Review ArticleAbstract
This scientific work is devoted to a review of literary sources regarding the surgical treatment of patients with fractures of the proximal humerus, which showed divergence of opinions between specialists in regards to the choice of optimal strategy for surgical treatment of patients of different age groups. Despite the development of a wide range of surgical methods and methods of fixation, various complications are observed in the postoperative period, which indicates the need for further optimization of methods for surgical correction of fractures of this localization.
Keywords: Humerus; Proximal Humerus Fractures; Osteosynthesis; Plate
Relevance of the Subject
According to the WHO, fractures of the surgical neck of the
humerus account for approximately 5-15% of all injuries of
the human skeleton bones, moreover in 60% of cases they are
characterized by multi-fragmented fractures and are accompanied
by a pronounced displacement of the fragments, which contribute
to special difficulties in choosing the tactics of surgical treatment or
reposition of bone fragments with conservative treatment [1]. The
severity of displacement of bone fragments depends on the energy
strength of the injury, which in 85% of cases is characterized by
the absence of displacement of bone fragments due to low-energy
injuries, in which surgical intervention is not required, and they
are treated conservatively. However, a correct assessment when
developing indications for conservative treatment allows achieving
good functional results in 80–87% of cases [2,3]. Difficulties in
reposition of bone fragments according to AA Kolomiyets et al.
(2006) up to 50% of cases are caused by interposition of soft tissues
between fragments that prevent closed reposition [4,5].
Despite the high achievement in the surgical treatment
of fractures of the surgical neck of the humerus according to
E. Weber et al. (1998) complete restoration of damaged limb
function was noted only in 38% of cases [5,6]. Most authors
believe that conservative treatment should not be abandoned,
while others consider it to be ineffective. In general, the result
of treatment depends on the severity of the injury, the type of
fracture, the quality of the reposition, and also to a large extent on
the patient’s persistence and level of motivation. The best results
are observed in active patients with a high level of self-discipline
[3, 7]. The domestic literature describes more than 30 different
methods of surgical treatment of fractures of the surgical neck of
the humerus. Most often authors use: osteosynthesis of external
fixation devices of various design, fixation of bone fragments with
transossal sutures, osteosynthesis with pins, plates and screws
, intramedullary osteosynthesis (with blocking and using rigid
constructions of the “TEN-pin” type), as well as the establishment
of a unipolar endoprosthesis of the shoulder joint in cases of severe
destruction of the proximal humerus [7,8].
Handoll H.H. et al (2015) divided the surgical methods of
treatment for fractures of the proximal humerus into the following:
1. Closed reduction and percutaneous fixation with pins;
2. Extrafocal fixation;
3. Open reposition and internal fixation by a plate;
4. Open reposition and fixation by tightening loop method;
5. Intramedullary fixation;
6. Hemiartroplasty (prosthesis of the humeral head);
7. A total shoulder joint prosthesis (anatomical or reverse)
[4,9].
Despite the development and widespread use of quite a
few different methods of surgical intervention, postoperative
complications and unsatisfactory results range from 12 to 35%
in the form of instability of the installed plate, nail migration, the
appearance of impingement syndrome, aseptic necrosis of the
humeral head [10,11]. When choosing the operational method for
stabilization of fragments, it is necessary to focus on the data of the
X-rays taking into account the state of the bone tissue, the size and
number of bone fragments in which the choice of tactics in each
case is individual [12,13]. As known, good bone consolidation of
fractures of the surgical neck of the humerus in patients can be
achieved only after adequate reduction of bone fragments in the
open. The group of authors believes that it is necessary to operate
patients at the earliest possible time and surgery technique should
be minimally invasive, using low-traumatic fixatives to prevent the
development of complications such as avascular necrosis. The very
beginning of the history of the surgical treatment of patients with
fractures of the surgical neck of the humerus is associated with the
use of pins as an osteosynthesis.
Closed percutaneous pinning can be performed in patients with
biphasic proximal shoulder fractures with good bone density with
the appropriate equipment - an electron-optical transducer [14,15].
Due to insufficient stability of osteosynthesis with pins and for the
prevention of pin migration S.I. Makarova et al. (2007) after closed
reposition and fixation with pins, gypsum limb immobilization is
applied for 3-4 weeks. Other authors adhere to similar tactics when
performing gypsum immobilization after osteosynthesis with
pins for a period of two to six weeks [16,17]. All known methods
of percutaneous fixation with pins have common drawbacks:
difficulty achieving anatomical reposition, insufficient stability of
osteosynthesis, risk of damage to blood vessels and nerves during
pinning (Pankov I. O., 2003). Nevertheless, at present, many foreign
authors consider this technique to be a method of choice for multifragment
fractures, especially in elderly patients . Jacob in 1991
revealed the development of avascular necrosis in 26% of cases
with percutaneous fixation, and in 2008 R. Bogner et al. obtained a
significantly better result in 3% of cases [12,18].
The rapid development of the history of surgical treatment of
fractures of the proximal end of the humerus began with the use of an external fixation apparatus by the American surgeon J. Emsberry
in 1831 [19]. In 1951 G.A. Ilizarov proposed an apparatus for
transosseous osteosynthesis (TOO), which differs from others in
its expanded ability to move bone fragments and low invasiveness,
the prototype of which is the Witmozer’s device. According to
N.V. Tyulyaev et al. (2011) external fixation devices are used for
diaphyseal fractures of the upper limbs in 25 - 42% of cases with
closed injuries and in 50% with open [11,20]. Based on data from
514 patients with fractures of different levels of the humerus
Raengulov (2000) gives recommendations on the choice of surgical
treatment. External fixation devices are advisable in order to reduce
the morbidity and complexity with closed unstable fractures of the
humerus, open and multi-fragmented, contaminated fractures, and
only in urgent order, creating conditions for temporary fixation of
fragments and for the implementation of subsequent measures
[5,21].
A common drawback of external fixation devices is that they do
not always allow the efficient reposition of fragments, especially in
cases of chronic fractures, comminuted fractures, in the presence of
angular and rotational displacements. Furthermore, the imposition
of external fixation devices is a rather complicated surgical
operation and in some cases presents serious inconvenience
Makarova S. I., 2007. An individual differentiated approach to
the tactics of surgical treatment for fractures-dislocations of the
proximal humerus in adults interested many scientists, which led
to the development of various fixation devices, from pin fixation
to more modern, biological types of osseous fixators [7,22]. E. Sh.
Lomtatidze et al. (2003) while analyzing the functional results of
surgical treatment of proximal humerus fractures while considering
the age and nature of the fracture, concluded that osteosynthesis
with plates and nails is more appropriate for young patients to
obtain the best long-term results, and in elderly patients over 60
years of age the most delicate and at the same time reliable fixation
method is recommended [15,23].
In case of multi-fragmented (three- and four-fragmented)
fractures, caused by high-energy injuries, it is impossible to achieve
sufficient adequate fixation by using pin fixation, which led to the
development and use of more optimal types of plates, such as BIOS,
LCP, DCP, providing stable fixation of fragments that do not violate
the normal anatomy and functionality of the shoulder segment
[24,25]. Since L. Böhler declared in 1964 that the treatment of
fractures of the humerus should be exclusively surgical, a lot of
time has passed and now surgical treatment is the “gold standard”
due to the development of modern methods of intramedullary
and bone osteosynthesis. The first application of intramedullary
osteosynthesis of the humerus belongs to Kuncherу. In the first
half of the twentieth century, fractures of the humerus due to the
large number of complications associated with the migration of the
structure, and the lack of rotational stability made us look for new
ways to solve the existing problem. Indications for intramedullary
osteosynthesis for fractures of the proximal humerus are limited.
It is used in patients with two-fragment fractures. With this
method of treatment, the risk of damage to the radial and axillary
nerves by nails is high (Kies T.R., 2001). Improving the technique of
open intramedullary osteosynthesis in 1974, A. Kapandij proposed
intramedullary rods for the treatment of stable subcapital fractures
[26]. In 1984 H. Seidel proposed HLN (humeral locked nail) - a pin
for the humerus, having a locking hole at the apex, which allows
stable fixation of fragments of fractures of the head of the humerus
[27]. The advantages of the open reposition and internal fixation
method (ORIF) are anatomical reconstruction, early mobilization of
the limb and a good functional result. However, there is an opinion
that “even technically competently performed fixation with a highquality
implant does not always allow to avoid the subsequent
migration of nails or a fracture of the plate, and consolidation in the
correct position is not guaranteed in the future” [28]. With fractures
and dislocations of the proximal humerus, indicators of avascular
necrosis development vary within 35% with ORIF methods [17]
compared with closed reposition and fixation of fragments by pins,
which in the latter occurs in 2.4% to 11% cases [5,20].
In one of his work, P. Gierer (........) explains the reason for the
development of avascular necrosis with osteosynthesis of the
humeral head in cases where the fracture line passes through the
articular surface [18]. The application of the above mentioned
methods is targeted only for stable options of fractures of the
proximal end of the humerus, which prompted scientists to develop
optimal osteosynthesis methods that provide stable fixation
simultaneously with stable, as well as unstable fractures with
multi-fragmented humerus fractures, especially in elderly patients
[18,19]. Given the global trend to perform minimally invasive and
less traumatic surgeries, as well as the need to restore the function
of the operated limb as soon as possible, closed intramedullary
osteosynthesis with proximal blocked shafts can be considered
one of the most promising methods of treatment for comminuted
fractures of the proximal humerus [4,5]. In recent decades, a lot of
scientific works have appeared in the literature dedicated to closed
reposition with blocked intramedullary osteosynthesis (BIOC) of
the humerus for fractures of the proximal humerus representing a
number of advantages, such as the absence of an open reposition of
bone fragments with preservation of biological material (primary
hematoma) for complete osteoreparation , the possibility of stable
fixation of the fracture area due to the installation of multi-plane
nails on the proximal and distal parts of the segment and early
development of a segment, providing stimulation of bone fusion
and prevents contracture and stiffness in adjacent joints.
The BIOS technique has become widely used among many large
schools and has led to the development of more standardized device
options, after analyzing its results and identifying shortcomings
[14,18]. The earliest versions of the intramedullary pins, such as
the Rush shaft, did not provide adequate fixation stability, including
rotational, which led to the migration of retainers and required repeated surgical interventions. The weak point of the second
generation lockable pins such as Polarus nail and Targon PH is
weak fixation with proximal locking nails, which can lead to the
migration of pins. [28,29]. Continuing the development of advanced
third generation options, such as the Stryker T2 Proximal Humeral
Nail and Synthes Proximal Humeral Nail, showed sufficient fixation
strength and stability of proximal locking nails. The solution to the
problem of pin migration is based on the implementation of nailto-
nail, spiral blade technology. The use of a proximal shoulder pin
allows minimally invasive osteosynthesis with the lowest risk of
infectious complications compared to other surgeries.
However, osteosynthesis with a standard proximal shoulder pin
can damage the tendons of the rotator cuff and cause postoperative
pain in the shoulder joint . A proximal lockable plate is better for
fixation of fractures in young patients, but the fixation of fractures
in patients with osteoporosis remains a problem. In 40% of cases,
complications when using plates are associated with errors in
surgical technique. Plate fractures occur in 1.9%, impingement -
in 2.6%, the formation of a false joint - in 2.6%, wound infection
- in 3.9%, loss of reposition - in 7.1%, necrosis of the humeral
head - in 3.9% of cases [21].Scientists at the Clinic of the
Republican Specialized Scientific and Practical Medical Center for
Traumatology and Orthopedics of the Republic of Uzbekistan offer
a pin-shaft apparatus developed in the clinic for three- and fourfragment
fractures of the proximal humerus in elderly patients. The
installation of a pin-shaft apparatus is very easy and less traumatic
when used with reliable fixation and preservation of motor function
in the shoulder joint, a patent for a utility model was obtained (FAP
20100015).
The history of bone osteosynthesis dates back to 1969, when the
AO group proposed the use of T-shaped plates together with large
spongy nails. Until the early 2000s, they were used exclusively for
AO type A2 fractures, and for B and C type fractures this technique
was recognized as ineffective since it was often accompanied
by complications, such as the instability of fragments due to the
instability of the metal structure itself, impingement of a massive
structure with an acromial process of the scapula, often leading to
revision intervention [28]. Currently, the use of various types of
plates, such as plates of CITO, AO / ASIF, LSP, DSP, etc., are referred
to as bone osteosynthesis. One of the founders of AO (Association
for the Study of Internal Fixation Methods of AO / ASIF) is Robert
Danis (1880 - 1962), who believes that based on functional reasons,
each fracture in itself is already an indication for surgical treatment.
In his opinion, surgery should be performed as soon as possible.
AO / ASIF itself was created in 1958 and four basic principles of
osteosynthesis were then formulated:
1. Anatomical reposition (perfect matching of fragments
during surgery)
2. Rigid stable fixation.
3. Preservation of blood supply to bone fragments.
4. Early active movements.
Also today, many authors support the above principles in their
functional activities.
At one time, AS / ASIF plates were rational in use, became
widespread in all developed schools of the world, led to many
controversial disagreements with large-scale use, on the basis of
which, new improved bone retainers were developed [22,27]. The
only drawback of the AO / ASIF plate is the lack of compression
when it is installed on the surface of the cortical layer of the bone
due to classic simple holes, and also is not a retainer of choice in
patients with multi-fragmented fractures arising from osteoporosis
[5,30]. The unresolved issue is the choice of the type of fixation
between the plate and the shaft for fractures of the proximal humeral
metaepiphysis. According to many researchers, when comparing
the type of osteosynthesis with three- and four-fragment fractures
of the proximal humerus, there is a significant difference between
the use of two types: lockable plates and lockable shafts from a
position of stability is not detected, however, osteosynthesis with
a shaft can be performed less invasively. Many scientists explain
that the expression “stability” can be either absolute or relative,
reaching during surgery depending on the location of the fracture.
For diaphyseal fractures (femoral, humerus fracture in the
middle third) it is enough to: restore the segment length, get rid
of angular deformation and rotational displacement. Therefore, in
place of absolute stability in the treatment of diaphyseal fractures
– stability is quite relative. A consequence of achieving relative
stability is fusion with the formation of periosteal callus [1]. On
this basis, already in the late 80s - early 90s, coming from the
surgical principles of AO, the first - “anatomical reposition” was
rephrased to “functional reposition”. The plates are used in two
directions, with the aim of neutral fixation in comminuted and
multifragmented fractures and to create conditions for compression
or dynamization in the absence of fragments. Deriving from that
plates are distinguished as follows: 1) plates with round holes; 2)
plates with oval holes; 3) dynamically compressing plates; 4) plates
with angular stability of the nail. Currently, plates with dynamic
compression are the most commonly used: DCP (S. Perren et al.
1969) and LC-DCP (S. Perren et al. 1989).
The configuration of the holes of the plates with dynamic
compression is that at the final stage of introducing the nail into
the bone, its head “slides” towards the middle of the plate, whereby
the convergence of fragments occurs over the area of the fracture
fragments. The possibilities of bone osteosynthesis expanded
significantly with the advent of plates with angular stability of nails,
since they allow stable fixation with relatively small dimensions
of the structure [14]. In the presence of osteoporosis, osteopenia
in patients with three-, four-fragment fractures, osteosynthesis
with proximal shoulder plates with angular stability is indicated
(LCP). The advantages of using such plates are obvious. These
include stable fixation of the fracture, a decrease in the likelihood
of secondary displacement of fragments due to fragment lysis.
This allows you to start earlier movement development[16]. Data
from PubMed.gov. being one of the largest information resources,
showed the results of the technique, universally recognized as
the “gold standard” - osteosynthesis with LCP-type plates in 340
patients over the period from 1992 to 2012.
Both methods have a large number of supporters and
opponents, since both have disadvantages and certain advantages
as well [12,13]. According to A.M. Foruria lacks rotational stability
in the broken segment when using LCP plates as osteosynthesis, led
to the development of LPHP plates, which have greater resistance
to torsion loads The angular stability and rotational stability of
the LPHP type plate are due to the location of the installed nails
under different angular flatnesses relative to each other, which
ensures rigid fixation of the shoulder head to the plate, and also
does not exert pressure on the periosteum and cortical layer of the
bone itself, thereby not disturbing blood circulation in the bone
fragments [2,31]. Plate osteosynthesis requires extensive access,
which, in turn, increases the risk of osteonecrosis of the humeral
head due to impaired vascularization. Furthermore, rather bulky
bone constructions can cause subacromial impingement, and in
the presence of osteoporosis there is a risk of failure of the bone
fixation. The disadvantage of plate osteosynthesis without angular
stability of the nails is also the development of plate instability,
including accompanied by its fracture [28].
For several years, many authors proposed in the case of
three- and four-fragment fractures to do primary hemiartroplasty
(according to Neer) or to perform unipolar shoulder joint
replacement taking into account the inefficiency and many
disadvantages of the known bone and intraosseous methods of
osteosynthesis [32]. Despite the large number of conservative
and surgical methods used to treat patients with injuries of the
proximal humerus, there is no unified approach to the choice of a
particular treatment option depending on the age of the patient,
the nature of the displacement of bone fragments and the duration
of the injury. Given the diverse nature of fractures of the proximal
humerus, the choice of treatment for patients with fractures of
the proximal humerus should be individual. Taking into account
the above data on the analysis of numerous literature sources, it
should be noted that the issues of surgical correction of fractures
of the proximal end of the humerus remain one of the unresolved
chapters of modern traumatology. Despite the developments, the
majority of operational methods and modern fixation devices with
biological significance, the percentage of unsatisfactory results and
various problems of difficult to solve complications remains quite
high, which on the whole represents the real relevance of this work
and needs to be considered as a promising area for further research
work.
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