Percutaneous Fixation of Three- And Four-Part Fractures of the Proximal Humerus

Abstract

Untreated 3-and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).

Osteosyntheseverfahren bei dislozierten proximalen Humerusfrakturen

“…Abweichend von den Neer-Dislokationskriterien wird heute die Indikation zur Osteosynthese tendenziell weiter gestellt werden, insbesondere bei instabilen Frakturen und dislozierten Tubercula [21,23].…”

“…Die Therapie der dislozierten Mehrfragment-und Luxationsfrakturen wird nach wie vor kontrovers diskutiert [2, 3, 5,6,8,10,11,12,13,14,15,16,17,20,21,22,23,25,27,28,29,30,31,32,33,34]. Die rein konservative Therapie dislozierter 3-und 4-Fragment-Frakturen führt über-wiegend zu schlechten Ergebnissen mit schmerzhafter Bewegungseinschrän-kung [10,19,32].…”

“…Aufgrund des höheren Kopfnekroserisikos und mechanischer Nachteile [12,15] mit entsprechend schlechten Ausheilungsergebnissen im osteoporotischen Knochen [22,27] findet die 4,5-T-Platte der AO in den letzten Jahren immer seltener Anwendung und wurde weitgehend von unterschiedlichen minimalosteosynthetischen Operationsverfahren abgelöst [6,10,11,12,14,16,21,22,26,33,34].…”

“…Dennoch ist die Nekroserate niedriger, als bisher von herkömmlichen Plattenosteosynthesen berichtet wurde, die in der Regel mit ausgedehnteren Frakturfreilegungen verbunden waren [12,15,22,27]. Sie befindet sich in vergleichbarer Größenordnung, wie von Hessmann u. Rommens [7] über die Osteosynthese mit der Kleeblattplatte (4,5% Teilnekrosen, 1,5% komplette Humeruskopfnekrosen) oder von Resch et al [21] über die gedeckte Minimalosteosynthese (9% Teil-und Totalnekrosen) berichtet wurde. In Übereinstimmung mit Hessmann u. Rommens [7] …”

Percutaneous K-Wire Fixation for a Comminuted Proximal Humerus Fracture – A Case Report.

“…Initially, the technique was applied to the management of two-part surgical neck fractures [7] where it was as successful as open methods. More recently, closed reduction and percutaneous fixation with pins and cannulated screws has been applied to the management of three-and even four-part proximal humerus fractures [8,9,10]. Although these approaches to more complex fractures are challenging, vascularity of the humeral head seems to be more reliably preserved than in open treatments that require soft-tissue dissection to place rigid fixation implants [11].…”