Injury (1989) 20, 195-199 Printed in Great Britain 195

Treatment of displaced fractures of the proximal humerus: transcutaneous reduction and Hoff mann’s external fixation

Bjarne Kristiansen Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Denmark

Experience wifh transcutaneow reduction ana’extenuzlfiration of displaced fracture.5 of the proximal humerus is presented in a series of 28 cases followed for I year or more. In 18 cases near-anatomicalfradure reduction was obtained, while no improvement of fracture position was seen in IWO cases. Loosening of the pins was a major complication in five cases, all in patients with severe osteoporosis or head splittingfiactures, where fracture reduction was unsatisfacfoy.

The functional results were satisfactory, and Ihe method is considered a useful alternative in the freafment of these difficult fracfures.

Introduction

A technique of transcutaneous reduction and external fixa- tion of displaced fractures of the proximal humerus has been presented in experimental as well as clinical series. A low risk of neurovascular complications or interference with motion of the glenohumeral joint (Kristiansen, 1987), a satisfactory fracture reduction and stability (Kristiansen and Kofoed, 1987) and safer healing and superior functional results as compared with closed treatment (Kristiansen and Kofoed, 1988) were found.

This report describes the technique of reduction of the different types of proximal humeral fractures and, by analys- ing the technical and functional results of 28 consecutive cases followed for I year, discusses the indications for using this method in the treatment of these difficult fractures.

Patients and methods

In 27 patients (16 females, 11 males) with a median age of 66 years (range 18-37 years), 28 fractures were treated by transcutaneous reduction and external fixation using the Hoffmann apparatus. According to the Neer classification system (Neer, 197O), eight fractures were classified as two- part fractures, 14 as three-part fractures and six, of which one was dislocated, as four-part fractures.

Technique of reduction Reduction is performed with the patient under general anaesthesia using image intensifier control.

Two-part fractures. In the surgical neck fracture a medial displacement of the shaft is seen due to the pull from the

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pectoralis muscle. A Steinman pin is introduced into the humeral head thus maintaining the position of this fragment. Reduction is then performed by manipulation of the shaft (Fig. 1).

Figure 1. Displaced surgical neck fracture. A. Transcutaneous reduction using a Steinmann pin. B. External fixation.

196 Injury: the British Journal of Accident Surgery (1989) Vol. ZO/No. 4

a

b

Figure 2. Displaced three-part fracture. u, Internal rotation of the head due to an avulsion of the greater tuberosity. A. Transcu- taneous derotation of the head using a Steinmann pin. B. Reduc- tion of the greater tuberosity using a Hoffmann half-pin. C. External fixation of fragments. b, External rotation and abduction of the head due to an avulsion of the lesser tuberosity. A. Transcu- taneous derotation. B. External fixation.

Figure 3. Four-part fracture with depression of the articular frag- ment. A. Transcutaneous elevation using a Steinmann pin. B. Transfixation of the greater tuberosity to the articular fragment by two half-pins. C. External fixation.

Three-part fractures. In these fractures a rotational dis- placement of the humeral head is present due to the dis- ruption of the rotator cuff. Detachment of the greater tuberosity allows the head to become internally rotated, while a detachment of the lesser tuberosity allows the head to become externally rotated and abducted. The head frag- ment is derotated by the Steinman pin. If present, an avulsion of the greater tuberosity can be reduced by one of the half-pins in combination with manipulative extension- abduction of the shaft (Fig. 2).

Four-part fractures. Because of an elimination of the pull from the subscapularis as well as the supraspinatus, no rota- tional displacement occurs, but a depression of the articular fragment between the tuberosities is present. Using the Steinman pin as an elevator this part can gently be reduced (Fig. 3).

Following reduction Iwo half-pins are drilled into the head and three pins into the shaft laterally, just penetrating the medial cortex. A neutralizing bar is applied and the Steinman pin removed. Early functional exercises are started postoperatively. Daily cleaning of the pin sites with chlor- hexidine 0.05 per cent is performed. The pins are removed in the outpatient clinic after 4 weeks.

Results

Of the 28 cases, 22 were managed by the technique as the primary choice between 6 and 72 h after injury. Six cases

Kristiansen: Treatment of displaced fractures of proximal humerus 197

were treated by primary closed reduction, but because of secondary displacement had transcutaneous reduction and external fixation performed 1 to 4 weeks after injury. Multiple injuries were present in three cases.

The quality of reduction in relation to type of fracture is outlined in Table I. Good reduction was defined as a con- version of a displaced fracture into a minimally displaced fracture, where no segment was displaced more than 1.0 cm or angulated more than 45” (Neer, 1970). Fair reduction was the situation where contact between fragments was obtained, but some displacement was still present, and poor

Table I. Quality of transcutaneous reduction in relation to type of fracture in 28 cases of displaced fractures of proximal humerus

Reduction

Type of fracture

Two-part Three-part Four-part Total

Good 6 8 4 18 Fair 2 5 1 8 Poor 1 1 2

a

Figure 4. a, Four-part dislocation

tion and external fixation.

b

fracture. b, After closed reduc-

reduction as no improvement in fracture position. Examples of reduction are illustrated in Figs. 4-7.

In two cases temporary paraesthesia of the brachial plexus were noted postoperaCvely. No persistent neurolo- gical deficiency was found. In two cases a lesion of the axillary artery was present preoperatively, one of which was treated primarily elsewhere, and first seen in our department after 72 h. In both cases vascular surgery was performed in addition to fracture management.

Secondary displacement was seen in two patients, both of whom sustained direct injury to the Hoffman apparatus. In one of these patients reduction and refixation was per- formed and healing in a good position resulted. In the other patient persistent loosening of the head pins and pin tract infection required their removal and parenteral antiobiotic therapy. Infection was controlled, but delayed union and refracture after I year resulted. In two other cases a combi- nation of loosening and major infection was seen, while aseptic loosening was found in two cases. A total of five patients thus had the pins removed before the scheduled time and were classified as failures of technique. These cases were not followed for late functional examination. The rate of loosening, with or without infection, in relation to type of fracture and quality of reduction is seen in Table II. In four of

a

Figure 6. a, Three-part fracture with avulsion of greater tubero- sity and medial displacement of shaft. b, After transcutaneous reduction and external fixation.

a b a

Figure 5. a, Four-part fracture with depression of articular frag- ment. b, Following transcutaneous elevation and transfixation.

Figure 7. a, Two-part fracture with medial displacement and abduction of shaft. b, Following reduction and fixation.

198 Injury: the British Journal of Accident Surgery (1989) Vol. 20/No. 4

Table II. Cases with loosening of pins in relation to type of frac- ture and quality of reduction. The figures in brackets are the total number of cases in each group

Number of cases with pin loosening, type of fracture

Reduction

Good Fair Poor

Two-part

0 (6) 1 (2)

Three-part

0 (8) 2 (5) 0 (1)

Four-part

0 (4) 1 (1) 1 (1)

Table III. Functional results in relation to type of fracture in 19 cases of displaced fractures of proximal humerus

Type of fracture

Results Two-part Three-part Four-part Total

Excellent 1 3 2 6 Satisfactory 3 3 1 7 Unsatisfactory 2 2 4 Poor 2 2

Median score (maximum: 90) 78 78 85 78

the five ‘loose’ cases, radiographic osteoporosis was evident, while the fifth case had a head-splitting fracture. Three of these patients could be characterized as chronic alcoholics, while this was the case in only two of the remaining 23 fracture cases.

Two patients died and two were lost to the l-year follow- up, which thus included 19 cases. The results were assessed according to a modification of the Neer score system (Neer, 1970) excluding the anatomic score and thus with a maxi- mum of 90 units (Table In). Thirteen cases (68 per cent) were classified as excellent or satisfactory, four (21 per cent) as unsatisfactory and two (II per cent) as poor. Including the technical failures in five of 28 cases, a total of 42 per cent of cases were not satisfactory.

One case of non-union was seen. In this case a poor reduction was noted but accepted because of good stability of the fracture-external apparatus system. Two cases of avascular necrosis were radiographically visible at the l-year follow-up. One occurred in a four-part fracture- dislocation in spite of good fracture reduction and normal healing. The other was seen in a case classified as a three-part fracture. In spite of healing and a satisfactory functional result persistent pain was evident.

Discussion

For badly comminuted fractures of the proximal humerus, which involve the articular surface, either total or partial joint replacement seems to be the treatment of choice (Neer, 1970; Tanner and Cofield, 1983; Stableforth, 1984). There is, however, no consensus on the treatment of displaced two-, three- and four-part fractures. The major disadvantages of closed methods have been reported to be poor reduction, instability leading to secondary displacement and pro- longed rehabilitation time (Leyshon, 1984; Stableforth, 1984; Mills and Home, 1985). Open reduction and internal fixation offers satisfactory stability, but is a demanding tech- nique sometimes leading to technical errors, with a risk of damage to the remaining blood supply to the head of the

humerus and avascular necrosis (Paavolainen et al., 1983;

Sturzenegger et al., 1984; Kristiansen and Christensen,

1986). Infection is seen in about 10 per cent of cases follow- ing internal fixation (Paavolainen et al., 1983; Kristiansen and Christensen, 1986). The functional results following arthroplasty in these fractures (Kraulis and Hunter, 1976; deAnquin and deAnquin, 1982); Willems and Lim, 1985) are not encouraging, probably because of difficulties in recon- structing the soft tissues.

The described technique of transcutaneous reduction offers good reduction in 64 per cent of cases and in only 7 per cent is it not possible to improve the fracture position. It is notable that it is also possible to obtain a good position in most four-part fractures. The simple external frame used seems to offer satisfactory stability as no redisplacements, except for the two cases of direct injury, were seen. The five cases of pin-track infection and/or pin loosening were seen in patients with severe osteoporosis or head-splitting frac- ture, where it was impossible to obtain near-anatomical frac- ture position. The one case of non-union was also found in a case of poor reduction. The functional results in the patients that accomplished the treatment were satisfactory with a median score of 78 (maximum 90), and found superior to most series published using the same score system. It seems evident that the most important factor is a good reduction, and that severe osteoporosis, alcoholism and head-splitting fractures are heads at risk in this regard.

Conclusion

Closed treatment, as the most gentle method, should be the first choice of treatment in displaced fractures and should continue closed if the fracture position after reduction is considered as stable. The technique of transcutaneous reduc- tion and external fixation should be reserved for cases with- out severe osteoporosis, and those where.good reduction is obtained, but considered as unstable. If transcutaneous reduction fails, open reduction and internal fixation should be performed in two- and three-part fractures, while primar- ily arthroplasty should be considered in comminuted head- splitting fractures and four-part fractures.

References

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Kristiansen: Treatment of displaced fradures of proximal humerus 199

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Paper accepted 14 February 1989.

Requests for reprints should be addressed to: Bjame Kristiansen, Aalykkevej 7B, Esrum, DK-3230 Graested, Denmark.