Early rehabilitation vs. conventional immobilization in nonoperative treatment of proximal humeral fracture: a systematic review.

OBJECTIVE: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF. MATERIALS AND METHODS: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups. CONCLUSIONS: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities.

Optimal immobilization position for conservative treatment of proximal humerus fractures by fracture type: a biomechanical cadaveric study.

In conservative treatment for proximal humerus fractures (PHFs), the immobilization position of the affected arm should not be determined uniformly. The aim of this study is to investigate the optimal immobilization position for conservative treatment of different types of PHFs. We hypothesized that the optimal position minimizing the deforming force in PHFs depends on the fracture components involved. PHF models involving either the surgical neck (SN) or greater tuberosity (GT) were created using 12 fresh-frozen cadaveric shoulders. In the SN model, the deforming forces on the pectoralis major muscle were measured in full adduction by increasing external rotation. In the GT model, the deforming force of the supraspinatus muscle was measured in neutral rotation by decreasing abduction, and the deforming force of the infraspinatus muscle was measured in full adduction by increasing internal rotation, respectively. In the SN model, the deforming force of the pectoralis major muscle increased significantly with external rotation from full internal rotation to neutral rotation (P = 0.006), indicating that the arm should be placed in full internal rotation. In the GT model, the deforming force of the supraspinatus muscle increased significantly with adduction from 45° of abduction to full adduction (P = 0.006); the deforming force of the infraspinatus muscle increased significantly with internal rotation from neutral rotation to full internal rotation (P = 0.006). These findings should be considered when placing the arm in abduction and neutral rotation so as to minimize the deforming force by either the supra or infraspinatus muscle. In conservative treatment for PHFs, the affected arm should be placed in a position that minimizes the deforming force on the fracture components involved.

[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]. / Die Behandlung der proximalen Humerusfraktur im Kindes- und im Jugendalter : Konsensusbericht der Sektion Kindertraumatologie der DGU.

BACKGROUND: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature. METHODOLOGY: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this. RESULTS: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X­ray images in 2 planes (true AP and Y­images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X­ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks). CONCLUSION: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit.

BACKGROUND: Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF. METHODS: Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination. RESULTS: Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination. CONCLUSIONS: Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted?

PURPOSE: 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS: A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS: 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION: We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.

Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial.

BACKGROUND: Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS: The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS: This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Does interferential current provide additional benefit to orthopedic rehabilitation for the patients with proximal humeral fractures? A randomized controlled study.

BACKGROUND: Approximately 80% of all proximal humeral fractures (PHFs) are non-displaced or minimally displaced fractures, which can be treated with conservative treatment. This study investigated the effect of interferential current (IFC) added to orthopedic rehabilitation on shoulder function, pain, and disability in patients with PHF. METHODS: This study was a prospective, double-blind, randomized, placebo-controlled conducted in physical medicine and rehabilitation outpatient clinic. Thirty-five patients were randomly separated into the IFC group (n = 18) and the sham group (n = 17). The orthopedic rehabilitation program was applied to all patients by the same physiotherapist three times a week for four weeks. Patients in the IFC group received the intervention for 20 minutes 3 times a week before the exercise. The same pads were performed for the sham group, but no electrical stimulation was applied. Constant-Murley score (CMS) for shoulder function, visual analog scale (VAS) activity pain, disabilities of the arm, shoulder, and hand (DASH) score, and paracetamol intake were recorded post-treatment, at 6 weeks and 18 weeks post-treatment. RESULTS: The demographic and fracture characteristics were not different between the groups. Significant differences were observed in the IFC and sham group in intragroup comparisons of total CMS, VAS activity pain, DASH score, and paracetamol intake over time (p < 0.001). Significant improvement over time was valid for all pairwise comparisons in both groups. However, no significant differences were detected between the IFC and sham group. CONCLUSION: IFC added to orthopedic rehabilitation could not appear to be an electrotherapy modality that could potentially benefit shoulder function and disability in patients with PHF.

Transitivity, coherence, and reliability of network meta-analyses comparing proximal humerus fracture treatments: a meta-epidemiological study.

BACKGROUND: Network meta-analyses can be valuable for decision-makers in guiding clinical practice. However, for network meta-analysis results to be reliable, the assumptions of both transitivity and coherence must be met, and the methodology should adhere to current best practices. We aimed to assess whether network meta-analyses of randomized controlled trials (RCTs) comparing interventions for proximal humerus fractures provide reliable estimates of intervention effects. METHODS: We searched PubMed, EMBASE, The Cochrane Library, and Web of Science for network meta-analyses comparing interventions for proximal humerus fractures. We critically assessed the methodology regarding the development of a protocol, search strategy, trial inclusion, outcome extraction, and the methods used to conduct the network meta-analyses. We assessed the transitivity and coherence of the network graphs for the Constant score (CS), Disabilities of the Arm, Shoulder, and Hand score (DASH), and additional surgery. Transitivity was assessed by comparing probable effect modifiers (age, gender, fracture morphology, and comorbidities) across intervention comparisons. Coherence was assessed using Separating Indirect from Direct Evidence (SIDE) (Separating Indirect from Direct Evidence) and the design-by-treatment interaction test. We used CINeMA (Confidence in Network Meta-analyses) to assess the confidence in the results. RESULTS: None of the three included network meta-analyses had a publicly available protocol or data-analysis plan, and they all had methodological flaws that could threaten the validity of their results. Although we did not detect incoherence for most comparisons, the transitivity assumption was violated for CS, DASH, and additional surgery in all three network meta-analyses. Additionally, the confidence in the results was 'very low' primarily due to within-study bias, reporting bias, intransitivity, imprecision, and heterogeneity. CONCLUSIONS: Current network meta-analyses of RCTs comparing interventions for proximal humerus fractures do not provide reliable estimates of intervention effects. We advise caution in using these network meta-analyses to guide clinical practice. To improve the utility of network meta-analyses to guide clinical practice, journal editors should require that network meta-analyses are done according to a predefined analysis plan in a publicly available protocol and that both coherence and transitivity have been adequately assessed and reported.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE: Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively. METHODS: We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups. RESULTS: Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts. CONCLUSIONS: For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients. LEVEL OF EVIDENCE: Level II-therapeutic studies: prospective cohort study.

Nonoperative Treatment for Displaced Proximal Humeral Fractures in Elderly Patients: Correlation Between Deviations and Clinical Outcomes / Tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em idosos: Correlação entre os desvios e os resultados clínicos

Abstract Objectives To describe the functional result of the conservative treatment of displaced proximal humerus fractures (PHF) using the American Shoulder and Elbow Surgeons (ASES) score after 12 months and assess whether the different initial classifications and radiographic measurements are related to clinical results. Methods Forty patients > 60 years old, with displaced PHUs submitted to conservative treatment were evaluated at standardized times (3, 6, and 12 months). The American Society of Shoulder and Elbow Surgeons (ASES), Constant-Murley and Single Assessment Numeric Evaluation (SANE) scales were used as clinical outcomes. Radiographic variables included the Neer and Resch classifications, the presence and displacement of tuberosity fracture, metaphyseal comminution, medial periosteal lesion, and angular and translational deviations of the head in the coronal and sagittal plane. Results The result of the ASES score was 77.7 23.2 for the whole sample, the mean absolute values of the Constant-Murley score were 68.7 16 and 82.6% for the scale relative to the contralateral side. The SANE scale at 12 months was 84.8 19. We observed that the severity of the Neer classification and the coronal plane angular deviation (measured by the head-shaft angle) and the presence of fractures in both tuberosities negatively influenced the ASES score after 12 months of treatment. Conclusion Nonoperative treatment of displaced proximal humerus fractures in elderly patients results in good clinical results. Clinical results are negatively influenced by the angular deviation of the humeral head and the presence of fractures of the greater and lesser tubercles, as well as by the Neer classification.

Resumo Objetivos Descrever o resultado funcional do tratamento não operatório de fraturas desviadas da extremidade proximal do úmero (FEPU) pela escala da American Shoulder and Elbow Surgeons (ASES, na sigla em inglês) após 12 meses e avaliar se as diferentes classificações e medidas radiográficas iniciais têm correlação com os resultados clínicos. Métodos Foram avaliados em tempos padronizados (3, 6 e 12 meses), 40 pacientes > 60 anos com FEPU submetidos ao tratamento não operatório. Foram utilizadas as escalas da ASES, Constant-Murley e Single Assessment Numeric Evaluation (SANE, na sigla em inglês). As variáveis radiográficas incluíram as classificações de Neer e Resch, a presença de fratura e desvio dos tubérculos, cominuição metafisária, lesão periosteal medial, desvios angulares e translacionais da cabeça no plano coronal e sagital e desvio dos tubérculos. Resultados Observamos resultados pela escala de ASES de 77,7 23,2 para toda a amostra, pelade Constant-Murley de 68,7 16e de 82,6% paraa escala em relação aolado contralateral.AescaladeSANEaos12mesesfoide84,8 19.Oscritériosradiográficosque apresentaram influência negativa no resultado clínico pela escala de ASES aos 12 meses foram a gravidade pela classificação de Neer e pelo desvio angular no plano coronal (mensurado pelo ângulo cabeça-diáfise) e a presença de fratura dos tubérculos. Conclusão O tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em pacientes idosos resulta em bons resultados clínicos. Os resultados clínicos são influenciados negativamente pelo desvio angular da cabeça do úmero e pela presença de fratura dos tubérculos maior e menor, assim como pela classificação de Neer.

Eficácia, segurança e custo-efetividade comparada de tratamentos cirúrgicos e conservadores de fratura de úmero proximal: revisão rápida de evidências / Comparative effectiveness, safety and cost-effectiveness between surgical and conservator treatments for proximal humeral fracture: a rapid review of evidence

Tecnologia: Hemiprótese de ombro ajustável. Próteses de cabeça excêntrica reproduzem a anatomia da extremidade proximal do úmero. Indicação: Reconstrução da extremidade proximal do úmero no tratamento de fraturas complexas de úmero. Pergunta: o tratamento cirúrgico é superior ao tratamento conservador, para tratamento de fratura proximal de úmero, com melhores desfechos funcionais, menos complicações, menor mortalidade? Os efeitos terapêuticos da prótese de ombro excêntrica são superiores aos da prótese de ombro Neer II em pacientes com fratura proximal de úmero submetidos a hemiartroplastia de ombro nos desfechos de resultados funcionais e complicações cirúrgicas? Métodos: Levantamento bibliográfico foi realizado em bases de dados Pubmed, BVS e Google com estratégias estruturadas de busca. Foi feita avaliação da qualidade metodológica das revisões sistemáticas com a ferramenta AMSTAR e para os estudos econômicos, foi utilizado o QHES checklist. Resultados: Foram identificados 485 registros nas bases de dados internacionais e nacionais. Após a remoção de duplicatas e exclusão dos não elegíveis, pela análise de título e resumo, foram selecionadas quatro revisões sistemáticas e um estudo econômico. Conclusão: Não há evidências suficientes de ensaios clínicos para informar qual a melhor escolha entre as intervenções (não cirúrgicas, cirúrgicas ou de reabilitação) para essas fraturas. Não foram encontrados estudos brasileiros sobre eficácia e custo-efetividade das diferentes abordagens cirúrgicas bem como os tipos e marcas de próteses entre si

Technology: Adjustable shoulder hemi prosthesis. Eccentric head prostheses reproduce the anatomy of the proximal extremity of the humerus. Indication: Reconstruction of the proximal extremity of the humerus in the treatment of complex humerus fractures. Question: Is surgical treatment superior to conservative treatment, for the treatment of proximal humerus fractures, with better functional outcomes, less complications, less mortality? Are the therapeutic effects of the eccentric shoulder prosthesis superior to those of the Neer II shoulder prosthesis in patients with proximal humerus fractures who underwent shoulder hemiarthroplasty in the outcomes of functional results and surgical complications? Methods: Bibliographic survey was carried out in Pubmed, BVS and Google databases with structured search strategies. The methodological quality of systematic reviews was assessed using the AMSTAR tool and for economic studies, the QHES checklist was used. Results: Were they identified 485 records in international and national databases. After removing duplicates and excluding the ineligible ones, by analyzing the title and summary, four systematic reviews and one economic study were selected. Conclusion: There is not enough evidence of clinical trials to inform which is the best choice between interventions (nonsurgical, surgical or rehabilitation) for these fractures. No brazilian studies were found about the efficacy and cost-effectiveness of the different surgical approaches, as well as the types and brands of prostheses between them

Evidencia orientada al paciente: tratamiento de fracturas desplazadas de húmero proximal en adultos / Treatment of displaced fractures of the proximal humerus in adults

El tratamiento de fracturas desplazadas de húmero proximal puede realizarse de manera conservadora o quirúrgica. A partir de una viñeta clínica en la cual una señora adulta mayor tiene una fractura de húmero proximal por una caída de su propia altura se realizó una búsqueda bibliográfica que identificó una revisión sistemática Cochrane que compara ambas alternativas de tratamiento. Los resultados clínicos que resume esta revisión indican que el tratamiento quirúrgico no sería superior al tratamiento conservador y se asociaría a un número mayor de procedimientos quirúrgicos adicionales. (AU)

The treatment of displaced fracture of the proximal humerus can be managed surgically or conservatively. From a clinical vi-gnette in which an elderly woman suffers a proximal fracture of the humerus due to a fall from her own height, a bibliographic search was run and identified a Cochrane systematic review which compared both treatment options. The clinical results sum-marized in this review indicated that surgical treatment would not be superior to conservative management. Furthermore, surgi-cal treatment would be associated with a greater number of additional surgical procedures. (AU)

Fracturas de húmero proximal: valoración clínica y resultado funcional en pacientes con osteonecrosis de la cabeza humeral / Proximal humerus fractures: clinical assessment and functional outcome in patients with osteonecrosis of the humeral head

Introducción: Las fracturas de húmero proximal de tres o más fragmentos presentan riesgo elevado de necrosis, siendo éste el segundo sitio más frecuente sólo después del fémur, presentándose causas traumáticas y no traumáticas, siendo las traumáticas las más comunes, presentando una incidencia de 13 a 34% en fracturas de más de cuatro fragmentos. El propósito de este estudio es valorar el resultado funcional de pacientes con antecedente de fractura humeral proximal y osteonecrosis con manejo conservador. Material y métodos: Se presenta un estudio descriptivo, retrospectivo, observacional con seguimiento de 6 a 12 meses de pacientes mayores de 60 años con diagnóstico de fractura de húmero proximal con manejo conservador, en el período comprendido de Enero de 2004 a Noviembre de 2009, se seleccionaron 122 pacientes que cumplían los criterios de inclusión, perdiendo el seguimiento de 12 de ellos, con edad promedio de 71.02 años con rango de 60 a 92 años, 41 hombres y 69 mujeres, realizándose escalas de DASH y CONSTANT. Resultados: Posterior a la realización de las escalas de valoración funcional se realiza la validación de dichos resultados obteniendo un coeficiente de correlación de 0.80 siendo estadísticamente significativo. Conclusión: El tratamiento conservador debe ser reservado sólo en pacientes que cumplan con las características necesarias. Dependiendo del tipo de fractura y las características del individuo, el tratamiento siempre está enfocado a la estabilización y a la movilización temprana y en la obtención de la recuperación funcional precoz. Encontrando en este estudio que las fracturas tratadas de forma conservadora, desarrollan algún estadio de osteonecrosis de la cabeza pero con adecuada función casi similar a la extremidad sana.

Introduction: Fractures of the proximal humerus resulting in three or more fragments represent a high risk of necrosis. The former is the second most frequent site of necrosis, only after the femur, due to either traumatic or nontraumatic causes. The former are the most common, with an incidence rate of necrosis of 13-34% in fractures with more than four fragments. The purpose of this study is to assess the functional outcome of patients with a history of fracture of the proximal humerus and osteonecrosis treated conservatively. Material and methods: This is a descriptive, retrospective, observational study with a 6-12 month follow-up of patients older than 60 years of age with a diagnosis of fracture of the proximal humerus managed conservatively between January 2004 and November 2009. One hundred and twenty-two patients met the inclusion criteria and 12 were lost to follow-up. Mean age was 71.02 years with a range between 60 and 92 years; 41 males and 69 females. The DASH and CONSTANT scales were applied. Results: After applying the functional assessment scales and validating the results, the correlation coefficient obtained was 0.80, and it was statistically significant. Conclusion: Conservative treatment should be used only in patients who meet the necessary criteria. Depending on the type of fracture and the patient's characteristics, treatment should always be aimed at stabilization, early mobilization, and early functional recovery. This study found that fractures treated conservatively eventually develop some degree of osteonecrosis of the head, but they have proper function, similar to that of a healthy limb.

Luxofractura anterior del hombro derecho con luxación posterior del codo: presentación de un caso / Previous dislocation and fracture of the right shoulder with posterior dislocation of the elbow: a case report

La luxofractura de hombro y la luxación de codo están descritas, pero son poco frecuente que ocurran en el mismo hemicuerpo. Caso clínico: paciente de 45 años, masculino, de piel blanca, que acudió al servicio de Traumatología del Hospital Universitario Martín Chang Puga de Nuevitas por presentar luxofractura de hombro y luxación posterior de codo en un mismo hemicuerpo, a causa de un accidente automovilístico. Se realizó reducción manual de urgencia de ambas luxaciones y control radiológico, con resultados satisfactorios. Se inmovilizó el codo con una férula posterior de yeso para el miembro superior y vendaje de Velpeau para el hombro. Se retiró inmovilización del codo a las tres semanas y la del hombro a las seis semanas. Posteriormente se comenzó con la rehabilitación, donde se obtuvo magníficos resultados con la función de ambas articulaciones y del miembro superior en general

Dislocation and fracture of shoulder and dislocation of elbow are described but is very unusual when they are concomitant and on the same side of the body.Clinical case: a case of a 45-year-old, male patient who was treated in the service of Traumatology at the University Hospital Martín Chang Puga from Nuevitas, presenting dislocation and fracture of the right shoulder and dislocation of the elbow on the same side of the body due to a car accident. Urgent manual reduction of both dislocations and radiological control, with satisfactory results took place. The elbow was immobilized with a backboard plaster splint and a Velpeau´s bandage for the shoulder. The immobilization devise of the elbow was removed after three weeks and that of the shoulder after six. Subsequently began rehabilitation, and great results were obtained with both joints and the upper limb functions

Avaliação do tratamento cirúrgico das fraturas em duas ou três partes do úmero proximal com o "sistema paraquedas" / Evaluation of surgical treatment of fractures in two or three parts of the proximal humerus with the "parachute technique"

OBJETIVO: Avaliar, através dos resultados clínicos, a eficácia e a segurança da técnica cirúrgica denominada "sistema paraquedas" aplicada em pacientes adultos que sofreram fraturas desviadas e instáveis em duas ou em três partes do úmero proximal. MÉTODOS: Durante o período de janeiro de 1995 a junho de 2006, 59 pacientes adultos com fraturas em duas ou em três partes desviadas e instáveis foram operados pelo Grupo de Ombro e Cotovelo do Serviço de Ortopedia e Traumatologia do Hospital do Servidor Público Estadual de São Paulo com a técnica do "sistema paraquedas". Este método consiste em uma banda de tensão intramedular e fixação extra medular em "8" unindo os fragmentos da fratura, utilizando um parafuso esponjoso de 6,5mm com rosca parcial, arruela e dois fios inabsorvíveis, produzindo uma síntese estável, com mínima agressão às partes moles vizinhas, não requerendo a posterior retirada do material. A forma final desta síntese lembra a figura de um paraquedas aberto. Os pacientes tiveram um seguimento pós-operatório mínimo de seis meses. Para o diagnóstico foram realizadas radiografias nas incidências da série trauma de ombro. As fraturas foram classificadas de acordo com o sistema proposto por Neer. Utilizamos a escala da Universidade da Califórnia em Los Angeles (UCLA) na avaliação dos resultados. RESULTADOS: Obteve-se 47 por cento de bons e 26 por cento de excelentes resultados com a técnica do "sistema paraquedas" de acordo com o escore da UCLA. CONCLUSÃO: A técnica do "sistema paraquedas" é opção segura e eficaz de tratamento das fraturas desviadas e instáveis em duas ou três partes do úmero proximal.

OBJECTIVE: To evaluate, through clinical outcomes, the efficacy and safety of the surgical technique called the "parachute technique" as applied to adult patients who suffered displaced and unstable fractures in two or three parts of the proximal humerus. METHODS: During the period from January 1995 to June 2006, 59 adult patients with two or three displaced and unstable fractures were operated by the Shoulder and Elbow Group of the Orthopedics and Traumatology Service of the Servidor Público Estadual de São Pauloïs Hospital using the "parachute technique". This method consists of an internal bone tension band and a settling external bone in "8" joining the pieces of the fractures, using a 6.5-millimeter spongy screw with a partial thread, a washer and two nonabsorbable sutures, creating a stable synthesis with little aggression to the surrounding soft tissue , requiring no posterior material ressection. The final shape of this synthesis is reminiscent of the shape of an opened parachute. The patients had a minimum of 6 months follow-up post-operation. For diagnosis, trauma series radiographs of the shoulder were taken. The fractures were classified according to the system proposed by Neer. We used the scale of the University of California, Los Angeles (UCLA), in the evaluation of results. RESULTS: There were 47 percent good and 26 percent excellent results using the "parachute technique" according to the UCLA score. CONCLUSION: the "parachute technique" is a safe and effective treatment for two or three part displaced and unstable fractures of the proximal humerus.

Fraturas da extremidade proximal do úmero: estudo comparativo entre dois métodos de fixação / Proximal humerus fractures: comparative study of two different fixation methods

OBJETIVO: Comparar o resultado do tratamento das fraturas da extremidade proximal do úmero. osteossíntese com a placa em t de pequenos fragmentos (grupo a), promovendo uma estabilização relativa, em contraposição à placa com parafusos bloqueados (grupo b). MÉTODOS: São alocados de forma aleatória 18 pacientes e avaliados prospectivamente, segundo critérios clínicos, escala funcional e parâmetros radiográficos da redução obtida. RESULTADOS: Pela escala analógica de dor a média aos seis meses de evolução foi 2,1 para o grupo a e 2,2 para o grupo b, a amplitude de elevação no grupo a foi de 140ºe de 143ºno grupo b e a pontuação na escala funcional da ucla foi respectivamente 30 e 31. Nas radiografias avaliadas; no grupo a, três pacientes obtiveram ângulos medidos após a estabilização entre 0º e 10º de desvio em relação à anatomia normal e seis entre 11º e 40º, no grupo b sete pacientes com ângulos entre 0º e 10º e dois entre 11º e 20º. CONCLUSÕES: Nos resultados precoces e tardios não ocorreram diferenças clínicas e funcionais nos dois grupos, prevalecendo uma alta incidência de bons resultados. as medidas radiográficas das reduções obtidas ficaram mais próximas do anatômico no grupo tratado com placas bloqueadas.

OBJECTIVES: The present study compares results of the treatment of patients with proximal humerus fractures using two different fixation methods: the t plate (group a) for small segments that provides a relative stabilization is compared to the locking screw plate that promotes a rigid fixation. METHODS: eighteen patients were randomly divided into two groups and evaluated prospectively according to clinical aspect, functional score and radiographic parameters of displacement after fixation. RESULTS: using the visual analogue scale - vas, the mean pain at six months of follow-up was 2.1 for group a and 2.2 for group b. the mean range of forward elevation was 140º in group a and 143º in group b. the mean ucla functional scale scores were 30 and 31, respectively. On the radiographic evaluation, the fractures of three patients in group a had between 0 and 10 degrees of displacement after stabilization and six patients had displacement between 11 and 40 degrees; for group b, seven patients had displacement between 0 and 10 degrees and three between 11 and 40 degrees. CONCLUSION: no early or late differences were found between groups in clinical and functional evaluations. in both groups, the prevalence of good results was observed. the reduction of the anatomical neck angles of the proximal humerus was closer to normal in the blocking screw group.

Consolidação em varo do terço proximal do úmero: resultados da osteotomia valgizante / Varus healing of humerus proximal third: results of valgus osteotomy

Objetivo: Avaliar os resultados dos pacientes submetidos à osteotomia valgizante do terço proximal do úmero mpregada no tratamento das consolidações viciosas em varo em pacientes que se queixavam de dor e limitação da levação do ombro. Métodos: Foram avaliados retrospectivamente oito pacientes submetidos à osteotomia valgizante, fixada com placa PFS 80, entre abril de 1996 e maio de 2003, operados pelo Grupo de Ombro e Cotovelo do Departamento de Ortopedia e Traumatologia da Santa Casa de São Paulo. Resultados: Foram satisfatórios em cinco casos e insatisfatórios em três, segundo os critérios da University of California at Los Angeles (VCLA). Conclusão: A osteotomia valgizante reduz a dor e melhora o grau de elevação do ombro, devido ao aumento do espaço subacromial.

Clasificación de las fracturas de la epífisis distal del húmero en adultos e informe de 54 casos / Classification for distal epiphyseal fracture of an isolated metacarpal bone

Se presenta la clasificación propuesta por el autor en 1980 para fracturas del extremo distal del húmero. Esta clasificación consta de VIII grados y facilitar el diagnóstico así como su relación con el tratamiento y con el pronóstico. Las grado I y II son extra-articulares, las grado III y IV intra-articulares con mínima lesión o no desplazadas; las grado V y VI intra-articulares desplazadas y con gran lesión del cartílago articular y las grado VII y VIII son las conminutas, con pérdida de cartílago, fractura del olécranon, expuestas o con lesión neurovascular. Se presenta una serie de 54 pacientes internados en el servicio de Traumatología de los Hospitales del ISSSTE y del Centro de Especialidades Médicas de la Ciudad de Xalapa, Veracruz, entre 1983 y 1993. Radiográficamente se ordenaron las lesiones de acuerdo con los VIII grados de la clasificación, aplicándoles el tratamiento propuesto según las mismas. Se hizo seguimiento clínico y radiográfico, estudiando dolor, movilidad y función, con una calificación de 0 a 10. El tiempo promedio de seguimiento fue de 3.5 años. Se tuvieron resultados excelentes en 12 casos; buenos en 15; regulares en 20 y malos en 7. Los pacientes que mejor resultado integral tuvieron fueron los de los primeros grados, y los regulares y malos fueron los de los últimos grados de la clasificación. Demostramos que nuestra clasificación propuesta en 1980 sigue vigente y será útil a otros ortopedistas

Deslizamientos epifisiarios traumáticos: revisión epidemiológica en un periodo de cuatro años / Traumatic epiphyseal separations: a epidermiologic review through a four-year period

Los deslizamientos epifisiarios traumáticos constituyen un problema muy común que debe tratarse correctamente y con oportunidad, o de lo contrario conducen ya sea a acortamiento o a deformidad de las extremidades. Se presenta una serie de 48 pacientes con 53 deslizamientos epifisiarios traumáticos en las extremidades. Todos recibieron tratamiento mediante manipulación cerrada en el Hospital Infantil de Morelia, en la etapa aguda, entre agosto de 1988 y julio de 1992. En ninguno se utilizó fijación interna. Los resultados de la reducción cerrada tanto clínica como radiológicamente han sido excelentes en el 90 por ciento de los casos. Ninguno desarrolló deformidad ni acortamiento.