Percutaneous Pinning for Surgical Neck Fracture: Method of Choice—Opposes
This is a broad statement and there is no doubt that in selected proximal humerus fractures percutaneous pinning is superior to plate fixation. However, unstable two- and three-part fractures in young patients may require plate fixation for reliable union. Comminuted higher energy injuries do well with dual-plate fixation. Older patients with four-part fractures are still best treated with hemiarthroplasty with tuberosity osteosynthesis. Percutaneous pinning, while being minimally invasive, is not without complications. Complications, including pin tract infections and subsequent septic arthritis from migration of septic pins, have been reported. In addition, pin migration has been associated with potentially life-threatening complications due to the close proximity to neurovascular structures and the thoracic cavity. Loss of position of fracture fragments in the first several weeks of treatment is not uncommon with pin fixation. Open reduction and internal fixation (ORIF) may be necessary to obtain anatomic reduction and secure fracture fixation. Recent changes in the approach to plate fixation with lateral based incisions and variable angle locking screw fixation have improved ORIF outcomes.
Proximal humerus fractures are relatively common, accounting for approximately 4% of all fractures. The incidence approaches 70 fractures per 100,000 people and continues to increase due to an aging population.1 The majority of these fractures are minimally displaced and may be treated conservatively. However, proximal humerus fractures with significant displacement or associated soft tissue injury will require operative treatment to achieve satisfactory outcomes. A number of options exist for the surgical treatment of proximal humerus fractures, including closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), or hemiarthroplasty with tuberosity osteosynthesis. Hemiarthroplasty is typically reserved for elderly patients with four-part proximal humerus fractures at significant risk for avascular necrosis and certain three-part fractures. Within the ORIF group, several options for fixation exist, including plate fixation, intramedullary nailing, suture fixation, or a combination of these. The appropriate surgical method is dictated by the fracture pattern, reduction, stability, as well as bone quality. While percutaneous pinning may be a reasonable treatment for acute fractures with good bone stock, it is not sufficient fixation for fractures with comminution, poor bone quality, or significant displacement. These fractures are better suited for open reduction and stable internal fixation with angled blade plates or newer locking plate technology.
Percutaneous Pinning
The advantages of percutaneous pin fixation are that it may be done in a minimally invasive fashion, with only small stab incisions. This is advantageous because of its minimal soft tissue stripping and preservation of the blood supply to the fracture site. It is ideally suited for acute fractures in patients with good bone quality. Fractures that may be amenable to percutaneous pinning include displaced surgical neck fractures (Fig. 1), as well as certain three- and four-part fractures, in which the tuberosity fragments can be reduced anatomically.2 Jakob and coworkers3, 4 first reported a technique for percutaneous fixation of difficult four-part proximal humerus fractures. Subsequently, good results have been reported using these techniques; however, it remains a technically demanding procedure, and one that is not without its risk of complications. Percutaneous pin fixation requires that anatomic reduction is possible by closed manipulation. Fractures that cannot be closed reduced should be treated by open reduction and internal fixation. Elderly patients with significant osteopenia may not be good candidates for pin fixation because of poor bone quality. Pin fixation alone in osteopenic bone may lead to failure of fixation and loss of reduction. Pin migration due to poor fixation may lead to catastrophic complications. The close proximity of the neurovascular structures, as well as the thoracic cavity and lung, make pin migration complications life threatening. In addition, pin site complications are reported at rates as high as 8%.5 Despite aggressive pin site care, pin track infections can occur and can result in osteomyelitis or even septic arthritis. One option for avoiding pin site complications is the use of cannulated screws in exchange for pin fixation.
Figure 1. (A and B) Preoperative anterior posterior (AP) and axillary lateral radiographs demonstrating a displaced surgical neck fracture. (C) Postoperative AP radiograph following closed reduction and percutaneous pinning with two 2.5 mm threaded pins. (D) Postoperative radiographs 12 weeks after injury and 6 weeks after pin removal show a well-healed fracture in anatomic position.
Open Reduction and Internal Fixation
Open reduction and stable internal fixation has traditionally been the treatment of choice for most displaced proximal humerus fractures (Fig. 2A-D). The advantages of ORIF techniques are that fractures may be reduced anatomically. Most proximal humerus fractures may be adequately exposed using a standard deltopectoral approach, which is familiar to most orthopedic surgeons. In addition, recent reports have described using a superolateral deltoid splitting approach with preservation of the axillary nerve for fracture fixation. Improvements in fracture osteosynthesis technology, including locking plate technology and fixed angle blade plates, have led to improvements in fracture stability (Fig. 3). The ability to achieve adequate stability is crucial in fractures with comminution, diaphyseal extension, or fractures with poor bone quality. This is especially true in higher energy injuries, seen more frequently in younger patients, and resulting in comminuted proximal humerus fractures with diaphyseal extension into the humeral shaft. We prefer to fix these fractures with ORIF using dual-plate fixation (Fig. 4). A locking proximal humeral locking plate is applied laterally with locked screws into the humeral head, followed by a second LC-DCP or locking plate applied anterior to the bicipital groove, in a 90/90 position. This second plate is crucial in resisting the significant varus-deforming forces seen in these fractures. ORIF is also the procedure of choice for subacute fractures or malunions, in which closed reduction is not possible because of fracture callous or fibrous tissue at the fracture site. With the use of the newer implants, excellent outcomes have been reported for fracture healing and clinical outcomes in several series of proximal humerus fractures, including surgical neck fractures, as well as some three- and four-part fractures.6 Except in the young individuals, we prefer hemiarthroplasty with tuberosity reconstruction with a dedicated fracture stem.
Figure 2. (A and B) Pre- and postoperative operative AP radiographs of a “robust” 42-year-old male with a displaced surgical neck fracture treated with a dynamic locking plate. (C and D) Postoperative functional result. Note proximity of fingers to ceiling. (Color version of figure is available online.)
Figure 3. (A) Preoperative AP radiograph of a 32-year-old male with a displaced proximal humerus fracture involving the lesser tuberosity. (B and C) Postoperative AP and lateral fluoroscopic images demonstrate fracture reduction and fixation with a proximal humerus locking plate and screw fixation of the lesser tuberosity fragment.
Figure 4. (A) Preoperative AP radiographs of a 36-year-old male with a comminuted proximal humerus fracture with spiral extension down into the diaphysis. (B) Postoperative AP radiograph after ORIF with dual-plate fixation, utilizing a proximal humeral locking plate and an LC-DCP plate for stable fixation.
Proximal Humerus Arthroplasty for Fracture
Elderly patients with displaced four-part and some three-part fractures are at higher risk for avascular necrosis and failure of fixation. Primary hemiarthroplasty with tuberosity osteosynthesis is indicated in this patient population. Boileau and coworkers7 have shown the difficulties with shoulder arthroplasty for the sequelae of proximal humerus fractures. This can be minimized by achieving tuberosity healing at the time of initial fracture fixation. Attention to anatomic tuberosity osteosynthesis at the time of fracture arthroplasty is also crucial for outcomes (Fig. 5). Failures in tuberosity healing and malposition have been shown to be common reasons for poor results following proximal humerus fracture arthroplasty.8
Figure 5. (A) Preoperative AP radiograph of a 65-year-old female demonstrating a four-part proximal humerus fracture/dislocation. (B) Postoperative AP radiograph after proximal humeral hemiarthroplasty with tuberosity osteosynthesis.
Summary
Optimal treatment of proximal humerus fractures varies according to the fracture pattern, displacement, comminution, and patient factors such as age and bone quality. While some fractures, such as the displaced surgical neck fracture or certain comminuted fractures in patients with good bone quality, may be good candidates for percutaneous pin fixation, it may not be adequate fixation for some. Fractures with significant comminution or poor bone quality may require ORIF. Use of fixed angle plates and less invasive approaches have improved the results of ORIF for proximal humerus fractures. Hemiarthroplasty with tuberosity osteosynthesis remains the treatment of choice for certain three- and four-part fractures, especially in elderly patients with osteopenic bone.
References
1. 1Flatow EL. Fractures of the proximal humerus. In: Bucholz RW, Heckman JD editor. Rockwood and Green’s Fractures in Adults. ed 5. Philadelpia, PA: Lippincott Williams & Wilkins; 2002;p. 997–1040.
2. 2Fenichel I, et al.Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus: a retrospective study. Int Orthop. 2006;19:187–191. MEDLINE
3. 3Jakob RP, Miniaci A, Anson PS, et al.Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295–298.
4. 4Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the proximal humerus. J Bone Joint Surg Am. 1992;74:508–515. MEDLINE
5. 5Dander A, Dander A, Gomar F. Complications in operative treatment for displaced proximal humerus fractures. J Bone Joint Surg Br. 1995;77(suppl 2):146.
6. 6Koukakis A, Apostolou CD, Taneja T, et al.Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res. 2006;442:115–120.
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7. 7Boileau P, Chuinard C, Le Huec JC, et al.Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res. 2006;442:121–130.
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8. 8Boileau P, Krishnan SG, Tinsi L, et al.Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11:401–412. Abstract | Full Text |
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Shoulder Service, The Carrell Clinic, Dallas, TX.
Address reprint requests to Wayne Z. Burkhead, Jr, MD, The Carrell Clinic, 9301 N. Central Expressway, Suite 400, Dallas, TX 75231, 214-220-2468.
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