Open reduction and internal fixation with plate and screw is one of the most widely used surgical methods in the treatment of proximal humeral fractures in the elderly. In recent years, more and more studies have shown that it is very important to strengthen the medial column support of the proximal humerus during the surgery. At present, orthopedists often use bone graft, bone cement, medial support screw and medial support plate to strengthen the support of the medial column of the proximal humerus when applying open reduction and internal fixation with plate and screw to treat proximal humeral fractures. Therefore, the methods of strengthening medial column support for proximal humerus fractures and their effects on maintaining fracture reduction, reducing postoperative complications and improving functional activities of shoulder joints after operation are reviewed in this paper. It aims to provide a certain reference for the individualized selection of medial support methods according to the fracture situation in the treatment of proximal humeral fractures.
ObjectiveTo investigate the clinical results of locking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation.
MethodsBetween January 2011 and August 2012, 16 patients with proximal humeral fractures (AO type C2) were treated by locking-plate with an intramedullary fibular allograft. The clinical data were retrospectively analysed. There were 5 males and 11 females with an average age of 64 years (range, 55-70 years). The injury causes were falling injury in 12 cases, traffic accident injury in 3 cases, and sports injury in 1 case. The duration between injury and operation ranged from 2 to 6 days (mean, 4.5 days). The imaging data were used to judge the fracture healing, and to measure the neck-shaft angle and the height of humeral head; the disability of arm, shoulder, and hand (DASH) score, short-form 36 health survey scale (SF-36), and Neer score were used to evaluate the function of the shoulder after surgery.
ResultsPrimary healing of incision was obtained in all patients; no complication of vascular and nerve injury occurred. Sixteen cases were followed up 12-24 months (mean, 18 months). All fractures healed at 18-24 weeks (mean, 20 weeks). No complication occurred as follows:re-displacement, necrosis, rejection reaction, and loosening or extraction of screws. At last follow-up, the neck-shaft angle was 126.6-136.9° (mean, 132.5°), showing a little lost when compared with intraoperative angle (130.5-138.0°, 134.0° on average). At 12 months after surgery, the height loss of humeral head was 1.8-4.6 mm (mean, 2.0 mm); the passive anteflexion of the shoulder was 130-160° (mean, 148°); the active anteflexion was 120-145° (mean, 136°); the external rotation was 30-65° (mean, 56°); the internal rotation was 15-25° (mean, 19°). And the DASH score was 2-53 (mean, 12); the SF-36 score was 50-95 (mean, 89). According to Neer score for shoulder function, the results were excellent in 10 cases, good in 4 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 87.5%.
ConclusionLocking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation has satisfactory clinical results because of stable fixation, high clinical outcome scores, and low internal fixation failure.
ObjectiveTo review the literature about the clinical application and research progress on medial support augmentation of plate osteosynthesis for proximal humeral fractures, and to provide reference for clinical treatment.MethodsThe literature concerning medial support augmentation of plate osteosynthesis for proximal humeral fractures in recent years was extensively reviewed, as well as the biomechanical benefit and clinical advantage were analyzed thoroughly.ResultsMedial support augmentation of plate osteosynthesis for proximal humeral fractures is very important, especially in osteoporotic and/or comminuted fractures. Many medial support augmentation methods have been proposed which can be divided into extramedullary support and intramedullary support. It can also be divided into autogenous bone support and allogenic bone support according to the material and source, divided into medial column support, calcar support, and humeral head support according to the support site, and divided into fibular shaft support, femoral head support, anatomic fibula support according to the shape of the augmented fixation. At present, clinical and biomechanical researches show that medial support augmentation is an effective treatment for proximal humeral fractures.ConclusionAs an important treatment strategy for the treatment of proximal humeral fractures, the medial support augmentation of plate osteosynthesis gets the focus from the biomechanical studies and clinical treatment. However, there are still widespread controversies among orthopedic surgeons regarding the support mode, site, implant shape, and material of medial column support for augmentation of proximal humeral fractures. More high-quality clinical trials and biomechanical researches as well as multi-disciplinary integration, are needed to provide better strategy treatment for the treatment of proximal humeral fractures.
ObjectiveTo explore the biomechanical stability of the medial column reconstructed with the exo-cortical placement of humeral calcar screw by three-dimensional finite element analysis. MethodsA 70-year-old female volunteer was selected for CT scan of the proximal humerus, and a wedge osteotomy was performed 5 mm medially inferior to the humeral head to form a three-dimensional finite element model of a 5 mm defect in the medial cortex. Then, the proximal humeral locking plate (PHILOS) was placed. According to distribution of 2 calcar screws, the study were divided into 3 groups: group A, in which 2 calcar screws were inserted into the lower quadrant of the humeral head in the normal direction for supporting the humeral head; group B, in which 1 calcar screw was inserted outside the cortex below the humeral head, and the other was inserted into the humeral head in the normal direction; group C, in which 2 calcar screws were inserted outside the cortex below the humeral head. The models were loaded with axial, shear, and rotational loadings, and the biomechanical stability of the 3 groups was compared by evaluating the peak von mises stress (PVMS) of the proximal humerus and the internal fixator, proximal humeral displacement, neck-shaft angle changes, and the rotational stability of the proximal humerus. Seven cases of proximal humeral fractures with comminuted medial cortex were retrospectively analyzed between January 2017 and December 2020. Locking proximal humeral plate surgery was performed, and one (5 cases) or two (2 cases) calcar screws were inserted into the inferior cortex of the humeral head during the operation, and the effectiveness was observed. Results Under axial and shear force, the PVMS of the proximal humerus in group B and group C was greater than that in group A, the PVMS of the internal fixator in group B and group C was less than that in group A, while the PVMS of the proximal humerus and internal fixator between group B and group C were similar. The displacement of the proximal humerus and the neck-shaft angle change among the 3 groups were similar under axial and shear force, respectively. Under the rotational torque, compared with group A, the rotation angle of humerus in group B and group C increased slightly, and the rotation stability decreased slightly. All the 7 patients were followed up 6-12 months. All the fractures healed, and the healing time was 8-14 weeks, with an average of 10.9 weeks; the neck-shaft angle changes (the difference between the last follow-up and the immediate postoperative neck-shaft angle) was (1.30±0.42)°, and the Constant score of shoulder joint function was 87.4±4.2; there was no complication such as humeral head varus collapse and screw penetrating the articular surface. ConclusionFor proximal humeral fractures with comminuted medial cortex, exo-cortical placement of 1 or 2 humeral calcar screw of the locking plate outside the inferior cortex of the humeral head can also effectively reconstruct medial column stability, providing an alternative approach for clinical practice.
Objective To review the biomechanics of internal fixators for proximal humeral fractures, and to compare the mechanical stabil ity of various internal fixators. Methods The l iterature concerning the biomechanics of internal fixators for proximal humeral fractures was extensively analyzed. Results The most important things for best shoulder functional results are optimal anatomical reduction and stable fixation. At present, there are a lot of methods to treat proximal humeral fractures. Locking-plate exhibites significant mechanical stabil ity and has many advantages over other internal fixators by biomechanical comparison. Conclusion Locking-plate has better fixation stabil ity than other internal fixators and is the first choice to treat proximal humeral fractures.
ObjectiveTo analyze the effectiveness of proximal humeral internal locking system (Philos) plate for proximal humerus fracture.
MethodsThirty-three patients with proximal humerus fracture were treated with open reduction and internal fixation with Philos plate between January 2009 and January 2014. There were 19 males and 14 females, aged 23-89 years (mean, 56.6 years). The left side was involved in 15 cases, and the right side in 18 cases. The injury causes included falling in 20 cases and traffic accident in 13 cases. All cases received X-ray and CT scan and three-dimensional reconstruction before operation. According to the Neer classification, 8 cases were rated as two-part fractures, 15 cases as three-part fractures, and 10 cases as four-part fractures. The interval time between injury and surgery was 1-7 days (mean, 3.67 days). Postoperative functional outcome was evaluated using the Constant-Murley score.
ResultsInfection and liquefaction occurred in 2 cases respectively, which was cured after corresponding treatment; primary healing of wound was obtained in the other 29 cases. Five patients had shoulder pain. The patients were followed up 11-47 months (mean, 33 months). The mean time of fracture union was 7.5 months (range, 5-9 months) on the X-ray films. Humeral head necrosis occurred in 2 patients with Neer four-part fractures, and internal fixation failure occurred in 3 patients (2 screw broken and 1 plate broken) with four-part fractures (2 cases) and three-part fractures (1 case), which was cured after conservative treatment. At last follow-up, the mean Constant-Murley score was 70.5 (range, 42-90); the results were excellent in 3 cases, good in 21 cases, moderate in 6 cases, and poor in 3 cases.
ConclusionSatisfactory results can be expected for proximal humeral fracture by using of the proximal humeral internal locking system plate based on strict indication and early rehabilitation training.
Objective To evaluate the cl inical significance of minimally invasive percutaneous plate osteosynthesis (MIPPO) appl ied in Neer II, III parts fractures of proximal humeraus. Methods The cl inical data were retrospectively analyzed, from 30 patients with Neer II, III parts fractures of proximal humeraus in accordance with selection criteria, who were treated with manual reduction and plaster external fixation (11 cases, non-operative group) or with MIPPO (19 cases, operative group) between January 2008 and May 2010. In non-operative group, there were 6 males and 5 females with an average age of 60 years (range, 56-80 years) and with an average time of 10 hours (range, 3-24 hours) between injury and reduction, including 8 cases of Neer II and 3 cases of Neer III. In operative group, there were 13 males and 6 females with anaverage age of 65 years (range, 45-78 years) and with an average time of 3 days (range, 1-5 days) between injury and operation, including 9 cases of Neer II and 10 cases of Neer III. There was no significant difference in gender, age, fracture type, and time from injury to operation (P gt; 0.05). The shoulder joint function before and after treatments was evaluated according to Constant-Murley Score (CMS) and American Shoulder and Elbow Surgeons’ Form (ASES) scoring systems. Results Thirty patients were followed up. In operative group, the follow-up time ranged from 11 to 18 months (mean, 12 months); all incisions healed by first intention with no compl ication of internal fixation failure, infection, or nerve injury. In non-operative group, the follow-up time ranged from 9 to 15 months (mean, 11 months). The X-ray films showed that fractures healed without humeral head necrosis in 2 groups. The bone heal ing time in operative group and non-operative group was (11.47 ± 2.48) weeks and (11.82 ± 2.44) weeks, respectively, showing no significant difference (t=0.369, P=0.889). The CMS score and ASES score at each time point after treatment were significantly better than those before treatment (P lt; 0.05); the CMS scores in operative group were better than those in non-operative group at 3 weeks, 3 months, and 1 year after treatment (P lt; 0.05); and the ASES score in operative group was better than that in non-operative group at 3 weeks and 3 months after treatment (P lt; 0.05), but no significant difference was found at 1 year after treatment (P gt; 0.05). Conclusion MIPPO fixation using the locking compression plate is an effective option for Neer II, III parts fractures of proximal humeraus. It can provide good functional recovery of the shoulder joint so that patients can get back to their normal l ife as soon as possible.
ObjectiveTo review the advancement made in the understanding of valgus impacted proximal humeral fracture (PHF). MethodsThe domestic and foreign literature about the valgus impacted PHF was extensively reviewed and the definition, classification, pathological features, and treatment of valgus impacted PHFs were summarized. Results PHF with a neck shaft angle ≥160° is recognized as a valgus impacted PHF characterized by the preservation of the medial epiphyseal region of the humeral head, which contributes to maintenance of the medial periosteum’s integrity after fracture and reduces the occurrence of avascular necrosis. Therefore, the valgus impacted PHF has a better prognosis when compared to other complex PHFs. The Neer classification designates it as a three- or four-part fracture, while the AO/Association for the Study of Internal Fixation (AO/ASIF) categorizes it as type C (C1.1). In the management of the valgus impacted PHF, the selection between conservative and surgical approaches is contingent upon the patient’s age and the extent of fracture displacement. While conservative treatment offers the advantage of being non-invasive, it is accompanied by limitations such as the inability to achieve anatomical reduction and the potential for multiple complications. Surgical treatment includes open reduction combined with steel wire or locking plate and/or non-absorbable suture, transosseous suture technology, and shoulder replacement. Surgeons must adopt personalized treatment strategies for each patient with a valgus impacted PHF. Minimally invasive surgery helps to preserve blood supply to the humeral head, mitigate the likelihood of avascular necrosis, and reduce postoperative complications of bone and soft tissue. For elderly patients with severe comminuted and displaced fractures, osteoporosis, and unsuitable internal fixation, shoulder joint replacement is the best treatment option. ConclusionCurrently, there has been some advancement in the classification, vascular supply, and management of valgus impacted PHF. Nevertheless, further research is imperative to assess the clinical safety, biomechanical stability, and indication of minimally invasive technology.
