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Clinical Orthopaedics and Related Research®

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01-12-2011 | Symposium: Fractures of the Shoulder Girdle

Locked Plating of Proximal Humeral Fractures: Is Function Affected by Age, Time, and Fracture Patterns?

Authors: Clifford B. Jones, MD, FACS, Debra L. Sietsema, PhD, Daniel K. Williams, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 12/2011

Abstract

Background

Locking plate fixation of proximal humeral fractures improves biomechanical stability. It has expanded the indications of traditional open reduction internal fixation and become increasingly common for treating unstable, displaced proximal humeral fractures. Despite improved stability it is unclear whether these improve function and if so for which patients.

Questions/purposes

We therefore determined patient function after a locked plating technique for the treatment of unstable proximal humeral fractures based on age, time, fracture pattern, and associated injures.

Patients and Methods

We retrospectively reviewed 66 patients with 69 proximal humeral fractures treated with a locked proximal humeral plating technique from 2002–2006 using prospectively gathered data. Function was measured using the Short Musculoskeletal Function Assessment (SMFA), Disability of the Arm, Shoulder, and Hand (DASH), and SF-36 at 6, 12, and 24 months. Fracture healing was determined radiographically and complication rates were determined from the medical records.

Results

At 2 years, DASH scores were 26.5 and 37.4 for isolated and polytrauma patients, respectively. For age differences, DASH scores were 33.1 and 28.9 for ages younger than 60 and 60 years old or older, respectively. At 2 years, SMFA scores were higher (worse) in older compared with younger patients. Function, but not bother continues to improve in younger patients up to 2 years. More severe fracture patterns performed worse in all SMFA indices at 2 years. Polytrauma patients consistently experienced worse mobility than isolated injury patients at each time interval.

Conclusions

With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1 year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. Long-term functional deficits persist.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg. 2004;13:191–195.PubMedCrossRef

Agudelo J, Schurmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21:676–681.PubMedCrossRef

Anglen J, Kyle RF, Marsh JL, Virkus WW, Watters WC 3rd, Keith MW, Turkelson CM, Wies JL, Boyer KM. Locking plates for extremity fractures. J Am Acad Orthop Surg. 2009;17:465–472.PubMed

Baron JA, Barrett J, Malenka D, Fisher E, Kniffin W, Bubolz T, Tosteson T. Racial differences in fracture risk. Epidemiology. 1994;5:42–47.PubMedCrossRef

Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, Keller RB. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7:612–618.PubMedCrossRef

Beaton DE, Katz JN, Fossel AH, Wright JG, TArasuk V, Bombardier C. Measureing the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14:128–146.PubMed

Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson AN. Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg Am. 2011;93:121–131.PubMedCrossRef

Bjorkenheim, JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: A retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004;75:741–745.PubMedCrossRef

Busse JW, Bhandari M, Guyatt GH, Heels-Ansdell D, Mandel S, Sanders D, Schemitsch E, Swiontkowski M, Tornetta P 3rd, WAi E, Walter SD. Use of both Short Musculoskeletal Function Assessment questionnaire and Short Form-36 among tibial fracture patients was redundant. J Clin Epidemiol. 2009;62:1210–1217.PubMedCrossRef

10.

Charalambous CP, Siddique I, Valluripalli K, Kovacevic M, Panose P, Srinivasan M, Marynissen H. Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures. Arch Orthop Trauma Surg. 2007;127:205–210.PubMedCrossRef

11.

Cornell CN. Tension-band wiring supplemented by lag-screw fixation of proximal humerus fractures: a modified technique. Orthop Rev. 1994;Suppl:19–23.

12.

Cornell CN, Levine D, Pagnani MJ. Internal fixation of proximal humerus fractures using the screw-tension band technique. J Orthop Trauma. 1994;8:23–27.PubMedCrossRef

13.

Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37:691–697.PubMedCrossRef

14.

Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older pateint. J Bone Joint Surg Br. 2001;83:799–804.PubMedCrossRef

15.

Darder A, Darder A Jr, Sanchis V, Gastaldi E, Gomar F. Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band. J Orthop Trauma. 1993;7:497–505.PubMedCrossRef

16.

Esser RD. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clin Orthop Relat Res. 1994;299:244–251.PubMed

17.

Esser RD. Treatment of three- and four-part fractures of the proximal humerus with a modified cloverleaf plate. J Orthop Trauma. 1994;8:15–22.PubMedCrossRef

18.

Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005;430:176–181.PubMedCrossRef

19.

Fenichel I, Oran A, Burstein G, Perry Pritsch M. Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus; a retrospective study. Int Orthop. 2006;30:153–157.PubMedCrossRef

20.

Galatz LM, Iannotti JP. Management of surgical neck nonunions. Orthop Clin North Am. 2000;31:51–61.PubMedCrossRef

21.

Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;434:123–129.PubMedCrossRef

22.

Gardner MJ, Lorich DG, Werner CM, Helfet DL. Second-generation concepts for locked plating of proximal humerus fractures. Am J Orthop. 2007;36:460–465.PubMed

23.

Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20:602–607.PubMedCrossRef

24.

Gibson JN, Handoll HH, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2001;1:CD000434.PubMed

25.

Gibson JN, Handoll HH, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2002;2:CD000434.PubMed

26.

Hawkins RJ, Switlyk P. Acute prosthetic replacement for severe fractures of the proximal humerus. Clin Orthop Relat Res. 1993;289:156–160.PubMed

27.

Healy WL, Jupiter JB, Kristiansen TK, White RR. Nonunion of the proximal humerus. A review of 25 cases. J Orthop Trauma. 1990;4:424–431.PubMed

28.

Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006;442:100–108.PubMedCrossRef

29.

Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J Shoulder Elbow Surg. 2008;17:21–28.PubMedCrossRef

30.

Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int. 2005;16(Suppl 2):S65–72.PubMedCrossRef

31.

Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427–433.PubMedCrossRef

32.

Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: Normative values from the general population. J Bone Joint Surg Am. 2002;84:208–215.PubMed

33.

Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295–298.PubMed

34.

Karanicolas PJ, Bhandari M, Taromi B, Akl EA, Bassler D, Alonso-Coello P, Rigau D, Bryant D, Smith SE, Walter SD, Guyatt GH. Blinding of outcomes in trials of orthopaedic trauma: an opportunity to enhance the validity of clinical trials. J Bone Joint Surg Am. 2008;90:1026–1033.PubMedCrossRef

35.

Kettler M, Biberthaler P, Braunstein V, Zeiler C, Kroetz M, Mustschler W. Treatment of proximal humeral fractures with the PHILOS angular stable plate: Presentation of 225 cases of dislocated fractures [in German]. Der Unfallchirurg. 2006;109:1032–1040.PubMedCrossRef

36.

Khan AA, Khan SU, Hossain Z. Intrathoracic migration of a humeral orthopedic pin. J Cardiovasc Surg. 2003;44:275–277.

37.

Kim KC, Rhee KJ, Shin HD. Tension band sutures using a washer for a proximal humerus fracture. J Trauma. 2008;64:1136–1138.PubMedCrossRef

38.

Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res. 2006;442:115–120.PubMedCrossRef

39.

Kristiansen B, Christense SW. Plate fixation of proximal humeral fractures. Acta Orthop Scand. 1986;57:320–323.PubMedCrossRef

40.

Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22:153–158.PubMedCrossRef

41.

Lin J, Hou SM, Hang YS. Locked nailing for displaced surgical neck fractures of the humerus. J Trauma. 1998;45:1051–1057.PubMedCrossRef

42.

Moonot P, Ashwood N, Hamlet M. Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Br. 2007;89:1206–1209.PubMedCrossRef

43.

Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.PubMed

44.

Neer CS 2nd. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg. 2002;11:389–400.PubMedCrossRef

45.

Neer CS 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77–82.PubMedCrossRef

46.

Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg Am. 2008;90:233–240.PubMedCrossRef

47.

Poolman RW, Swiontkowski MF, Fairbank JC, Schemitsch EH, Sprague S, de Vet HC. Outcome instruments: rationale for their use. J Bone Joint Surg Am. 2009;91(Suppl 3):41–49.PubMedCrossRef

48.

Sharafeldin K, Wuinlan JF, Corrigan J, Kelly IP. Functional follow-up of locking plate fixation of fractures of the proximal humerus. Eur J Orthop Surg. 2008;18:87–92.CrossRef

49.

Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short Musculoskeletal Function Assessment questionnaire: Validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999;81:1245–1260.PubMedCrossRef

50.

Voigt C, Woltmann A, Partenheimer A, Lill H. Management of complications after angularly stable locking proximal humerus plate fixation [in German]. Chirurg. 2007;78:40–46.PubMedCrossRef

51.

Ware J, Kosinski M, Gandek B. SF-36 Health Survey: Manual & Interpretation Guide. Lincoln, RI: Quality Metric; 2000.

52.

Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7:85–89.PubMedCrossRef

Title: Locked Plating of Proximal Humeral Fractures: Is Function Affected by Age, Time, and Fracture Patterns?
Authors: Clifford B. Jones, MD, FACS
Debra L. Sietsema, PhD
Daniel K. Williams, MD
Publication date: 01-12-2011
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 12/2011
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-011-1935-6

At a glance: The STEP trials

Springer Medicine

Locked Plating of Proximal Humeral Fractures: Is Function Affected by Age, Time, and Fracture Patterns?

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

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