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      Clinical Application of Nail‐Plate Fixation in the Treatment of Complex Proximal Third Humeral Fracture: A Case Report and Literature Review

      case-report

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          Abstract

          Background

          Proximal humeral fractures with increasing incidence are common over the past decades. Among them, the complicated and displaced ones, especially combined with the proximal third humeral shaft fractures, need to be treated surgically. Humeral intramedullary nail and locking plate are the most frequently used options. However, few studies address the application of nail‐plate combination for management.

          Case presentation

          A 49‐year‐old man struck by a car was referred to our emergency trauma center. The X‐ray and three‐dimensional computed tomography (CT) showed a complex proximal humeral fracture with proximal third shaft fracture. No evidence of other associated injuries and neurovascular symptom of the injured left upper limb was shown by physical examination. Nail‐plate fixation was performed to restore the anatomic integrity of proximal humerus. The injured arm was maintained in a broad arm sling for 14 days after surgery. The active as well as positive movements under the instruction were encouraged as long as the pain could be tolerated from postoperative day 2. One year after the surgery, the fracture was healed, and the patient regained normal shoulder motion. The good clinical outcomes were obtained by application of nail‐plate fixation to treat complex proximal third humeral shaft fractures. Thus, this surgical intervention could be performed as an alternative.

          Abstract

          Clinical application of nail‐plate fixation in the treatment of complex proximal third humeral fracture. The postoperative radiographs revealed the healed fracture.

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          The importance of medial support in locked plating of proximal humerus fractures.

          Dean Lorich, John Barker, Yoram Weil … (2007)
          The purpose of this study was to determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support. University medical center. Thirty-five patients who underwent locked plating for a proximal humerus fracture were followed up until healing. For the initial and final radiographs, 2 lines were drawn perpendicular to the shaft of the plate, one at the top of the plate and one at the top of the humeral head, and the distance between them was measured as an indicator of loss of reduction. Medial support was considered to be present if the medial cortex was anatomically reduced, if the proximal fragment was impacted laterally in the distal shaft fragment, or if an oblique locking screw was positioned inferomedially in the proximal humeral head fragment. Multivariate linear regressions were performed to determine the effects that age, sex, fracture type, cement augmentation, and medial support had on loss of reduction. The presence of medial support had a significant effect on the magnitude of subsequent reduction loss (P < 0.001). Age, sex, fracture type, or cement augmentation had no effect on maintenance of reduction. Eighteen patients were determined to have adequate mechanical medial support (+MS group), and the remaining 17 patients did not have medial support (-MS group). In the +MS group, the average loss of humeral head height was 1.2 mm, and 1 case of articular screw penetration occurred that required removal. In the -MS group (without an appropriately placed inferomedial oblique screw and either nonanatomic humeral head malreduction with lateral displacement of the shaft or medial comminution), loss of humeral height averaged 5.8 mm (P < 0.001). There were 5 cases in this group in which screw penetration of the articular surface occurred (P = 0.02), 2 of which required reoperation for removal. All fractures in both groups healed without delay, and none required revision to arthroplasty. Achieving mechanical support of the inferomedial region of the proximal humerus seems to be important for maintaining fracture reduction. Locked plates in general do not appear to be a panacea for these fractures and are unable to support the humeral head alone from a lateral tension-band position. However, there are several factors that are in the surgeon's control that may improve the mechanical environment. Achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.
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            Predicting failure after surgical fixation of proximal humerus fractures.

            Dietmar Krappinger, Nicola Bizzotto, Stephan Riedmann … (2011)
            Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup. Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support. The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors. Preoperative assessment of the local BMD and the patients' biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered. Copyright © 2011 Elsevier Ltd. All rights reserved.
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              Proximal humeral fracture treatment in adults.

              Peter Strohm, Norbert P. Suedkamp, Dirk Maier … (2014)
              Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.
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                Author and article information

                Contributors
                Xiaoming Wu:
                ORCID: https://orcid.org/0000-0002-7280-6455
                drwxm@263.net
                Journal
                Journal ID (nlm-ta): Orthop Surg
                Journal ID (iso-abbrev): Orthop Surg
                Journal ID (doi): 10.1111/(ISSN)1757-7861
                Journal ID (publisher-id): OS
                Title: Orthopaedic Surgery
                Publisher: John Wiley & Sons Australia, Ltd (Melbourne )
                ISSN (Print): 1757-7853
                ISSN (Electronic): 1757-7861
                Publication date (Electronic): 02 September 2022
                Publication date Collection: August 2023
                Volume: 15
                Issue: 8 , Shoulder and Elbow Surgery ( doiID: 10.1111/os.v15.8 )
                Pages: 2187-2192
                Affiliations
                [ 1 ] Department of Orthopaedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine Shanghai Jiao Tong University Shanghai China
                Author notes
                [*] [* ] Address for correspondence Xiaoming Wu, MD, Department of Orthopaedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, No. 650 Xin Songjiang Road, Songjiang District, Shanghai 201620, China. Tel: +86‐021‐37798561; Fax: +86‐021‐37798564; Email: drwxm@ 123456263.net

                Author information
                https://orcid.org/0000-0002-7280-6455
                Article
                Publisher ID: OS13445
                DOI: 10.1111/os.13445
                PMC ID: 10432451
                PubMed ID: 36056587
                SO-VID: 75b2b50e-9488-4d01-bb21-31e4c18ea3da
                Copyright © © 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date revision received : 22 July 2022
                Date received : 11 July 2022
                Date accepted : 23 July 2022
                Page count
                Figures: 6, Tables: 1, Pages: 6, Words: 3551
                Categories
                Subject: Case Report
                Subject: Case Reports
                Custom metadata
                source-schema-version-number 2.0
                cover-date August 2023
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.3.3 mode:remove_FC converted:16.08.2023

                Keywords: clinical application,clinical outcomes,complex fracture,nail‐plate fixation,proximal humerus fracture
                Data availability:
                Keywords: clinical application, clinical outcomes, complex fracture, nail‐plate fixation, proximal humerus fracture

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