Displaced Proximal Humeral Fractures: PART II. · PDF fileFm. 1-13 Fun. 1-C Fig. 1-B:...
Transcript of Displaced Proximal Humeral Fractures: PART II. · PDF fileFm. 1-13 Fun. 1-C Fig. 1-B:...
The PDF of the article you requested follows this cover page.
This is an enhanced PDF from The Journal of Bone and Joint Surgery
1970;52:1090-1103. J Bone Joint Surg Am.CHARLES S. NEER, II
THREE-PART AND FOUR-PART DISPLACEMENTDisplaced Proximal Humeral Fractures: PART II. TREATMENT OF
This information is current as of June 5, 2010
Reprints and Permissions
Permissions] link. and click on the [Reprints andjbjs.orgarticle, or locate the article citation on
to use material from thisorder reprints or request permissionClick here to
Publisher Information
www.jbjs.org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint Surgery
Displaced Proximal Humeral Fractures
PAnT II. TREATMENT OF rfHIOEEI)A1OT ANI) 1�OUR-PART DISPLACEMENT*
BY CHARLES S. NEEIt, II, M.D.t, NEW YORK, N. Y.
Freiii the Dparlnient of Orthopaulic Surgery, College of Physicians and Surgeons-, Columbia
L.nivcrstty, (111(1 The New York ()rthopacdic IIo.s-pital, Columbia-Presbyterian iledical Center,
�Vew York
Iii the �)rece(ling article, a descriptiotu 1115(1 classification of fractures o)f tlse
proximal euid (.)f thue humerus was Presetste(i. Sitsce the select.iots of treatment. seemed
nu)st. (hifficl.llt its patients with three-part. and four-part displacen�ents, it was
tisouglit importatit. to compare tise results of the various methods used its recent
years. The j)urpose of this study was to analyZe the results of closed reduction, open
reduction, ausd l)rosthset.ic reconstruction atsd to cotssider tise teclsnical probleins
etscountered itt the treat.metst of these specific groups of fractures.
Material and Method
A consecutive series of 1 17 j)atietsts �vit.hs displaced three-part and four-part
fractures atid fracture-dislocations, followed for a minin�um period of one year, were
atiItlyze(I. All were treated by members of the permatsetit staff of the Xew York
Orthiopaedic Hospital-Columbia-Presbyterian Medical Center between the years
1953 lUi(l 1969. �fh age of tise patietits raisged from twenty-five to eighty-four
years 1115(1 averaged 53.3 years. The distribution of their ages by decades was: third,
two; fourth, teti; fifth, tweisty-otse; sixth, forty-three; seventh, tlsirt.y-otse; eighths,
nine; 1111(1 uiiusthi, one. rfls(� 1Ett.ieIstI4 1usd beets followed for from otse to sixteen years;
the ltverltge j)et’iO(l of follow-up after itsjury waS 4.5 years. Thirty-seveti pat.ieists
were followed for fi’om oi5e to two years; forty-six, two to five years; fourteen, five to
tets s-ears; Iuti(l twenty, ten to sixteets years. r1�l)(� results in these patieusts were rated
by the nutnet-ical systens (lescribe(l its the j)recednsg i)aper.
11’elttfllo’tst of the eustire series, according to classification, is show-n its Table I.
Closed reduction utsder atiesthesia was atten�j)ted in seveisty-seven patients and t.lse
1)Ositiotl \\�ItS accepted iii tlsirty-otse patietst.s ��-ho were theti treated by a Velpeau
bandage, a hanging cast., or overhead ultiar-piti tractiots. Opeti reduction was
performed iii forty-three patients iii whom the articular segmetst. was discarded itsfive atsd internal fixation was used iii thse remaitsing thirty-eight: ��-ire loops its
sixteeti, Rush nails in eight, silk or nylon in six, splnses in three, Kirschtser wires or
screw-s its fout’, 11usd staples in one. Prosthetic replacement of the Isead atsd recots-
structious of the tuberosit.ies were (lone �fl fort.v-t.hsree patients.
Findings and Results
‘I’/i ree-Part Fractures and Fracture-Dislocations
Group Jj/
There were twetity-three fractures of this type, in w-hichs there was a displace-
meist of over 1.0 centimeter of the greater tuberosity and the shaft but the articular
segmerst remaitsed its contitsuity w-it.h the lesser t.uberosit.y. The attached .subscapu-
* Head iii part at the Annual Meeting of The American Academy of Orthopaedic Surgeolss,
New York, N.Y., January 21, 1969.
t 161 Fort Washingtotu Aveisue, New York, N. Y. 10032.
1090 THE JOURNAL OF BONE AND JOINT SURGERY
DISPLACED PROXIMAL HUMERAL FRACTURES 1091
TABLE I
TREATMENT BY CLASSIFICATION
No. of Closed Open
Patients Treatment Reduction Prosthesis
Three-PartGroup IV 23 7 14 2GroupV 13 3 7 1
VI anterior 17 6 5 6
VI posterior 8 2 4 2
Four-Part4-part fracture 19 7 5 7
VI anterior 31 4 3 22VI posterior 6 0 3 3
117 31 43 43
TABLE IIRESULTS OF CLOSED REDUcTu0N
No. of ReductiotsPatients Accepted
Satisfactory
Result
Three-PartGroup IV 12 7 0
Group V S 3 0VI anterior 13 6 2VI posterior 6 2 1
Fonir-Part
4-part fracture 12 7 0
\.l anterior 23 4 0\_I posterior 3 0 0
3
hans tendots interrsallv rotated the head, exaggeratitsg the defect. in the rotato)r cuff
and causing the articular surface to face posteriorly (Fig. 3-A).
Closed reductiots was consistently unsuccessful its twelve patietsts ; how-ever,
closed treatment in overhead tractiots or hanging casts was contitsued in six patietsts.
In two patients, treated its Isanging casts, non-unioti developed at the surgical-neck
level (Fig. 1-C). In the other four patients disabling malunioni� occurred, with resorp-
tion of the head in one (Table II, Fig. 1-A). Open reduction was performe(l its four-
teen Patieists (Figs. 3-A, 3-B, and 3-C), two of whom had beets initially treated
in traction. Their results were: four excelletst, five satisfactory, atsd five failure. The
five poor results from opets reductiots followed technical errors consistitsg its failure
to approximate tise tuberosities and to repair the defect in the rotator cuff. The
vertical fixatiors (Rushs nails, sphine.s, or Kirschtser wires) failed to hold the tuberos-
ities in apposition (Fig. 6-B). Noti-utsions occurred itu three of these patients at the
level of t.he surgical neck (Table III). A prosthsesis ��-as used early its the series itu
two patients and their results w-ere rated as one excellent and one satisfactory
(Table III).
Group V
In thirteen fractures there w-as displacemerst of the lesser tuberosity and shaft
w-hile the greater tuberosit.y remaitsed its continuity withs the articular segment. Thse
external rotators caused the articular surface to face anteriorly (Fig. 4-A).
Eight were treated by closed reduction without success. Closed treatment was
continued in five patieists, four in overhead traction, and one in a Velpeau bandage,
VOL. 52-A, NO. 6. SEPTEMBER 1970
Fm. 1-13 Fun. 1-C
Fig. 1-B: Atutetoposterior roeuutgetl((gt-atli sh((witug tnalmutuioiu of a ( u-loup-\ t litee-paut fi:ict mite iuuwhich t he aut ici tInt si uuface is fm-i tug �iiuI eti( )il\.
Fig. 1-C: Non-utuiotu of a ( tomip-I V t htee-patt ft:ict mire treated itua haiugiiug (‘list-
1092 C. S. NEER, II
THE JOURNAL OF BONE AND JOINT SURGERY
Fig.. I-A, I-B, at uI I-C: 1 ((‘i ut gem gtams sh Wj tug t he utus:utisfact ((iv result S (If (-II )se(l t (1(1 tiwttt
fou t lutee-1I:(tt fuact uu-e�.Fig. 1-A: Axill sty oct utgem gram sb wit ug t he nsau-ked 0(11511 (iv (lisI)la(-etsselut it u a ul)almuuiit edi-(I(ttl-IV thuee-pait ftaet tie. 1111’ liii i(’Iulai surface faces backward atu(l i� latgelv c veted liv t lie
great ci tibet-sit .
followed by futictiouial exercises. TIse fractures utsited but with sigtiificatit rotational
deformity (Fig. 1-B), and much of’ thse head resorbed in otie pat ietst. One elderly
pat ietst was satisfied with hiet’ t’ecovet’y but all teceive(l poor tiunserical rat itigs(Table II). Opets reduction was performed its seveti patietits (Figs. 4-A, 4-B, atid
4-C). The results were: two excellent, two satisfactory, 11usd t hree failut’es. Each
failure was (hue to loss of fixatioti followitig thse use of a Rusls nttil or sphitse. Wire-loop
fixatioui auid cuff repair cotssistetstly gave satisfactory results (Table III). Ouse
VOL. 52-A, NO. 6, SEPTEMBER 1971)
I)ISPLACED PROXIMAL HUMERAL FRA(TUIIES 1093
patietit had tt torts axillary artety that required a vein graft 1usd, (luritsg this proce-
dure, the fracture was tteated w’ith a prosthesis. I’�our yeat’s later site was givets au
unsatisfactory futsctional rating, largely, hsow-ever, because all three cords of the
brachiial h)leXus 1Usd beets damaged by the itsjury (Table III).
Group VI, A oterior
There were seventeen subcoracoid fracture-dislocatiouss of this type, its �vhicls
the lesser tuberosity and its soft parts remaitsed its coustiuiuitv with the articular
segment.
Closed i’ecluctiots was attempted its thirteen pat ietsts ausd foutid to be (lifficult.
The subscapularis, attached to the head,
tended to prevetst its being reduced (Fig.
2-A). Eyeii when reduction was accom-
plislsed. the subscapularis often rotated
the Isead so tlsat thse articular surface faced
posteriorly, causing it to appear to be
its the upside down position (Fig. 2-B).
Closed reduction was accepted its six
patieist.s, two of whsons obtained satis-
factory ratings. Late rotatiotial displace-
ment by the subscapularis led to limited
range utah discomfort in the four otlser
patieists treated by closed methods (Table
Ii). Open reduction, wire-loop fixatiots,
and cuff repair resulted in good ratitsgs ins
three patietits. Spotty avascular changes
its the head were the rule, but. the cir-
I ________FIG. 2-B
Figs. 2-A, 2-B, auud 2-C: Auit eu’opost eu-iou- r )eiut geuuogu’ams sh wiuug t lie diffic illles etuc( tit u I eted iii
(‘lOse(l te_itt(’t i(uuof fu’act ut’e-dislocat iouus.Fig. 2-A: Auuteu’iou- t hu’ee-pau’t lesiouu showuu while I tact iouu was applied tutudet atuest hiesia. The
suthscaptulatis, at t ached to the head, pu’eveuuted its beiuug u’educed. -
Fig. 2-B: Same type of fum’t uu’e-dislocat iou as that showuu itt Fig. 2-A followitug (‘lose(lu’e(lmucttot.
The head appeat’s to be upside dowtu becamtse the stubscaptularis has (lIsted it 50 that I he alt icularo’au-tilage faces posteriou’lv.
Fig. 2-C: htucteased displacemeuut atud bu�u’hial plexus svmptotiis followitug t hitee attenipts tou’edtuce auu auuteiiou’ fommu-paut lesiouu by matuiptmlatiouu.
Three-partGroup I� 14 4 5 5 2 1 1GroupV 7 2 2 3 1 1VI anterior 5 2 1 2 Ii 4 1VI posterior 4 2 1 1 2 2
Four-partFour-part
fractureVI anteriorVI posterior
Ft,. 3-A
FIG. 3-B FIG. 3-C
THE JOURNAL OF BONE AND JOINT SURGERY
1094 c. s. NEER, II
TABLE III
O1’ERATJv: RESULTS OF EIGI(TY-SIX FRACTURES AND FRACTURE-DISLOCATIONS
Open Re( luction (Forty-three) Prost .hesis (Forty-thre--)
No. ofPatients
Excellent(90 units)
Satis-factory
(80 units)
Unsatis-factory
(70 lunuts)Failure
(Less)No. of
PatuentsExcellent(90 units)
Satis- Insatis-factory factory
(80 units) (To lunuts)Failure
(Less)
30 10 9 11 ii 1 7 1 2
5 5 7 1 65 5 22 3 18 13 :t 3 3
13 32 4 2713
Figs. 3-A, 3-B, atud 3-C: Ui’oup-I\ I 1st-ce-partfracture iuu which the greatet- ttiberositv is de-tached allowitig t.he subscaptularis to t-otate thehead inward, causitig the art ictular surf ace to facebackward.
Fig. 3-A: Pt-eopet’at ive atut etopost em It (emit -
genogram shosviuug the typical uotatorv displace-metit.
Fig. 3-B: Phsotogt’aph made itu the opet’atitsgloom showitig the biceps tetudotu ( forceps ) over-
lyitug the greater t uberosi lv fi-agnset it atud the culltear at the i’otatom itutervah, Ski ti hI oks lime Oil theedge of the stubscapularis teuudoui which is causitugthe articuilar sturface to face postel-i(It-l.
Fig. 3-C: Showing the atuat ((nut-al repait �f the
lesion showtu iiu Figs. 3-A auud 3-B LIV at)t)t’oxi-mat itug the t uuheu-osities ssit Is a wire loop mudrepair of the rotator-cuff defe(’t . The sttblmtxat iotu
disappeared as the mtuscles regai tied t I )t ue.
FIG. 4-B FIG. 4-C
Figs. 4-A, 4-B, auud 4-C: Group-V three-part fracture iii which the lesser Imuberositv is deta(’heclallowitug the exteruual rotators to rotate the head exteruially, causiuug the articuular sturface to face
anteri( Irly.Fig. 4-A: Preoperative auuteroposterior roent geuiogram showiuug rotatory dusplacemeuut.Fig. 4-B: Photograph made in the operatilug room to show the artictular surface preseiuting jiust
heuieat h the clavipectoral fa.scia. The skin hook is on the lesser tuherosity. This appearauu(’e hassuggest ed the term false fracture-dislocation.
Fig. 4-C: Excellent wire loop repair of the lesiots shown its Figs. 4-A mid 4-B l.y approximatingthe tuberosities 11usd shaft ausd repairiusg the rotator-cuff defect.
I)ISPLACED PROXIMAL HUM ERAL FRACTURES 1093
VOL. 52-A, NO. 6, SEPTEMBER 1970
culatiots, derived from the lesser tuberosity, was adequate to prevent FesO)1’1)tiOfl
of the head (Fig. 6-C). One of thse two failures of open reduction was due to a 1)ost-
operative w’ound infection in a patient who had been in traction for two weeks
prior to surgery and the other to loss of fixation in a patietit treated withs screw
fixation (Table Ill). Prosthetic reconstruction was performed in six l)sutients,
ti) of whsoni hiad gletsoid fractures and whose shoulders had beets dislocated for
over two months. Thse results i�’ere: four satisfactory, otse unsatisfactory, and one
failure (Table III). Thse failure was due to a large glenoid-rim fracture 1usd persistent
subluxation (Fig. S-B). Thse utssatisfactory result was causeol by a brokets wire that
permitted thie greater tuberosity to) redisplace (Fig. S-A).
Gioup VI, Posterior
In eighst posterior fracture-disloca-
tiouss the greater tuberosity remained
attached to the head atsd a severe rota-
tional detormity ��‘as present through the
surgical neck. Four of the patients had
been i tsj ured clut’itig electroshock therapy.
Closed reductioti was attempted in
six patients with success in only one
patient, whso obtained ats excellent result.
Iticomplete reduction was accepted in one
other patient ivhso had non-union at the
surgical neck (Table II). Open reduction
was performed its four patients. The
anterior deltopectoral approach was used
and the head w’as relocated by leverage
with a flat itsst.rumetst. The results were:
;�fl:;t’�’� J�.._,_�-1.,
FIG. 5
1096 C. S. NEER, II
THE JOi.RNAL OF BONE AND JOINT SURGERY
tw’o excellent, one satisfactory, and one failure (Table Ill). The failure was due
to non-utsion followitsg liush-tsail fixations (Fig. 6-A). A prosthesis was used iti two
lesiouss, otse of whsich hsad beets repeatedly manipulated and was several weeks old.
The other had beets utidiagnosed for fout’ months. Botls patients evetitually a-
chsieved satisfactory ratitigs (Table III).
Foni’-Part Fractures aial Fi’aet arc-Dislocations
Four-Pail Fractuie
Nineteets fractures witis displacement of both tuberosities were encountered. Its
each patietst the at-ticular segmetst was displaced laterally, out of contact with the
gletsoid, and wa.s detachsed from a source of blood supply.
Closed reductiots was attempted its twelve patietst.s, five of’ wisom later came to
surgery. Noise of the reductions were good because retraction of the tuberosity
persisted, atsd it was tiot possible to obtain good contact for tise articular fragment.Nevertheless, closed treatment was cotstinued its seven patients, resulting in four
Ph (I ogi’aphi made i mu the ((perat.itsg ioom (if a fottt’-paut.atutetiot’ fract uum’e-dislocatioiu, �. n up VI,showiiug the detacised head segnsetst which is a ‘‘shell fragmetut’’ withotut blood supply. Closedu-educt ion hsad failed aiim! at stut’gerv it was tuot possible to ((htaiui good approximat iotu (If the frag-metut with the tet macted I tuberosities.
nots-uniotss at the surgical neck, one complete resorption of the lsun4eral head, and
two disabhitig malutsions, each wit.ls sigtsificant humeral-head necrosis (Table II).
Five open reductiotss were perfo)rmed, and the results its all were rated failure. Each
effort to obtaiui coustact bet.weets isead atsd tuberosities so that thse articular frag-
metst mighst become revascularized failed (Fig. 7-B). The head was removed its one
patietst atsd resorbed its three. Otse patient had a postoperative woutsd itsfection
(Table III). A prosthesis was used with recotsstructiots of the tuberosity ttuid cuff in
seveti patietits (Fig. 11). The results were otse excehletst 1usd six satisfactory (Table
III).
Group VI, A ntei’ior
There were t hsirtv-ouse subcoracoid fracture-dislocations its w-hsich bot Is t ubet’os-
ities were detached from the articular segmeist (Fig. 2-C). The t.uberosities were
usually retracted, but its twelve Patients tisey were held in approximatiots by the
rotator cuff.
Fi� 6-C
Figs. 6-A, 6-B, and 6-C: I )epicl ing errors of fixatioti at open redmuct iou of Ihsree-part fract tures.Fig. 6-A: Axillary roeuutgeuuograns made two years after liush-usail fixatiouu of a thtee-part
posterior fract ure-dislocat ion, showiuig usonu-ttuuious.Fig. 6-B: Auuteroposterior roeuut.geuuogram of a u�oti-uusious a Groiup-I V I hree-fragnseuut lesuous
that had beets fixed with Kirschuier wires autd without repair of the rotator cull.Fig. 6-C: Auut eropost erior roeuitgenogram of a three-part. auit erior fract ture-dislocat iou niade
two years after opeut rediictiouu. Good approximation of the tuberosities loud a good (luff repair was
obtaitsed bttt the wire loop (lid uuot secture thse shaft., resultiusg its delayed unious.
DISPLACED PROXIMAL HUMERAL FRACTURES 1097
VOL. 52-A, NO. 6, SEPTEMBER 1970
Closed reductiots was attempted in twenty-three atsd accepted its four patietsts.
Whsen the tuberosities were iseld together by the itstact cuff, thsey seemed to prevetst
relocatioti of the hsead. When they were retracted, it was tsot possible to obtain
adequate boise cotstact for the hsead. Manipulation appeared to cotitribute to
tseurological symptoms its five pat.ietsts (Fig. 2-C). All four lesioiss treate(l by closed
methods resulted its failure, two due to resorptiots of the head atid two due to tson-
union (Table II). Open reduction was performed its five patients (Fig. 5). It was
difficult to maiustain cotst.act. between the fragments, susd the hsead was discarded
during two operatioiss. All five results are classified failures because of discar(led or
ava.scular heads (Table III, Fig. 7-A). Tw’enty-two patietits were treated by
prosthetic replacement. Tise results were three excelleist, eight eets satisfactory, and
one failure (Table III). Tlse failure was due to a postoperative woutsd itsfect ion.
Group VI, Posterior
In six patients thse head was dislocated posteriorly and is-as detached; both
tuberosities were retracted.
FIG. 7-A FIG. 7-B
Figs. 7-A and 7-B: Complicatiouss of open reduction its four-part lesions.Fig. 7-A: Atsteroposterior roent.geusogram made two years after open reduction of a four-part
fractuure-dislocation which failed because of resorptioms of the head.Fig. 7-B: Anteroposterior roent.genogram made ouse year after failure of Rush-nail fixation for a
four-part. fractutre showiuug avascular usecrosis, Isous-union of the head, and tuberosity retractions,iusdicative of a large rotator-cuff defect.
1098 C. S. NEER, II
THE JOURNAL OF BONE AND JOINT SURGERY
TABLE IV
Loe.st. Coimphmc.sTuoxs: ONE HUNDRED .SND SEVENTEEN FRACTURES ANI) FR.scTuaE-DtsLoc;tTIoxs
T hree-part (61) F our-part (56)
ClosedTteatment
(20)
OpenReduction
(30)Prosthesis
(11)
Closed
Tueatnsetit(11)
OpenReduction
(13)Prosthesis
(32)
Infections
Nous-uumsiomi
Avascula.m mue(’tosis
�\1alutiiots
Neum’ova.scular
Head discarded
Urssat isfactot-’s- Result
32
12
1
62
2 2
1
63
2
1
16
5
1
17 11 * 3 ii 13 1
* 1’e(’lsfli(’al eu’rou’s in seven.
Closed reductiots \V1t5 attempted witisout success in three patients (Table II).
Three lesiotss treated by open reduction resulted iii failure because of avascular
necrosis (Tstble III). The results w-ere rated satisfactory in three pat.ietst.s in whom a
h)rosthsesis was used (Table III).
Coin plicat bus
There were tio significant systemic complicatiouss. Five patients had sustained
their injuries duritsg electroshock therapy for psychoses, sevets were alcoholic, one
hladI epileptic seizures, two had multiple injuries, atsd seven had petsdiisg litigation.
Xotse of these problems proved an overwhelming deterrent to recovery. Local
complications are summarized in Table IV.
I nfection: Three postoperative wound infect.ioiss occurre(l. Two followed open
re(luctiolss that had beets (lelayed. One followed prostisetic replacement and was
promptly cotstrohled by removal of thse prosthesis and the administration of local
an(1 systemic antibiotics. All resulted in failure.
Fig S-C: Roemstgenogram nsade with the arm at the side fottr years after delayed surgery for afract.ure-dislocatious complicated by myositis ossificauis.
Fig. 8-I): Same patieust a.s shown iui Fig. 8-C with the arm overhead, demouustmatiuig that adequate
range had beeui attained four years after the complicatiots.
DISPLACED PROXIMAL HUMERAL FRACTURES 1099
VOL. 52-A. NO. 6, SEPTEMBER 1970
Figs. 8-A thsrough S-D: Complicat iotis of prosthetic replacemeuut, illtustrated by auutetoposteriorroeustgenograms.
Fig. 8-A: Result rated failure because a brokets wiu’e allowed tlse I (uberosity I( met uact omu theseveuuth day aft.er operat.ioui.
Fig. 8-B: Failure to recouust rtuct a fouur-nsoust h-old Isuslerior fiact mure-disl( (‘at l( itu with a large
gleuioid-rim fract tire.
Non-union: There i�’ere sixteets established non-unions at the surgical tseck of
whsich time followed closed treatment, six a hangitsg clLst (Fig. 1-C), and two over-
head t.ractiols. Distractiots appeared to be a causal factor. Six non-utsiotss followed
opens reduction of three-part fractures tisat were inadequately itsternally fixed (Figs.
1100 C. S. NEER, II
THE JOURNAL OF BONE AND JOINT SUtIGEtOY
. Ascending branch� anterior circumflex
Ful. �)
Illuuslmatitug hue tsseth(((I ((f explou’iuug a(’(tte fu’act.uuu’es. The defect iuu the totatou’ iuuteuval is (Ic-vel( (I)Cd Pt( )XitiulullV, av( imliuug i i uj uu’v I o I lie blo d su�)plv If t he 1ie�sd svhicls emuI (‘is b (t u(’ i uu I lie
vit’iuuitv ((f 1Ise liicipital gmo�(ve �uud tubeu’osities.
Fig. I I ): ‘Fhie usset Isoti f uepaiti i ug a I luuee-patt lesi (t u aft eu ( pet u ted tu(’t i( Ii u- ‘l’lie I mil iet� si I l(’s ute
appu-oximated �suud secuuued to the shaft with stuouig buuied wiue sutmutes, Two wit-c loops ate tuow
puefeu’ued. flue rotator-t-uuff (Iefe(’t is repan.Fig. 11: TIse method (f m’epaim-itug a foui’-paut fmact mute with a puost lsesis.All I mihetosit v fuagnseuuts
ate appu’oxiusated uuudeu t Ise head of t he pu’ost hesis wit ls two hturied wiu’e loops TIst’ defect iii I hueu((tat((t (‘tiffis suOti’ed It is tt((t aiwa s iue(’essau’y 1(1 divide the louug head of the biceps
6-A and 6-B). Nouu-uiiioii of the head segment was pt’so’tit iii most patietits witls
avascular tiect’osis (F’ig. 7-B).
A u’a.sculai’ necrosis’: Cohlapse of the at’t icular suu’face occurred its only two of
t I uirt �‘ t hsree-part lesions treated by opeti reductiots (Table IV). (.)f t I sirt eeti pat.ietits
witls four-part lesions treatetl by open reduction, however, the head was (lisCau’(led
iii five 1111(1 resO)rbe(.l in six (Fig. 7-A).
_llalunion: Rot ato)ry displacemetst in thsree-part fractures could not be cots-
tt’olled by closed met Isods (Figs. 1-A, 1-B, 2-A, mtuid 2-B). The result usually itscluded
DISPLACED PROXIMAL HUMERAL FRACTURES 1101
significant discomfort. and loss of external rotation and abduction. One patient with
fixed retractiots of the greater tuberosit.y and malunion of the glenoid (Fig. S-B) and
another with loss of fixation of the tuberosities (Fig. 8-A) accounted for two of the
failures of prosthetic replacement (Table IV).
Neurom’ascular: Tets patients were first seen with neurological deficits, involvitsg
the axillarv 1Usd median iserves in four, axilla.ry and radial nerves in two, ulisar userve
ins two, and all three in two. Repeated efforts at closed reductiots was thought to have
ilsCreased t.hsese symptoms in several patients (Fig. 2-C). Deficits persisted its four
patients, one of whom received an unsatisfactory rating (Table IV).
Transitory subluxation: This w’as common after all types of treatmeust (Fig.
3-C). It disappeared as tise muscles regained tone.
Myositis ossificans: Pericapsular bone formation occurred after all three
methods of treatment : three after closed reduction, five after opets reduction, atsd
six after prosthetic replacement. (Figs. S-C and S-D). Predispositsg factors seemed to
be soft-tissue injury as in fracture-dislocations, repeated manipulatiots, and delayed
reduction beyond sevets days.
Failure of metal: There was no instance of dislocation or loosening of the stem
of a prosthesis. The ��‘ire loops fragmented in one patieist, between two and tsine
years after surgery, but caused no discomfort..
Over-all Results
The results of closed reduction, opets reduction, and prosthetic replacenienst are
summarized in Tables II and III. A minimum of one year was required for reason-
able recovery aisd, in general, the results improved with time.
Closed treatment appeared inadequate for active patietsts in eithser group. It
produced satisfactory ratings in only three of thirty-nilse patients with three-part
lesions arid consistently failed in thirty-eight patients with four-part displacements.
Open reduction was performed in thirty patients with three-part displacements
and appeared effective. There were eleven failures but thsese w’ere largely due to
technical errors (Figs. 6-A and 6-B). Suture fixation of the tuberosities atsd cuff
repair yielded satisfactory or excellent results in 86 per cent. (Fig. 10). Severe
necrosis w’iths resorption of the head rarely occurred. Patients with four-part lesions,
however, had uniformly poor results because the head had beets discarded or
resorbed.
Prosthetic replacement was used in thirty-tw-o patieists w’ith four-part. displace-
meists (Fig. 11). The typical result was satisfactory but imperfect. atsd t.he recovery
period was prolonged. The average numerical rating was 82 units. There w’ere few
complicatiotss. These results in patients with four-part lesiotis were quite superior
to those of either closed or open reduction.
Operative Technique
During the course of this study, some techniques were found to be of value and
some problems and errors in technique became apparent.
1. Anteroposterior and lateral roentgenograms of the upper end of the humerus
are essential preoperat.ively in planning the procedure and avoiditig unnecessary
tissue damage.
2. Reconstruction is difficult and delay beyond two w’eeks renders it. more
difficult, because of fixed retraction of the tuberosities, formation of cicatrix,
deposition of pericapsular bone, and softening of the fragmeists.
3. The preoperative pain in the sisoulder reduces the efficacy of skits prepara-
t.ion, and the injured tissue invites infection. It is important that the skins be cleansed
scrupulously under anesthesia and that. adherent plastic drapes be used.
VOL. 52-A. NO 6, SEPTEMBER 1970
1102 c. S. NEER, II
4. The deltopectoral approach with detachment of tise ansterior 7.6 centimeters
of the (leltOid from clavicle is preferred. Acromiotsectomy or inadequate reattach-
meust of tise deltoid is especially disabling.
5. After divisiots of the clavipectoral fascia, the w’outsd should be irrigated free
of clots �U5d the teisdon of the long head of the biceps shsould be used aS a guide to
the interval between the greater and lesser tuberosities (Fig. 3-B).
(1. Itsjury to the blood supply of the head and the anterolateral artery � cats be
avoi(le(l by developiisg the itsterval defect in the rotator cuff (Fig. 9). Its doubtful
cases the itsterval shsould be explored before a final decision to discard the head is
made.
7. At open reduction, fixation by two strong buried wire loops is much more
efficietst than by screws, nails, or Kirschner wires. After the tuberosities are secured
together atsd to the shaft., the rotator cuff is repaired (Fig. 10).
S. if a prosthesis is us-ed (Fig. 11), a tight fit of the s-tern within the medullary
canal is essential. Four stem sizes are curretitly available, each with appropriate drill
specifications. The articular surface must be positioned so as to face in 30 degrees ofretroversion to provide stability against dislocation. The fragrnetsts of thse t.uberosi-
ties are approximated betseaths the prosthesis w’iths two wire loops and nhe rotator
cuff is tisen repaired.
9. Adhesions cats be mitsimized by the use of assisted extertial rotat.iots exercises.
These are started at about four days after surgery atsd progress as rapidly as the
repair j)ernsits, working itsitially for range and much later for strength.
10. Patients sisould be warned preoperatively of thse protracted course of re-
isabilitlttiots, and later they shsould be etscouraged by their surgeots to have con-
fidetice Itildi take pride in tiseir accomplishments.
Discussion
Diuritsg the period required to collect. this series, more than 1300 proximal humer-
111 fractures were seen its our clinic. This figure does not, however, accurately portray
tlse prevalence of the severe multifragment itsjuries ansotsg injuries to the proximal
end of the Isumerus sitsce matsy in the series w’ere referred from other hospitals. The
majority of patients who sustaitsed these disablitsg fractures were healthy in-
dividluals its their active �‘ears. Therefore, although these injuries are uticommots,
the�’ pose su significatst problem.
Tlse classification used may seem cumbersome, but. it. seems muds more repre-
sentative of the actual type of lesions encountered than thse oversimplified classifica-
tiotss of the past. For thse purpose of evaluating therapy, at least, our classification
hsa.s l)rOved useful. For example, if thse over-all results after opens reduction are com-
1)ared with those of Ktsight. and Mayne, there were 44 per cent. satisfactory result�sin this series of forty-tlsree procedures as compared withs 46 per cent satisfactory
results its twenty-six procedures ins the series of Knight and Mayne. Yet ��‘hen t.hse
techtsically good opens reductiotss in our three-part fractures are considered, tise
results were excellent or satisfactory in 86 per cent. It. is not possible to separate
thsis group its Knight. 1usd Maytse’s series. Thus, it is. possible isow to recognize the
value of open reductions ins the various types of fracture and to detect. its deficietscies
in the four-part. fracture.
Summary
A stu(ly of 117 thsree-part tusd four-part displaced proximal humeral fractures,
followed for from otse to sixteen years, is presented. The ages of the patients averaged
55.3 years. Treatment began w’iths closed reduction in sevetsty-seven patients, the re-
sult of whsich were accepted ins thirty-one. Open reduction was doise in forty-thsree
THE JOURNAL OF BONE AND JOINT SURGERY
DISPLACED PROXIMAL HUMERAL FRACTURES 1103
patietst.s, and prosthetic replacement in forty-three patient��. Their results were
rated by a numerical system. Closed reduction was found inadequate for active,
healthy patients in either group. This was because of uncontrollable rotatory (us-
placement in three-part fractures and avascular necrosis of the detached lie-sd in
four-part fractures. \Iost of the poor results of open reduction ins three-part (lis-
placements w’ere due to errors in reduction or fixation while those in four-part
displacements w’ere due to avascular necrosis of the head. It. w’as concluded that thse
preferable method for three-part fractures was open reduction tusd that for four-part
fractures w’as prosthetic replacement. Using these indications, the typical result w’as
satisfactory but imperfect atid many months were required for maximum recovery.
Surgical errors and technique are discussed.
References
1. KNIGHT, II. A., ausd MAYNE, J. A.: Commiusuted Fractures amsd Fracture 1)islocatiouss Ituvolvinigthe Artictular Surface of the Humeral Head. J. Boise ausd Joint. Surg., 39-A: 1343-1355, l)ec.1957.
2. LAtNG, P. G.: The Arterial Supply of the Adult humerus. J. Bouse and Joint Surg., 38-A: 1105-1116, Oct. 1956.
3. NEEuS, C. S., II: Displaced Proximal hlumeral Fractures. Part I. Classificatiouu and Evalualious.J. Boise ausd Joiust Surg., 52-A: 1077-1089, Sept. 1970.
VOL 52-A, NO. 6, SEPTEMBER 1970