Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial

BACKGROUND: Fractures of the proximal humerus are common injuries and account for 4-5 percent of all fractures, second only to hip and wrist fractures. The incidence is positively correlated with age and osteoporosis, and is likely to increase. Displaced four-part fractures are among the most severe injuries, accounting for 2-10 percent of proximal humeral fractures. The optimal intervention is disputed. Two previous randomised trials were very small and involved a noticeable risk of bias, and systematic reviews consequently conclude that there is inadequate basis for evidence-based treatment decisions. We aim to compare the effect of osteosynthesis with angle-stable plate with non-surgical management, and the effect of primary hemiarthroplasty with both osteosynthesis and non-surgical management. METHODS/DESIGN: We will conduct a randomised, multi-centre, clinical trial including patients from ten national shoulder units within a two-year period. We plan to include 162 patients. A central randomisation unit will allocate patients. All patients will receive a standardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation. Patients will be followed at least one year. The primary outcomes will be the overall score on the Constant Disability Scale, and its pain subscale, measured at 12 months. A blinded physiotherapist will carry out the assessments. Other secondary outcomes are Oxford Shoulder Score, and general health status (Short Form-36)

Posterior fracture-dislocation of the shoulder. A superior subacromial approach for open reduction

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft. </jats:p

Fixation of humeral surgical neck fracture using contoured pins versus straight pins: a mechanical study

The conventional procedure for displaced fracture of the surgical neck of the humerus uses straight pins inserted from the lateral aspect towards the head of the humerus. The objective of this study was to compare the mechanical properties of fixation by contoured (curved) pins to those fixed with regular straight pins. A transverse osteotomy was made in 30 fresh-frozen sheep humeri in the proximal metaphyseal bone region, and pins were inserted using either three parallel straight pins or three contoured pins in different planes. The assemblies were subjected to bending or rotational stresses at the fracture site. Loads versus deformations were acquired during loading and rigidity was calculated. Results showed that in bending, fixation with straight pins was 31% more rigid compared to contoured pins (p < 0.001), and in torsion, fixation using contoured pins was 21% more rigid compared to straight pins (p < 0.001). A combination of the two fixation types should be considered