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Cureus Apr 2024This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary... (Review)
Review
This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.
PubMed: 38711710
DOI: 10.7759/cureus.57691 -
Journal of Shoulder and Elbow Surgery Dec 2023Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current...
BACKGROUND
Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans.
METHODS
Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability.
RESULTS
The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91).
CONCLUSION
Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.
Topics: Humans; Observer Variation; Reproducibility of Results; Elbow Injuries; Ulna Fractures; Fracture Dislocation; Joint Dislocations; Ulna; Elbow Joint; Monteggia's Fracture
PubMed: 37479178
DOI: 10.1016/j.jse.2023.06.018 -
Bulletin of the Hospital For Joint... Sep 2023Hill-Sachs lesions are a challenging clinical problem in the context of anterior shoulder instability. Historically, unless very large, these lesions were thought to be...
Hill-Sachs lesions are a challenging clinical problem in the context of anterior shoulder instability. Historically, unless very large, these lesions were thought to be less significant than glenoid defects. Recently, more importance has been placed on whether a Hill-Sachs lesion is on-track or offtrack, with off-track lesions predisposing patients to higher risk of postoperative recurrent instability. Given the high risk for recurrent shoulder instability in patients with Hill-Sachs lesions that are off-track, augmentation procedures, such as the remplissage procedure, are often indicated alongside a Bankart repair. The proposed advantages of the remplissage include directly addressing the Hill-Sachs lesion to prevent engagement, the ability to address any associated intraarticular pathologies during the arthroscopy, and to avoid a more invasive open procedure with a higher complication rate. Remplissage has been shown to reduce the recurrence rate compared to those undergoing arthroscopic Bankart repair alone and to have a comparable recurrence rate to the Latarjet procedure in the appropriately selected patient while also having a much lower complication rate than the Latarjet procedure.
Topics: Humans; Bankart Lesions; Joint Instability; Shoulder Joint; Amputation, Surgical; Arthroplasty
PubMed: 37639347
DOI: No ID Found -
Orthopedics 2023The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse...
The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [. 2023;46(5):274-279.].
Topics: Humans; Female; Aged; Male; Arthroplasty, Replacement, Shoulder; Reoperation; Retrospective Studies; Treatment Outcome; Frailty; Shoulder Pain; Range of Motion, Articular; Shoulder Fractures; Humeral Fractures; Shoulder Joint; Humerus
PubMed: 37018624
DOI: 10.3928/01477447-20230330-02 -
Journal of Shoulder and Elbow Surgery Aug 2023Reverse shoulder arthroplasty (RSA) has become an increasingly popular treatment option for proximal humerus fractures in the elderly. There is however contradictory... (Meta-Analysis)
Meta-Analysis Review
HYPOTHESIS
Reverse shoulder arthroplasty (RSA) has become an increasingly popular treatment option for proximal humerus fractures in the elderly. There is however contradictory evidence on the impact of timing of RSA on patient outcomes. It remains unclear if poor results after initial nonsurgical or surgical management can be improved with delayed RSA. The aim of this systematic review and meta-analysis is to compare the outcomes of acute RSA and delayed RSA for the treatment of proximal humerus fractures in the elderly.
MATERIALS AND METHODS
A systematic search was performed on 4 databases for studies that compared acute RSA with RSA used after prior nonoperative or operative treatment. Studies with a mean cohort age of <65 years were excluded. Demographical data, clinical outcome scores, range of motion measurements, and postoperative complications were collected from the included studies.
RESULTS
Sixteen studies were included for data analysis. Compared with delayed RSA cohorts, acute RSA cohorts had higher forward flexion (124.3° vs. 114.9°; P = .019), external rotation (24.7° vs. 20.2°; P = .041), and abduction (113.2° vs. 99.8°; P = .03). Compared with RSA after conservative management, acute RSA had greater external rotation (29.9° vs. 21.4°; P = .043). The acute RSA cohort had significantly higher American Shoulder and Elbow Surgeons (76.4 vs. 68.2; P = .025) and Constant-Murley scores (65.6 vs. 57.3; P = .002) compared with the delayed RSA cohort. Subgroup analyses showed significantly greater Constant-Murley (64.9 vs. 56.9; P = .020) and Simple Shoulder Test scores (8.8 vs. 6.8; P = .031) with acute RSA compared with RSA after conservative treatment. The American Shoulder and Elbow Surgeons score was higher in the acute RSA cohort compared with RSA after open reduction internal fixation (77.9 vs. 63.5; P = .008). The overall complication rate per 100 patient-years was 11.7 for the acute RSA cohort and 18.5 for the delayed RSA cohort (risk ratio: 0.55; P = .015).
CONCLUSION
Based on the current evidence, acute RSA presents better clinical outcome measures and range of motion measurements, with decreased complication rates than RSA performed after prior nonoperative or operative treatment.
Topics: Humans; Aged; Arthroplasty, Replacement, Shoulder; Shoulder; Shoulder Joint; Shoulder Fractures; Treatment Outcome; Range of Motion, Articular; Humeral Fractures; Retrospective Studies
PubMed: 37024039
DOI: 10.1016/j.jse.2023.03.006 -
Archives of Orthopaedic and Trauma... Oct 2023To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO...
Fracture line and comminution zone characteristics, and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humeral fractures: complex proximal humerus fracture map.
PURPOSE
To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humerus fractures.
METHODS
Computed tomography images of 201 OTA/AO 11C3 fractures were included. Fracture lines were superimposed to a 3D proximal humerus template, created from a healthy right humerus, after fracture fragment reduction on 3D reconstruction images. Rotator cuff tendon footprints were marked on the template. Lateral, anterior, posterior, medial, and superior views were captured for the interpretation of fracture line and comminution zone distribution as well as to define the relationship with anatomic landmarks and rotator cuff tendon footprints.
RESULTS
A total of 106 females and 95 males (mean age = 57.5 ± 17.7 [range 18-101] years) with 103 C3.1-, 45 C3.2-, and 53 C3.3-type fractures were included. On the lateral, medial, and superior humeral surfaces, fracture lines and comminution zones were distributed differently in 3 groups. Tuberculum minus and medial calcar region were significantly less severely affected in C3.1 and C3.2 fractures than C3.3 fractures. The supraspinatus footprint was the most severely affected rotator cuff footprint area.
CONCLUSIONS
Specifically defining the certain differences for repeatable fracture patterns and comminution zones in OTA/AO 11C3-type fractures and the relationship between the rotator cuff footprint and the joint capsule may contribute to the decision-making process of surgeons.
Topics: Male; Female; Humans; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Rotator Cuff; Shoulder Fractures; Tomography, X-Ray Computed; Fractures, Comminuted; Humeral Fractures; Humerus; Fracture Fixation, Internal
PubMed: 37378893
DOI: 10.1007/s00402-023-04962-3 -
Injury Nov 2023The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during... (Review)
Review
The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.
Topics: Humans; Sternoclavicular Joint; Fracture Fixation, Internal; Shoulder Dislocation; Joint Dislocations; Fractures, Bone; Thoracic Injuries; Hemorrhage
PubMed: 37634999
DOI: 10.1016/j.injury.2023.110983 -
The Journal of the American Academy of... Sep 2023The surgical treatment of proximal humerus fractures, though common, is associated with surprisingly high complication rates upward of 34%. Obtaining a reduction and... (Review)
Review
The surgical treatment of proximal humerus fractures, though common, is associated with surprisingly high complication rates upward of 34%. Obtaining a reduction and placing a stable fixation can be challenging because many fractures treated surgically are comminuted and occur in osteoporotic bone. Nevertheless, innovations in technique and implant design are mitigating some failures. These innovations include the use of fibular strut allograft and other fixation adjuncts, the correct placement of calcar screws and other locking fixation, and having a systematic approach to reduction and intraoperative imaging to ensure the restoration of anatomy. This review and accompanying video highlight various technical strategies to maximize the success of surgical treatment for these challenging injuries.
Topics: Humans; Fracture Fixation, Internal; Bone Plates; Shoulder Fractures; Transplantation, Homologous; Humeral Fractures; Humerus
PubMed: 37384877
DOI: 10.5435/JAAOS-D-22-01211 -
The Journal of Bone and Joint Surgery.... Jul 2023Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for...
Functional and Clinical Outcomes After Plate Osteosynthesis Versus Intramedullary Nailing of a Humeral Shaft Fracture: The Results of the HUMMER Multicenter, Prospective Cohort Study.
BACKGROUND
Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for humeral shaft fractures. However, it is undecided which treatment is more effective. This study aimed to compare functional and clinical outcomes of these treatment strategies. We hypothesized that plating would result in an earlier recovery of shoulder function and fewer complications.
METHODS
From October 23, 2012, to October 3, 2018, adults with a humeral shaft fracture, OTA/AO type 12A or 12B, were enrolled in a multicenter, prospective cohort study. Patients were treated with plating or nailing. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley score, ranges of motion of the shoulder and elbow, radiographic healing, and complications until 1 year. Repeated-measure analysis was done with correction for age, sex, and fracture type.
RESULTS
Of the 245 included patients, 76 were treated with plating and 169 were treated with nailing. Patients in the plating group were younger, with a median age of 43 years compared with 57 years for the nailing group (p < 0.001). The mean DASH score after plating improved faster over time, but did not differ significantly from the score after nailing at 12 months (11.7 points [95% confidence interval (CI), 7.6 to 15.7 points]) for plating and 11.2 points [95% CI, 8.3 to 14.0 points] for nailing). The Constant-Murley score and shoulder abduction, flexion, external rotation, and internal rotation displayed a significant treatment effect (p treatment ≤ 0.001), in favor of plating. The plating group had 2 implant-related complications, whereas the nailing group had 24, including 13 nail protrusions and 8 screw protrusions. Plating resulted in more postoperative temporary radial nerve palsy (8 patients [10.5%] compared with 1 patient [0.6%]; p < 0.001) and a trend toward fewer nonunions (3 patients [5.7%] compared with 16 patients [11.9%]; p = 0.285) than nailing.
CONCLUSIONS
Plating of a humeral shaft fracture in adults results in faster recovery, especially of shoulder function. Plating was associated with more temporary nerve palsies, but fewer implant-related complications and surgical reinterventions, than nailing. Despite heterogeneity in implants and surgical approach, plating seems to be the preferred treatment option for these fractures.
LEVEL OF EVIDENCE
Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
Topics: Adult; Humans; Fracture Fixation, Intramedullary; Prospective Studies; Fracture Fixation, Internal; Humeral Fractures; Bone Plates; Postoperative Complications; Humerus; Treatment Outcome; Fracture Healing
PubMed: 37220192
DOI: 10.2106/JBJS.22.00647 -
Journal of Orthopaedic Trauma Oct 2023To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus...
OBJECTIVES
To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis.
DESIGN
Retrospective.
SETTING
Academic medical center.
PATIENTS/PARTICIPANTS
Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type.
INTERVENTION
Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP.
MAIN OUTCOME MEASUREMENTS
Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores.
RESULTS
The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group.
CONCLUSION
Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Topics: Humans; Shoulder; Retrospective Studies; Fracture Fixation, Internal; Shoulder Fractures; Treatment Outcome; Humerus; Osteoporosis; Bone Plates; Humeral Fractures
PubMed: 37296091
DOI: 10.1097/BOT.0000000000002645