Non-operative treatment versus tension-band osteosynthesis in three- and four-part proximal humeral fractures. A retrospective study of 34 fractures from two different trauma centers

Thirty-four patients with three- and four-part proximal humeral fractures from two different trauma centres were studied retrospectively. Sixteen were treated without osteosynthesis and compared with 18 patients treated with tension-band fixation. Fracture classification and clinical examination were made by the same persons in both groups. Most of the three-part fractures healed with good pain relief and good function in daily life but often with a loss of motion. Four-part fractures often led to pain, loss of motion and of function. Conservative treatment seemed superior to tension-band fixation for three-part fractures. Four-part fractures healed with better function and range of motion after tension-band fixation.     

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.     

Closed management and percutaneous fixation of unstable proximal humerus fractures

BACKGROUND: In dealing with displaced proximal humerus fractures, there is still much controversy in treatment modalities. The latest investigations emphasize the concept of minimal exposure and rigid fixation. METHODS: The technique of closed reduction and percutaneous fixation with cannulated screws and k-pins was performed on 19 patients with two- and three-part proximal humerus fractures. The outcomes were evaluated with a mean follow-up of 21 months. RESULTS: All except one case had a solid union of the fracture. Sixteen of 19 patients (84%) acquired good or excellent results according to Neer's classification. No further collapse or avascular necrosis was found. CONCLUSION: The method of closed reduction and percutaneous fixation, although technically demanding, yields satisfactory results in displaced proximal humerus fracture. Cannulated screws provided rigid fixation that was the underlying tenet for early functional retrieval.     

Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs

The intraobserver reliability and inter-observer reproducibility of the Neer classification system were assessed on the basis of the plain radiographs and computerized tomographic scans of twenty fractures of the proximal part of the humerus. To determine if the observers had difficulty agreeing only about the degree of displacement or angulation (but could determine which segments were fractured), a modified system (in which fracture lines were considered but displacement was not) also was assessed. Finally, the observers were asked to recommend a treatment for the fracture, and the reliability and re-producibility of that decision were measured. The radiographs and computerized tomographic scans were viewed on two occasions by four observers, including two residents in their fifth year of postgraduate study and two fellowship-trained shoulder surgeons. Kappa coefficients then were calculated. The mean kappa coefficient for intraobserver reliability was 0.64 when the fractures were assessed with radiographs alone, 0.72 when they were assessed with radiographs and computerized tomographic scans, 0.68 when they were classified according to the modified system in which displacement and angulation were not considered, and 0.84 for treatment recommendations; the mean kappa coefficients for interobserver reproducibility were 0.52, 0.50, 0.56, and 0.65, respectively. The interobserver reproducibility of the responses of the attending surgeons regarding diagnosis and treatment did not change when the fractures were classified with use of computerized tomographic scans in addition to radiographs or with use of the modified system in which displacement and angulation were not considered; the mean kappa coefficient was 0.64 for all such comparisons. Over-all, the addition of computerized tomographic scans was associated with a slight increase in intraobserver reliability but no increase in interobserver reproducibility. The classification of fractures of the shoulder remains difficult because even experts cannot uniformly agree about which fragments are fractured. Because of this underlying difficulty, optimum patient care might require the development of new imaging modalities and not necessarily new classification systems.     

Assessment of the AO classification of intracapsular fractures of the proximal femur

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra- and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used.     

Jones' fractures and related fractures of the proximal fifth metatarsal

At least three fracture types occur in the proximal fifth metatarsal: the Jones' fracture, the proximal diaphysial stress fracture, and the tuberosity avulsion fracture. Each has distinct characteristics. The diaphysial stress fracture is commonly confused with the Jones' fracture, thereby obscuring vital differences in prognosis and treatment. Anatomical and biomechanical characteristics, as well as vascular studies of the proximal portion of the fifth metatarsal, are discussed in an attempt to better understand their diverse healing potentials. Guidelines for treatment are controversial, and must frequently be individualized. Although surgical intervention for certain proximal fifth metatarsal fracture types may speed recovery time, most fractures heal with immobilization. Treatment of displaced, intra-articular fractures, delayed unions, and nonunions usually requires operative methods.     

Periprosthetic humeral fractures: mechanisms of fracture and treatment options

The mink (Mustela vision) is a top trophic level species that readily bioaccumulates environmental pollutants and is considered to be a sensitive indicator of ecosystem health. Spatial trends in levels of organochlorine and heavy metal contaminant burdens were determined from 1991 to 1995 for wild mink from western Northwest Territories (NWT), Canada. Tissue samples from 207 mink from seven communities were analyzed for residues of 63 organochlorines and 10 heavy metals. All groups of organochlorines were detected in mink livers at relatively low levels; maximum community means were 9.52 ng/g sigma DDT and 73.07 ng/g sigma PCB (sum of 43 congeners). There was a general trend of decreasing organochlorine burdens along a northerly or westerly gradient for some groups of compounds, primarily sigma DDT, sigma PCB, sigma chlordane and dieldrin. Toxic equivalents (TEQs) of mink liver tissue were low, with the maximum community mean of 0.28 pg/g wet weight (5.5 pg/g lipid weight). Levels of heavy metal burdens in liver and kidney tissues were found to be relatively low, with the exception of Hg, which was found at moderate levels. There was no obvious geographic trend to the pattern of heavy metal burdens. The available evidence suggests that long-range atmospheric transport is the main source of the organochlorine contaminants observed. Local conditions (geology, water and soil chemistry, diet, etc.) may determine heavy metal burdens. Levels of contaminants in NWT mink appear to be one to two orders of magnitude lower than levels observed to cause reproductive impairment, reduced survival of kits, or lethality in adult mink. In the western NWT mink may be the best indicator to assess trends in environmental contaminants and ecosystem health; periodic monitoring is recommended.     

The conservative and surgical therapy of traumatic humeral shaft fractures

Sixty-three patients with humeral shaft fractures were evaluated clinically and radiographically 18 months after injury; 27 patients were treated surgically (group A) and 36 patients conservatively (group B). Analysis of the results according to a score by Kwasny revealed 6.2 points in group A and 2.2 points in group B (P < 0.0001; F = 46.9). The results of these two comparable groups suggest that conservative treatment of humeral shaft fractures is superior regarding mobility of the shoulder and elbow, strength, the incidence of neurological complications, pain, subjective rating and cosmesis. There were no differences on roentgenograms between the two groups (P = 0.48).     

Treatment of humeral shaft fractures by retrograde locked nailing

From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.     

Ender nailing of acute humeral shaft fractures in multiple injuries

From January 1987 to April 1993, 25 multiply injured patients were treated with closed intramedullary Ender nail fixation of the humeral shaft. Criteria for the procedure were humeral diaphyseal fractures with associated multiple injuries. Seventeen distal and mid-shaft fractures were treated via a modified anterograde approach in which the rotator cuff is not violated. Eight proximal third fractures were treated via the standard retrograde approach. Postoperative follow-up averaged 36 months. Full range of motion was attained 17 of the 25 patients. Of the eight remaining patients, three with a slightly limited range of motion achieved full range of motion following nail removal; three had preoperative radial nerve palsy which resolved within 1 year, and two patients required follow-on plating. In 92 per cent (23 of 25) there were no incidences of infection or non-union. Flexible nails avoid complications of reaming. The modified anterograde approach allows excellent shoulder motion since it does not violate the rotator cuff. Ender nails provide excellent fixation and clinical outcome in the multiply injured patient and are cost effective compared with interlocking nails.     

Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation

BACKGROUND: The G6PD deficiency is a red cell enzymopathy very frequent in certain Mediterranean countries. In Menorca (Balearic Islands), a relatively high incidence of favism carried us to study the prevalence of this alteration, taking advantage of the "Campaign for detection of heterozygous beta-thalassaemia to prevent the homozygous beta-thalassaemia" that we make annually. METHODS: We studied a total of 1139 school boys between 13-14 years old for three consecutive school years. We used the methylene blue as screening test and the deficiency of G6PD was confirmed with enzymatic quantification in the haemolysate. We also analysed the clinical manifestations and studied the relatives. RESULTS: We have confirmed 11 cases of G6PD deficiency (prevalence of 9.7/1000), all of them native of the island. The clinical manifestations were: in 6 cases (54.5%) no clinical manifestations were found, 5 cases (45.4%) had presented neonatal jaundice and 2 cases (18.2%) had suffered a favism crisis. The study of relatives permitted us to analyse 26 additional samples (17 women and 9 men), detecting in 8 of them (4 women and 4 men) the enzymopathy . CONCLUSIONS: The prevalence of G6PD deficiency in Menorca is one of the highest in Spain. Most of the carriers are asymptomatic, the most important clinical manifestations being the neonatal jaundice and favism. The screening test used is efficient for unmistakable hemizygotes detection.     

Treatment of closed humeral shaft fractures with intramedullary elastic nails

PURPOSE: Our purpose is a retrospective study of the results of diaphyseal humeral fracture treatment by elastic intramedullary nailing in comparison with plate osteosynthesis. METHODS: Thirty cases were reviewed, with an average follow-up of 2 years. In 14 cases, flexible nails were used, and in the remaining 16 cases, A-O plates were used. We considered patients' sex and age, fracture type according to the A-O classification, type of treatment, consolidation defects, additional therapeutic procedures, healing time, and functional recovery. The surgical technique of elastic nailing appeared very simple, safe, and rather atraumatic because the nail is introduced in a retrograde manner and does not need proximal interlocking. RESULTS: The results of elastic nailing, in terms of fracture healing time and functional recovery, appeared comparable with the results of plating, and complications appeared milder. CONCLUSION: We conclude that intramedullary elastic nailing is valid for routine use in appropriately selected humeral shaft fractures.     

A proximal humeral fracture, complicated by a pseudoaneurysm--a case report

Torsion of an accessory spleen is a rare entity that can have a variable clinical presentation. We report the computed tomographic (CT) findings of an acute torsion of an accessory spleen in a 13-year-old girl. CT disclosed a hypodense mesenteric mass with peripheral inflammatory changes.     

Acute closed humeral shaft fractures treated with dynamic compression plate

BACKGROUND: To define the efficacy of dynamic compression plates (DCPs) for the treatment of closed humeral shaft fractures. METHODS: A total of 165 patients with closed humeral shaft fractures were studied retrospectively. There were 120 patients who underwent open reduction and internal fixation with DCPs and no bone grafting (BG). Forty-five patients received the same procedures with BG. The mean follow-up period was 93 months. RESULTS: In the DCP without BG group, the average blood loss was 350 ml, operation time was 105 minutes, hospital stay was 8.5 days and fracture union time was 13.5 weeks. In the DCP with BG group, the average blood loss was 525 ml, operation time was 115 minutes, hospital stay was 7.9 days and fracture union time was 9.2 weeks. CONCLUSIONS: In our experience, DCPs are effective for surgical fixation of humeral shaft fractures. Prophylactic BG is recommended for cases with more comminution.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.