Open Reconstruction of Complex Proximal Metadiaphyseal Fragility Fractures of the Humerus

Abstract

Purpose: A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications. Methods: From 2008 to 2012, 21 such operations were performed; 18 were considered ''fragility'' fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative. Results: The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean ¼ 21, standard deviation ¼ 20, n ¼ 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15). Conclusion: Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.

The Old Supracondylar Fracture of Femur Treated by Gradual Deformity Correction Using the Ilizarov Technique Followed by the Second-Stage Internal Fixation in an Elderly Patient With Osteoporosis

“…14,15 Whereas we preferred the use of the dual plating for the case, which can increase the fracture stabilization similar to the other 2-column fracture types like tibial plateau, distal humerus and plafond fractures. 16,17 In our case, surgery was done by 1 incision lateral to femur. Fibrotic areas and bone sequesters were debrided completely, obtained cancellous bone graft from iliac crest placed in the fracture site, direct reduction done followed by temporary fixation with K-wires, and longlocked lateral distal femoral plate used for the lateral column, then, under direct vision with neurovascular protection, a relatively small reconstructive plate was used at anteromedial distal femur for the medial column.…”

Management of AO type 12C humerus proximal metadiaphyseal fractures with minimally invasive plate osteosynthesis in geriatric patients

“…James et al evaluated the results of 24 geriatric patients treated with open reduction and conventional plating for a complex metaphysodiaphyseal fracture and reported successful results. 20 However, as open reduction and conventional plating was used in that study, the current study can be said to be the first to report the use of the MIPO method to treat metadiaphyseal fractures in geriatric patients. As mean life expectancy will increase in the future, this subject will be of greater importance.…”

“… 16 , 17 In the geriatric patient group in particular, impingement syndrome may sometimes severely restrict daily living activities. 20 Removal of the implant may be required in treatment. 22 Brunner et al reported that it was necessary to remove the implant in 3 patients of a series of 15.…”

Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly

“… 4 , 6 , 25 Moreover, ORIF does not address the common concomitant issues of glenohumeral arthritis and rotator cuff pathology, which can be found with geriatric proximal humerus fractures. 26 – 28 Utilizing magnetic resonance imaging analysis of proximal humerus fractures, rates of rotator cuff tears from 42% to 70% has been demonstrated, which can be associated with limited functional outcomes. 29 , 30 As a result, the current operative approach to complex proximal humerus fractures in this population has shifted largely towards RTSA utilization, with increasing literature support.…”

“…Some authors have advocated for fixation with complete open or minimally invasive locked plating. 26 – 28 ORIF of proximal humerus fractures in this patient population is associated with higher levels of technical difficulty, 26 outcomes that are operator dependent, 26 the possibility of subacromial impingement syndrome due to hardware prominence, 7 risk of axillary and radial nerve palsies, 28 and a two- to threefold increased risk of all complications when compared to younger patients. 40 Robinson et al presented the large series of patients treated with ORIF and found overall nonunion rate of 7%.…”