Session VI Upper Extremity

The Use of Percutaneous Fixation for the Operative Management of Proximal Humeral Fractures

Dolfi Herscovici, Jr., DO, D. Saunders, DO, R. Sanders, MD, T. DiPasquale, DO, P. Gregory, MD

Tampa, Florida

Management of proximal humeral fractures has been addressed with open techniques, intramedullary nails, external fixation, and hemiarthroplasty. Because of the poor bone stock and comminution seen at times, the failure of fixation, and the occasional difficulty in surgical approaches, fixation of these injuries has at times proven to be difficult. However, the preservation of function and the patients' own anatomy should be the goal in fracture management.

Closed reduction and percutaneous fixation offers the advantages of avoiding an incision, protecting the tenuous soft tissue attachments of the fracture fragments while utilizing an indirect reduction technique to obtain a stable fixation and allow early active range of motion.

Materials and Methods: From April, 1991 through January, 1996, patients that presented with displaced proximal humeral fractures were retrospectively evaluated. Fracture patterns were classified using the AO criteria and described as being displaced if angulation was greater than 45 degrees, displacement was greater than one centimeter, or if the greater tuberosity was displaced greater than 0.5 centimeters on plain radiographs. Patients were included if their fractures were primarily managed with closed reduction and percutaneous fixation. Implants used for fixation included: k-wires, DHS guide pins, and 2.5mm schantz pins, with at least three pins or wires used for each fracture. Postoperatively, patients were placed into a sling for the first two days, then begun on passive and active assisted range of motion exercises. At two weeks patients were begun on active range of motion exercises. Between 8 and 10 weeks good callus was routinely noted on x-rays and implants were then removed in the office or as an outpatient procedure.

Results: 42 patients were identified with proximal humeral fractures. One patient died and nine patients were lost to follow-up leaving 33 patients with 34 fractures available for review. There were 17 females and 16 males with an average age of 50 years (13-88). Eleven fractures were on the right, 21 on the left and one had a bilateral injury. Follow-up averaged 8 months (2-47). There were 9-A2, 7-A3, 6-B1, 5-B2, 2-C2, and 2-C3 injuries; 5 of which presented with anterior dislocations. There were also 3 Salter-Harris type II injuries. DHS guide pins were used in 20 fractures, k-wires in 6, and 8 had schantz pins. Thirty-two fractures healed at an average of 2.6 months (2-4), with an average of 124 degrees of flexion and 112 degrees of abduction. However, when looking at the different types of fractures certain patterns of complications are seen. In the four C-type injuries, although healing occurred, 3 cases of avascular necrosis were identified which were revised with a hemiarthroplasty, and the fourth had loosening of her fixation resulting in a varus malunion. In the B-2 fractures; one had a non union requiring hemiarthroplasty and one had loosening of his k-wires resulting in varus malunion. In the B-1 injuries, there was one failure of k -wire fixation requiring an open plating, one developed an osteomyelitis and a third had a transient brachial plexopathy. Type-A fractures had some pin loosening (1) and a pin tract infection (1). Overall, the most commonly seen problems were loose pins (7 patients) and pin tract infections (3 patients).

Discussion: Proximal humeral fractures are difficult cases to manage but most can be treated nonoperatively. Percutaneous fixation provides a good option for surgical management of these injuries resulting in a 94% healing rate in this series. A threaded device (DHS or Schantz pins) is recommended when performing this technique but caution should be used in patient selection. Patients need to be informed about the possibility of pin loosening and infection; and, in those patients presenting with higher energy injuries, serial evaluations to monitor for avascular necrosis should be performed.