This systematic review of  overlapping meta-analyses reveals that although surgical treatment is more advantageous than and superior to non-surgical treatment for displaced 3-part and 4-part fractures of the proximal humerus, the former leads to a higher incidence of postoperative complications.

Humeral head histopathological changes in cuff tear arthropathy.

PURPOSE: The aim of this study was to investigate the histopathological changes in the humeral head in cuff tear arthropathy (CTA) compared with those in glenohumeral osteoarthritis (OA) and humeral neck fracture, which served as non-cuff tear controls. METHODS: Twenty-three humeral heads extracted at the time of shoulder prosthesis arthroplasty between June 2014 and July 2015 were evaluated in the present study. The diagnoses included four-part humeral neck fracture ( n = 4; average age, 85.0 years), glenohumeral OA ( n = 4; average age, 71.0 years), and CTA ( n = 15; average age, 73.0 years). The humeral heads were evaluated pathologically by hematoxylin and eosin and Safranin-O staining, and the thickness of the articular cartilage was measured. RESULTS: Fibrillation, thinning, and tearing of the cartilage were observed in the superior area of the humeral heads in CTA and glenohumeral OA. In CTA cases, clusters of chondrocytes in the cartilage were observed. Moreover, the thickness of the cartilage layer in the middle of the humeral head was 1.54 ± 0.07, 0.32 ± 0.46, and 2.19 ± 0.50 mm in humeral neck fracture, glenohumeral OA, and CTA, respectively. The cartilage layer in CTA was thicker than that in glenohumeral OA (CTA vs. OA: p < 0.05). CONCLUSION: OA changes in the superior area of the humeral heads and thickening of the cartilage layer from the middle to the inferior of the humeral heads were confirmed histopathologically, suggesting that simultaneous mechanical and nutritional factors might be contributing to CTA pathogenesis. The current study provided the better understanding of cartilage damage and thickening in CTA. This will help guide treatment options in the setting of CTA.

Inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of proximal humerus fractures.

BACKGROUND: This study aimed to explore the effect of retaining inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of proximal humerus fractures treated with a locking plate. METHODS: Twelve Synbone prosthetic humeri (SYNBONE-AG, Switzerland) were used for a wedge osteotomy model at the proximal humerus, in four groups. In the cortex contact + screw fixation group and cortex contact group, the inferomedial cortical bone contact was retained. In the screw fixation group and control group, the inferomedial cortical bone contact was not retained. Calcar screw fixation was implemented only in the screw fixation groups. The dynamic and static mechanical stability of the models were tested with dynamic fatigue mechanics testing, quasi-static axial compression, three-point bending, and torsion testing. RESULTS: The cortex contact + screw fixation group showed the longest fatigue life and the best stability. There was 35% difference in fatigue life between the cortex contact + screw fixation group and the cortex contact group, 43%between the cortex contact + screw fixation group and screw fixation group, and 63% between the cortex contact + screw fixation group and screw fixation group (P < 0.01). The cortex contact + screw fixation group showed the best axial compressive stiffness, bending stiffness, and torsion stiffness; these were successively decreased in the other three groups (P < 0.01). CONCLUSION: Retaining inferomedial cortical bone contact and fixation with two calcar screws maintained fracture stability with the highest strength and minimum deformation. Of the two methods, restoration of the inferomedial cortical bone support showed better dynamic and static biomechanical properties than placement of calcar screws alone.