OPEN HUMERAL

REDUCFION FRACTURES

AND AND

FIXATION

OF

PROXIMAL

FRACTURE-DISLOCATIONS

S. K. MODA,

N. S. CHADHA,

S. S. SANGWAN,

D. K. KHURANA,

A. S. DAHIYA,

R. C. SIWACH

From

the Medical

College

and

Hospital,

Rohtak,

Republic

of India

and

Open reduction fracture-dislocations

and

internal fixation of the proximal

was employed humerus. Our

in the freatment of 25 severely displaced aims were accurate reduction and stable

fractures fixation to

allow early mobilisation in 10 a bent semitubular in all six patients with

and to achieve full functional recovery. In 15 fractures an AO T-plate plate was employed as a blade plate. Excellent or satisfactory results
two-part

was used and were obtained with threeor

fractures

involving

the

surgical

neck; in four of the five patients

part fractures involving the surgical neck and tuberosities;.in nine of the 1 1 patients with fracture-dislocation; and in two of the three patients with split fractures of the humeral head. Overall results were good satisfactory in 21 of the 25 cases.

Unsatisfactory
complicated methods
(Neer

results

were articular

associated fractures

with rotator the rotator

cuff damage.
cuff its repair was fully exposed Callahan involva six-hole, to form or fracturea by

There is no consensus on the best way to treat fractures of the proximal humerus. Various
internal fixation using wires and screws

of

1970), plates and have been

Cubbins approach and Scuderi 1934). Two-part ing the surgical AO semitubular blade plate (Fig.

to allow and

(Cubbins,

plates (Bosworth
Kofoed

(Kristiansen 1949), 1987) reported

and external and T-plates but none

Christensen fixators (Paavolainen of these

1986),

blade

fractures

fracture-dislocations

(Kristiansen et at 1983) methods has

neck (Fig. la) were fixed with plate, bent and contoured ib). In three-part fractures

been

consistently successful. For full functional recovery anatomical reduction, stable fixation and early mobitisation are required. With these requirements in mind, we treated such fractures with AO T-plates or blade plates.

dislocations (Fig. 2a) a four-hole AO T-plate was used (Fig. 2b). In all cases, the plate was applied lateral to the tendon of the long head of biceps (Muller et at 1979) and special care was taken to ensure that the upper end of the plate did not AO bone impinge 6.5 mm on the acromion cancellous and distal inserted
fixation cuff damage,

when were An the lb).

the arm used

was in the

MATERIAL There were 25 patients

AND with

METHODS displaced fractures of the

abducted. cancellous for tary

possible, associated

screws 4.5 mm

proximally was

cortical plate, In
repair

screws where cases of

was

fixation lag-screw
to

of more
improve

fragments. through
(Fig.

interfragmen-

proximal humerus open reduction and and fracture-dislocations

tuberosity were not

or fracture-dislocations treated by internal fixation. Two-part fractures involving only the greater
included in this

rotator

a meticulous

managed differently An anteromedial Crenshaw (1987).

by a tension approach In

study since they band technique. was used as described and

were by intra-

performed. The
postoperatively

wound Passive

was
the

closed
arm was

over ofthe

a suction
in

drain
a

and started

wrapped

velpeau

fracture-dislocations

bandage. introduced.

mobilisation later, and active

shoulder were

was

24 to 48 hours
S. K. Moda,
of Orthopaedics N. S. Chadha,

exercises

gradually

MS Orth,
MS. FIAMS

Associate
Orth,

Professor
Formerly

and
Professor

Head,

Department

of Orthopaedics

S. S. Sangwan, D. K. Khurana,

MS. DNB Orth, Associate Professor MS Orth, Orthopaedic Registrar A. S. Dahiya, MS, D Orth, Orthopaedic Registrar R. C. Siwach, MS. DNB Orth, Orthopaedic Registrar Department of Orthopaedic Surgery, Medical College
Rohtak-l2400l Correspondence

OBSERVATIONS Most of the patients Twenty-two cause commonest were

AND

RESULTS age group three was a were road (20 to female. traffic

in the younger male injury and of

and

Hospital,

40 years). The accident. involved. the blade Results

were

(Haryana),
should

Republic

of India.

be sent to Dr S. K. Moda. Joint Surgery

1990

British Editorial Society ofBone and 0301-620X/90/6142 $2.00 J Bone Joint Surg [Br] 1990; 72-B : 1050-2.

Left and right The AO T-plate plate in 10. evaluated

THE JOURNAL

arms were almost equally was used in 15 patients and objectively

OF BONE

were

using
AND JOINT

the scoring
SURGERY

1050

OPEN

REDUCTION

AND

FIXATION

OF PROXIMAL

HUMERAL

FRACTURES

AND

FRACTURE-DISLOCATIONS

1051

Fig Figure la - Radiograph six weeks after injury. an oblique cancellous

la

Fig.

lb

of a left shoulder Figure lb - Three interfragmentary

with fracture of the surgical neck of the humerus and subluxation, months after fixation with a bent semitubular plate, reinforced with screw. There is solid bony union and the result was excellent.

Table

I. Results

based

on fracture

type
(Neers criteria)

Fracture

type

Number cases surgical neck 6

5 11 ofthe head 3

of

Excellent 5
-

Satisfactory 1
4 5 2

Unsatisfactory
-

Two-part
Three-part

fractures
fractures

1 2 1

Fracture-dislocations Split fractures

4
-

Fig. Figure Figure union 2a 2b and

2a with an intra-articular a four-hole AO T-plate

Fig.

2b after injury. is solid bony

Radiograph of a right shoulder Six months after fixation with the result was good.

three-part fracture, two weeks and cancellous screws. There

VOL.

72-B, No. 6, NOVEMBER

1990

1052

S. K. MODA,

N. S. CHADHA,

S. S. SANGWAN,

D. K. KHURANA,

A. S. DAHIYA,

R. C. SIWACH

system of Neer (1970) which employs a maximum of 100 units, distributed as follows : pain, 35 ; function, 30 ; range of motion, 25 ; anatomy, 10. An excellent score is 90 or more ; satisfactory, a failure scores results is shown 80 to 89 ; unsatisfactory, less than 70 units. An in Table I. Overall results 70 to 79 ; and analysis of our were excellent

Our results were damaged or was The the patient these 1949; 2.5%

better if the meticulously rate

rotator repaired. series

cuff

was

either

not to no

4% infection of Paavolainen

in our

is comparable In our series

et at (1983).

or satisfactory in 21 out of 25 cases (84%). Unsatisfactory results were in cases of intra-articular fracture or fracture-dislocation where either meticulous
reconstruction of

had nonunion or avascular necrosis nor have complications been reported by others (Bosworth Paavotainen et at 1983 ; Kristiansen and ChristenVariations upon the in the type of range injury, the was of motion recovered age, delay between exercise score of and of stable

sen 1986). depended or injury and programme, less than We the surgical fixation recovery
external

early

motion

could

the rotator cuff not be instituted.

could

not

be

done

operation and but in no case

rigour of the the postoperative

We had no major complication avascular necrosis or nonunion. high positioning of the plate,

such Technical

as osteomyelitis, problems like fixation, or screws patients fracture severe The

70 despite conclude neck with except

rotation.

the cases of periarthritis. that two-part, displaced treated for by plate a variable by early heal open with
fractures

fractures reduction full

and

unstable

penetrating the joint cavity were avoided. Two in the older age group, one with an intra-articular and one with a fracture-dislocation, developed periarthritis lower
in two

a blade

functional
fracture-

degree

of restriction reduction,

Intra-articular

with was
and cases

limitation fixed this led tendinitis

of

range

of

motion.

dislocations, fixation of the with rotator

treated a T-plate, cuff and

anatomical careful an early repair start but with

fragment Bicipitat

in 10#{176} 1 5#{176} to internal rotation to some limitation of external was encountered in one case.

or reconstruction to physiotherapy, some degree of

rotation.

also have limitation

No benefits commercial article.

satisfactory results of range of motion.

in any party form have been related directly

DISCUSSION The ing shoulder injury is especially because prior of the susceptible formation to stiffness of adhesions. of adhesions an essential fractures. achieves around followEarly the

received or will be received or indirectly to the subject

from a of this

mobilisation joints gliding the management T-plate stable

to maturation

REFERENCES DM. Blade plate fixation the surgical neck of humerus

141 :1111-3.

surfaces is, therefore, of proximal humeral plate, property applied,

step in The AO fixation

Bosworth

: technique

suitable

for fractures

or blade

and

similar

lesions.
7th ed.

JAMA
St. Louis,

of 1949; etc:

enough to allow immediate In this group of 25 patients

mobilisation. we achieved

excellent

or

Crenshaw
CV

AH. Mosby WR,

Campbells

operative

orthopaedics.

Co, 1987. Callahan

of JJ, Scuden S. Reduction of old or irreducible shoulder joint. Surg Gynecol Obstet 1934; 58:

satisfactory results in 21 (84%), some previously reported series. reviewed 41 cases of which and successful errors, like satisfactory ; Kristiansen tamed 49% good results. We attribute the avoidance plate, joint of technical an unstable by screws. screws areas.

an improvement over Paavolainen et at (1983) 74.2% were excellent (1986) in part positioning or obto the of the of the 6.5 mm Christensen results high

Cubbins

dislocations 129-35.

Kristiansen
humeral Kristlansen

B, Christensen
fractures. B, Kofoed

SW. Plate fixation for displaced Acta Orthop Scand 1986; 57:320-3.
fixation

proximal
of the J Bone
of internal

H. External

proximal
JointSurg[Br] Muller
fixation:

humerus
1987;
techniques

: techniques
69-B

and

of displaced preliminary

fractures results.

:643-6.
R, WllleneggerH Manua/ by the AO Group. 2nd fractures. Part Pauku ed. Berlin,

osteosynthesis, and penetration We think it important to use

ME, Allg#{246}werM,Schneider
recommended

etc : Springer-Verlag, NeerS

and

1979.
proximalhumeral I. Classification

canceltous metaphyseal
is mandatory

for fixation in the epiphyseal and Meticulous repair of the rotator cuff when it is damaged and personally exercises must be started early.

II. Displaced
evaluation.

J Bone Joint Surg [Am] Bj#{246}rkehbeim J-M,

proximal

1970; 52-A :1077-89. P,

fractures.

Panvolalnen

P,

StAtis

supervised

postoperative

treatment ofsevere 1983; 54:374-9.

humeral

P. Operative Acta Orthop Scand

THE JOURNAL

OF BONE

AND

JOINT

SURGERY