ObjectiveTo review the research progress on intra-articular screw penetration in proximal humeral fracture treated with locking plate. MethodsThe domestic and foreign literature about the proximal humeral fracture treated with locking plate was extensively reviewed. The incidence of screw penetration and risk factors were summarized from both primary and secondary screw penetrations, and the reasons of the intra-articular screw penetration and the technical solutions to avoid the penetration were analyzed. ResultsThe incidence of intra-articular screw penetration is about 11%-30%, which includes primary and secondary screw penetrations. The primary screw penetration is related to improper operation, inaccurate measurement, and “Steinmetz solid” effect, which results in inadequate fluoroscopy and blind zone. The secondary screw penetration is related to the loss of reduction and varus, collapse, and necrosis of the humeral head. The risk factors for intra-articular screw penetration include the bone mass density, the fracture type, the quality of fracture reduction, the applied location, number, and length of the plate and screws, and whether medial column buttress is restored. Improved fracture reduction, understanding the geometric distribution of screws, good intraoperative fluoroscopy, and reconstruction of medial column buttress stability are the key points for success. ConclusionThe risk of the intra-articular screw penetration in the proximal humeral fractures treated with locking plates is still high. Follow-up studies need to further clarify the cause and mechanism of screw penetration, and the risk factors that lead to screw penetration, in order to effectively prevent the occurrence of this complication.
ObjectiveTo evaluate the effectiveness of titanium elastic nails for severe displaced proximal humeral fractures in older children. MethodsBetween April 2009 and July 2012, 31 cases of severe displaced proximal humeral fractures were treated with closed or open reduction and fixation with 2 titanium elastic nails, and the clinical data were retrospectively analyzed. There were 23 boys and 8 girls, aged from 10 to 15 years (mean, 12.8 years). The causes of injury were sports injury (16 cases), traffic accident (11 cases), and falling from height (4 cases). The interval from injury to operation was 6 hours to 7 days (mean, 72 hours). According to Neer-Horwitz classification, 17 cases were rated as type III fracture and 14 cases as type IV fracture. There were 21 cases of metaphyseal fractures and 10 cases of epiphyseal fractures. ResultsSatisfactory reduction of fracture and stable fixation were obtained in all patients (closed reduction in 23 cases and open reduction in 8 cases). Primary healing was achieved in all incisions; no infection and neurovascular injury occurred. All patients were followed up 12-36 months with an average of 20 months. X-ray films showed that all fractures healed at 7-10 weeks (mean, 8 weeks). During follow-up, no disturbance of development or angulation deformity caused by premature physeal closure or bone bridge formation was observed. At last follow-up, the average Neer score of the shoulder was 95.7 (range, 83-100). The appearance and motion of the shoulder were normal. There was no significant difference in the upper extremity length between affected side and contralateral side[(67.68±2.56) cm vs. (67.61±2.54) cm; t=-1.867,P=0.072]. ConclusionTitanium elastic nails for severe displaced humeral fractures in older children is a safe and effective method with a low complication incidence.
Objective To review the biomechanics of internal fixators for proximal humeral fractures, and to compare the mechanical stabil ity of various internal fixators. Methods The l iterature concerning the biomechanics of internal fixators for proximal humeral fractures was extensively analyzed. Results The most important things for best shoulder functional results are optimal anatomical reduction and stable fixation. At present, there are a lot of methods to treat proximal humeral fractures. Locking-plate exhibites significant mechanical stabil ity and has many advantages over other internal fixators by biomechanical comparison. Conclusion Locking-plate has better fixation stabil ity than other internal fixators and is the first choice to treat proximal humeral fractures.
ObjectiveTo review the literature about the clinical application and research progress on medial support augmentation of plate osteosynthesis for proximal humeral fractures, and to provide reference for clinical treatment.MethodsThe literature concerning medial support augmentation of plate osteosynthesis for proximal humeral fractures in recent years was extensively reviewed, as well as the biomechanical benefit and clinical advantage were analyzed thoroughly.ResultsMedial support augmentation of plate osteosynthesis for proximal humeral fractures is very important, especially in osteoporotic and/or comminuted fractures. Many medial support augmentation methods have been proposed which can be divided into extramedullary support and intramedullary support. It can also be divided into autogenous bone support and allogenic bone support according to the material and source, divided into medial column support, calcar support, and humeral head support according to the support site, and divided into fibular shaft support, femoral head support, anatomic fibula support according to the shape of the augmented fixation. At present, clinical and biomechanical researches show that medial support augmentation is an effective treatment for proximal humeral fractures.ConclusionAs an important treatment strategy for the treatment of proximal humeral fractures, the medial support augmentation of plate osteosynthesis gets the focus from the biomechanical studies and clinical treatment. However, there are still widespread controversies among orthopedic surgeons regarding the support mode, site, implant shape, and material of medial column support for augmentation of proximal humeral fractures. More high-quality clinical trials and biomechanical researches as well as multi-disciplinary integration, are needed to provide better strategy treatment for the treatment of proximal humeral fractures.
Open reduction and internal fixation with plate and screw is one of the most widely used surgical methods in the treatment of proximal humeral fractures in the elderly. In recent years, more and more studies have shown that it is very important to strengthen the medial column support of the proximal humerus during the surgery. At present, orthopedists often use bone graft, bone cement, medial support screw and medial support plate to strengthen the support of the medial column of the proximal humerus when applying open reduction and internal fixation with plate and screw to treat proximal humeral fractures. Therefore, the methods of strengthening medial column support for proximal humerus fractures and their effects on maintaining fracture reduction, reducing postoperative complications and improving functional activities of shoulder joints after operation are reviewed in this paper. It aims to provide a certain reference for the individualized selection of medial support methods according to the fracture situation in the treatment of proximal humeral fractures.
Objective To evaluate the cl inical significance of minimally invasive percutaneous plate osteosynthesis (MIPPO) appl ied in Neer II, III parts fractures of proximal humeraus. Methods The cl inical data were retrospectively analyzed, from 30 patients with Neer II, III parts fractures of proximal humeraus in accordance with selection criteria, who were treated with manual reduction and plaster external fixation (11 cases, non-operative group) or with MIPPO (19 cases, operative group) between January 2008 and May 2010. In non-operative group, there were 6 males and 5 females with an average age of 60 years (range, 56-80 years) and with an average time of 10 hours (range, 3-24 hours) between injury and reduction, including 8 cases of Neer II and 3 cases of Neer III. In operative group, there were 13 males and 6 females with anaverage age of 65 years (range, 45-78 years) and with an average time of 3 days (range, 1-5 days) between injury and operation, including 9 cases of Neer II and 10 cases of Neer III. There was no significant difference in gender, age, fracture type, and time from injury to operation (P gt; 0.05). The shoulder joint function before and after treatments was evaluated according to Constant-Murley Score (CMS) and American Shoulder and Elbow Surgeons’ Form (ASES) scoring systems. Results Thirty patients were followed up. In operative group, the follow-up time ranged from 11 to 18 months (mean, 12 months); all incisions healed by first intention with no compl ication of internal fixation failure, infection, or nerve injury. In non-operative group, the follow-up time ranged from 9 to 15 months (mean, 11 months). The X-ray films showed that fractures healed without humeral head necrosis in 2 groups. The bone heal ing time in operative group and non-operative group was (11.47 ± 2.48) weeks and (11.82 ± 2.44) weeks, respectively, showing no significant difference (t=0.369, P=0.889). The CMS score and ASES score at each time point after treatment were significantly better than those before treatment (P lt; 0.05); the CMS scores in operative group were better than those in non-operative group at 3 weeks, 3 months, and 1 year after treatment (P lt; 0.05); and the ASES score in operative group was better than that in non-operative group at 3 weeks and 3 months after treatment (P lt; 0.05), but no significant difference was found at 1 year after treatment (P gt; 0.05). Conclusion MIPPO fixation using the locking compression plate is an effective option for Neer II, III parts fractures of proximal humeraus. It can provide good functional recovery of the shoulder joint so that patients can get back to their normal l ife as soon as possible.
Because of the complexity of proximal humeral fractures, the treatment of proximal humeral fractures has always been a challenge for clinicians. The MultiLoc intramedullary nail is a new type of internal fixation device which has been gradually used in the treatment of proximal humeral fractures in recent years. At present, it is mainly used in the Neer two- and three-part fractures, especially surgical neck fractures. Its flexible design can provide personalized and multi-plane fixation for fracture patients, “screw-in-screw” and medial supporting screw can effectively reduce the axial displacement and varus angle of humeral head, and minimally invasive surgical incision can reduce the injury of rotator cuff. This review focuses on the research status and related evidence of the design, operation, prognosis, and postoperative complications of MultiLoc intramedullary nail, in order to provide a theoretical basis for the application of MultiLoc intramedullary nail in fracture treatment, and enhance clinicians’ understanding of MultiLoc intramedullary nail as a new type of internal fixation device.
ObjectiveTo observe the influence of different humeral neck-shaft angle on the efficacy in the treatment of proximal humeral fractures with locking plate. MethodsA total of 106 patients with proximal humeral fractures were treated by locking plate between March 2009 and March 2013, and the clinical data were retrospectively analyzed. Of 106 cases, 58 were male and 48 were female, aged from 26 to 71 years (mean, 52.3 years). The causes were traffic accident injury in 54 cases, falling injury from height in 23 cases, falling injury in 21 cases, and others in 8 cases. According to the Neer classification, there were 32 cases of two-part fractures, 65 cases of three-part fractures, and 9 cases of four-part fractures. The time from injury to operation was 1-7 days (mean, 2.7 days). According to neck-shaft angle by X-ray measurements at 1-3 days after operation, the patients were divided into 3 groups:valgus group (>145°), normal group (126-145°), and varus group (<126°) to observe the influence of neck-shaft angle on efficacy. ResultsAccording to postoperative humeral neck-shaft angle, there were 10 cases in valgus group, 75 cases in normal group, and 21 cases in varus group. There was no significant difference in general clinical data among 3 groups (P>0.05). The patients were followed up 6-12 months. The X-ray results showed fracture healing, and no significant difference was found in fracture healing time among 3 groups (P>0.05). After 6 months, the varus angle of femoral head and visual analogue scale (VAS) score of normal group were significantly lower than those of valgus group and varus group (P<0.05). The excellent and good rate of Constant-Murley score was 78.67% (59/75) in normal group, and it was significantly higher than that in valgus group (60.00%, 6/10) and varus group (42.86%, 9/21) (P<0.05), but there was no significant difference between valgus group and varus group (P>0.05). The complication rate was 28.57% (6/21) in varus group, was 10.67% (8/75) in normal group, and was 20.00% (2/10) in valgus group, showing no significant difference among 3 groups (χ2=4.31, P=0.12). ConclusionReconstruction of normal neck-shaft angle is the key to good shoulder function and clinical efficacy in the treatment of proximal humeral fracture.
Objective To compare the effectiveness of locking plate and intramedullary nail in treatment of Neer two- and three-part fractures of the proximal humerus in the elderly. Methods A retrospective analysis was conducted on 86 elderly patients with Neer two- and three-part fractures of the proximal humerus met the selection criteria between January 2015 and December 2018. Forty-six patients were treated with locking plate fixation (locking plate group), and 40 patients with intramedullary nail fixation (intramedullary nail group). There was no significant difference in gender, age, cause of injury, fracture side and type, time from injury to operation, and comorbidities between the two groups (P>0.05). Visual analogue scale (VAS) score, American Shoulder and Elbow Surgery (ASES) score, Constant-Murley score, and shoulder range of motion (forward flexion, abduction, and external rotation) were compared between the two groups. X-ray films were taken to assess the fracture healing, and the neck-shaft angle was measured at 2 days after operation and at last follow-up, and the difference between the two time points was calculated. Results Patients in both groups were followed up 18-40 months, with an average of 30.4 months. There was no significant difference in follow-up time between the two groups (t=−0.986, P=0.327). X-ray films reexamination showed that the fractures of two groups healed, and the healing time was (11.3±2.1) weeks in locking plate group and (10.3±2.0) weeks in intramedullary nail group, which had significant difference between the two groups (t=2.250, P=0.027). The difference of neck-shaft angle was (7.63±7.01)° in locking plate group and (2.85±2.82)° in intramedullary nail group, which had significant difference between the two groups (t=4.032, P<0.001). There was no significant difference in Constant-Murley score, ASES score, VAS score, and shoulder range of motion between the two groups at last follow-up (P>0.05). Complications occurred in 13 cases (28.3%) of locking plate group and in 4 cases (10.0%) of intramedullary nail group, and the difference between the two groups was significant (χ2=4.498, P=0.034). Conclusion Both locking plates and intramedullary nails can be used for the treatment of Neer two- and three-part fractures of the proximal humerus in the elderly. The intramedullary nail fixation surgery is more minimally invasive, which has fewer postoperative complications and faster fracture healing.
ObjectiveTo assess the effect of surgical treatment or conservative treatment on the clinical outcomes for displaced 3-part or 4-part proximal humeral fractures in elderly patients. MethodsWe searched CNKI (between January 1979 and April 2014), Wanfang Data (between January 1982 and April 2014), Medline (between January 1946 and April 2014), PubMed (between January 1966 and April 2014), Embase (between January 1974 and April 2014) and Cochrane Database of Systematic Reviews (between January 2005 and April 2014) for randomized controlled trials comparing surgical treatment and conservative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients. The data were extracted and a Meta-analysis was made using RevMan 5.2. ResultsFive randomized controlled trials with a total of 226 patients were accepted in this Meta-analysis. The differences of Constant scores[WMD=0.48, 95%CI (-4.39, 5.35), P=0.85], incidences of avascular necrosisr of the humeral head[RR=0.66, 95%CI (0.37, 1.16), P=0.15], incidences of nonunion[RR=0.56, 95%CI (0.20, 1.58), P=0.27], incidences of osteoarthritis[RR=0.35, 95%CI (0.10, 1.22), P=0.10] between the two groups were not statistically different. The difference of incidences of additional surgery after primary treatment was statistically significant[RR=3.52, 95%CI (1.18, 10.45), P=0.02]. ConclusionThe results does not support the surgical treatment to improve the shoulder function when compared with conservative treatment for treating elderly patients with displaced 3-part or 4-part proximal humeral fractures. But surgical treatment increases the incidence of additional surgery after primary treatment. Considering surgery can increase the trauma and economic burden of patients, so the conservative treatment is suggested.