Optimal discussion for displace proximal humeral fractures should allow early mobilization with fiddling pain, maximal range of motion, and a minimal gamble of complications. These criteria may be obtained by a minimally incursive intramedullary device such as the Polarus collar. We have reviewed our early clinical results with this nail. The third option is hemiarthroplasty. Because of disappoint results and the complexity of this operation, hemiarthroplasty is reserved for selected patients such as those with clinical avascular necrosis or massive comminuted fractures ( Wijgman et alabama. 2002, Diercks 2003 ). up to 80 % of patients with proximal humeral fractures respond satisfactorily to nonoperative treatment ( Young and Wallace 1985, Hodgson et alabama. 2003 ). In some patients, displaced fractures require surgery. unfortunately, the results of the standard fixation devices have been inconsistent ( Robinson and Christie 1993, Adedapo and Ikpeme 2001, Resch 2003 ). One more advance appliance is the locking proximal humerus plate with angular constancy. Hente et aluminum. ( 2004 ) described good to very commodity results and Plecko and Kraus ( 2005 ) reported satisfactory results with this denture for 2-, 3-, and 4-part fractures. The smash must be by rights countersunk to avoid impingement. Guided multidirectional proximal engage is performed via exercise sleeves with 5-mm cancellate screws into the humeral pass, with a maximum of 5 screws. Angle-stable screws are not available with this plant. An end-cap with a polyethylene foundation can be used to hold the most proximal sleep together in position, by advancing the cap into the nail until the polyethylene base fully engages the threads of the fuck. By using the targeting device, price to the surrounding structures is prevented. The targeting device is besides used for guide placement of one or two 3.5-mm distal cortical screws ( Figures 1 and 2 ). The rotator cuff incision is closed after smash insertion. postoperatively, patients are immobilized with a sling for 1 workweek. thereafter, passive range-of-motion exercises are allowed, followed a soon as possible by active assisted movement.

The patient is operated under general anesthesia ( without muscle liberalization ) and placed in a beach-chair situation. After close fracture reduction, a small deltoid-splitting and rotator manacle incision is made. Under image-intensifier control, the medullary canal is opened with an awl precisely medial to the greater tuberosity. After initiation of the steer wire the humeral duct is reamed with a hand reamer. The breeze through connected to a targeting device is inserted over the lead wire into the medullary cavity. If reduction is unsatisfactory, a cannulate joystick inserted into the humeral head can be used. Another help for reduction can be to rotate the already inserted Polarus collar ( a utmost of 20° ) to align the fracture fragments. In 3 cases, all with a 2-part fracture, open reduction was necessity by an stretch incision. The fractures were classified according to Neer ( 1970 ) as ( displaced ) 2-, 3-, or 4-part fractures. A fracture is considered to be importantly displaced if one or more of the fracture segments is more than 45° angulated or displaced by more than 10 millimeter. Functional and radiographic consequence was measured at mean 12 ( 1–27 ) months of follow-up. Patients ’ shoulder officiate was assessed with the Constant score ( changeless and Murley 1987 ). Strength in the shoulder was measured with an isometric tensiometer. As it was not possible to obtain the strength score for all of the patients, as the measurement device was not always promptly available, we excluded the strength score ( 25 points ) and recalculated the Constant score as a percentage. This means that if a patient had no annoyance ( 15 points ), no limitations in casual living ( 20 points ), and a maximum range of apparent motion ( 40 points ), a score of 75/75 was potential and gave a constant score of 100 %. Like Rajasekhar et aluminum. ( 2001 ), we considered scores below 50 % to be a poor result, between 50 % and 75 % a satisfactory result, and scores above 75 % to be an excellent resultant role. postoperative complications were recorded. This review was performed at the Departments of Surgery of three Dutch trauma centers. All 35 patients with non-pathological proximal humeral fractures who were treated surgically with the Polarus nail between September 2002 and September 2004 were included. All operations were performed by 1 of the 4 aged injury surgeons at each department. 4 patients command removal of all or parts of the osteosynthesis under general anesthesia. 1 affected role was initially treated nonoperatively, but after 2 months junior-grade surgical discussion with a smash was performed because of delayed union with progressive displacement. After consolidation, the affected role had pain. The most proximal cheat was first removed, but with no effect, and 11 months after chief surgery the entire osteosynthesis was taken out but the pain persisted. Another patient besides suffered from persistent pain, thought to be caused by impingement of the proximal share of the smash. The nail was removed after consolidation, but with no effect. 1 affected role required removal of the proximal screw, as it extended into the glenohumeral roast. After this interposition, the Constant grade progressed from 11 % to 47 % but silent remained inadequate. A second patient besides required removal of the proximal prison guard because of outward migration, and this affected role recovered completely. 3 other patients had a minor complication : migration of a proximal screw, and removal under local anesthesia was necessary. Wound infections were not seen. 9 patients had minor to hard complications. 1 patient developed avascular necrosis of the humeral head after a move 2-part fracture, with a stay until placement of a standard collar of 4 days. A hemiarthroplasty was performed. nonunion occurred in one early affected role, a man with a proximal fracture with metaphyseal extension who was initially treated nonoperatively. After 16 days, a collar was inserted because of progressive shift. Nonunion developed and surgical rewrite was required after 10 months. The intramedullary nail down was removed and fixation was performed with screw-and-plate osteosynthesis. The patient had an alcohol addiction and was lost to follow-up. The median overall Constant score was 89 % ( 39–100 ) with a mean of 81 % ( without potency, maximum 75 points ) ( Tables 1 and 2 ). 20 patients reported no pain or balmy pain of the shoulder. 16 patients achieved 75 % or more of the potential utmost score of 40 points in the section concerning movement, as calculated in the Constant grudge. The day by day activities of 2 patients were badly impaired ; one had had a fracture that extended into the proximal humeral cheat and the other had had a 2-part humeral fracture with inadequate aligning of a prison guard into the glenohumeral joint. Both were treated nonoperatively at first, but osteosynthesis was necessary because of foster displacement. There were 19 patients with a Neer 2-part fracture, 5 with a 3-part fracture, and 2 with a 4-part fracture. In 9 cases, the fracture extended metaphyseally. The standard pinpoint was used in 26 patients ; the other 9 patients with metaphyseal propagation required the longer nail. Of the 35 operated patients 1 affected role died and 6 could not be traced, which left 28 patients ( 20 females ) for assessment. The median long time was 66 ( 34–90 ) years. In 14 cases the initial discussion was operative ; the other 21 patients were initially treated nonoperatively. Indications for primary operation were severe shift ( 12 patients ) and massive comminution ( 2 patients ). The indications for secondary coil surgery were progressive displacement ( 17 patients ) and nonunion ( 4 patients ). median delay until elementary operation was 4 ( 0–13 ) days and the median delay before secondary operating room was 21 ( 8–208 ) days .

Discussion

up to 80 % of all patients with proximal humeral fractures respond satisfactorily to nonoperative treatment ( Young and Wallace 1985, Hodgson et aluminum. 2003 ). Gaebler et alabama. ( 2003 ) studied a group of 507 patients with an average long time of 63 years, all with minimally displaced fractures, and found dependable to excellent results in 87 % after 1 year of nonoperative treatment. Koval et alabama. ( 1997 ) besides showed well to excellent results in 77 % of 104 patients with minimally displaced fractures, all of whom were treated nonoperatively.

The diverse discussion options for move proximal humeral fractures can be divided into three categories : nonoperative, osteosynthesis, and hemiarthroplasty. There is, however, distillery inadequate data for evidence-based decision make for the treatment of preempt proximal humeral fractures ( Cochrane review, Handoll et aluminum. 2003 ). Because of the disadvantages associated with other osteosynthesis techniques, we decided to study the result of the intramedullary Polarus nail. long-run results after nonoperative discussion of displace fractures were reported by Rasmussen et aluminum. ( 1992 ) in 16 move proximal 2-part fractures, 17 displaced 3-part fractures, and 9 displaced 4-part fractures. 26 of the 42 patients assessed the result as being excellent or satisfactory. Zyto ( 1998 ) besides found a high degree of affected role satisfaction at a minimum follow-up period of 10 years after nonoperative treatment of 9 preempt 3-part fractures and 5 displaced 4-part fractures. The mean Constant score was 59 ( SD 13 ) in patients with a 3-part fracture and 47 ( SD 8 ) in the 4-part fracture group. In this discipline adenine well as in the cogitation of Rasmussen et aluminum. ( 1992 ), the grade of patient satisfaction was unusually higher than the functional score. Zyto ( 1998 ) suggested that nonoperative discussion of displace 3-part fractures in aged patients should be considered. In another study, Zyto et aluminum. ( 1997 ) again suggested nonoperative treatment for move 3-part fractures in aged patients. In this sketch with 40 aged patients, he compared the functional consequence of nonoperative treatment with that of ten-sion-band wiring of displace multifragment fractures. The constant score was 65 ( SD 15 ) for the nonoperative group vs. 60 ( SD10 ) for the intervention group. As alone 3 patients had a 4-part fracture, no conclusions could be drawn for this group. Plate osteosynthesis can effectively reduce the fracture but may cause devascularization of the humeral fountainhead, scar, and stiffness ascribable to damage to the soft tissue ( Wijgman et alabama. 2002, Agel et aluminum. 2004 ). After an average of 10 years, Wijgman et aluminum. ( 2002 ) assessed the results of 60 patients with a 3- or 4-part fracture who had undergo fixation with cerclage wires or a T-plate. The constant scores were inadequate in only 13 patients. Hessmann et alabama. ( 1999 ) reviewed the results of plating in a rather young population of 98 patients ( 22 of whom were less than 50 years of historic period ) with 2-, 3-, and 4-part fractures. good to excellent results were obtained according to the Constant and Neer scores in 68 and 58 of the fractures, respectively. It has been recommended that AO plating be used in younger patients only, as fixation failure is coarse in aged, osteoporotic patients ( Robinson and Christie 1993 ). One relatively modern plant is the locking proximal humerus plate with angular stability. Hente et alabama. ( 2004 ) found good to very good results in 20 of 31 patients, but 5 had partial derivative avascular necrosis of the humeral head. Plecko and Kraus ( 2005 ) reported satisfactory results in 3/4 patients with a mean Constant score of 63. Because of disappoint results and the complexity of hemiarthroplasty, this intervention is reserved for selected cases such as massive grind fractures or avascular necrosis—or after former procedures ( Wijgman et alabama. 2002, Diercks 2003 ). Hemiarthroplasty gives adequate pain relief but has a poor functional result, and age is a main predictor of result. In our, and others, opinion nonoperative treatment of displace proximal humeral fractures frequently fail, resulting in pain and thus limiting activities of day by day survive ( Adedapo and Ikpeme 2001 ). We believe that during the first few months of nonoperative treatment after a preempt proximal humeral fracture, there is excessive pain and affray in casual living and sleep. We found that the shoulder serve 1 year after treatment with the Polarus pinpoint was more than satisfactory with a median Constant sexual conquest ( expressed as share of the maximal without strength, i.e. of 75 points ) of 89 % ( range 39–100 ). These results are comparable to those of 2 other published studies concerning the Polarus pinpoint. Rajasekhar et alabama. ( 2001 ) measured a median Constant score of 75 ( 25–88 ) points for patients aged over 60 years, and 70 ( 34–100 ) points for those younger than 60 years, in 25 patients treated with the Polarus complete. Adedapo and Ikpeme ( 2001 ) reviewed 23 patients with preempt 2-, 3- or 4-part shaft fractures. They found a mean Constant score of 88 ( 40–100 ), 67 ( 50-91 ), and 69 ( 40–94 ) points, respectively, at 1-year follow-up. unfortunately, the use of the Constant mark is rather confusing ; it is used in a unlike way in about every wallpaper. besides, in our study it was not always possible to obtain the forte score for all patients, so we had to exclude it and recalculate the Constant score as a share. Often the Constant score is recommended for use without force seduce, specially in aged and arthritic shoulders. We besides believe that, for the aged, strength is not the most significant issue in shoulder affair ; few limitations in day by day activity and absence of pain are of greater importance. The patients in our sketch for whom the measurement of military capability was not potential actually had a utmost score for the other parameters.

One of the advantages of this minimally invasive intramedullary device is the hypothesis of early postoperative mobilization with minor annoyance. There were major complications in 6 of the 23 patients, requiring revision surgery. Most complications were related to the position of the osteosynthesis. furthermore, we encountered 1 nonunion and 1 avascular necrosis of the humeral head. There is controversy concerning functional deterioration of the shoulder due to local rotator manacle damage at interpolation of the nail ( Robinson et aluminum. 1992 ). We consider that this is improbable, because alone a little incision is made in the rotator handcuff and this incision is carefully reconstructed after implantation of the nail down ( Kelsch et alabama. 1997, Gaullier et alabama. 1999, Kropfi et alabama. 2000 ). The only impingement we noted postoperatively was caused by inadequate position of the osteosynthesis. The running scores of the 3- and 4-part group in our series were a satisfactory as the 2-part group, suggesting that this method of treatment is besides desirable for preempt multifragmentary fractures of the proximal humerus. however, one should consider the humble number of patients ( newton = 7 ) reviewed with a 3- and 4-part fracture. Adedapo and Ikpeme ( 2001 ) reported 23 patients treated with the Polarus nail. In that study, the median Constant score in the 3-part group was 92 ( 40–100 ) points, and 67 ( 50–91 ) points in the 4-part group. It hush remains unmanageable to decide what the best treatment is for each different fracture of the proximal humerus. Until “ hard ” attest is provided, this decision will still be based on the experience and expertness of the regale surgeon, regarding the type of patient and the type of fracture. We believe that minimally incursive intramedullary obsession of displace 2-, 3-, and evening 4-part proximal humeral fractures is of value .

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