Size of greater tuberosity fragment: a risk of iatrogenic injury during shoulder dislocation reduction.

PURPOSE: Shoulder dislocation with greater tuberosity fractures (GTF) is becoming increasingly common, as is the number of cases of iatrogenic humeral neck fractures (IHNF) during reduction. This study investigated the relationship between size of greater tuberosity fragment and occurrence of IHNF in patients with shoulder dislocation and GTF. METHODS: A retrospective study was made to identify all patients presenting with shoulder dislocation with GTF between September 2014 and July 2016. There were 74 patients with an average age of 52.4 years (range 18-84 years) representing 76 cases of shoulder dislocation associated with GTF. Patient age, injury mechanism and location, treatment waiting time, and reduction method were noted. Using conventional anterior-posterior view radiographs, three points were identified as A, B, and C. Distance ratios between AC and AB were calculated, then the resulting ratio was compared to a critical value of 0.4. RESULTS: More iatrogenic fractures occurred in cases where the AC/AB ratio exceeded 0.4. Most (13) occurred during emergency Hippocratic manual reduction. Only five of 18 iatrogenic fractures (27.78%) occurred during surgery while under traction. Women ran a higher risk of iatrogenic fracture than men (female/male ratio 8:1). On average, women were older than men at the time of fracture (59.75 years for women vs. 42 years for men). CONCLUSIONS: A statistically significant relationship exists between size of greater tuberosity fragment and occurrence of iatrogenic humeral neck fractures during the reduction of shoulder dislocation. The larger the greater tuberosity fragment, the higher the incidence of iatrogenic humeral neck fractures. For such fracture dislocations, we recommend open reduction with internal fixation directly and using a Kirschner wire in advance to reinforce the proximal humerus before reduction of the shoulder.

Biomechanical comparison of screw-based zoning of PHILOS and Fx proximal humerus plates.

BACKGROUND: Treatment of proximal humerus fractures with locking plates is associated with complications. We aimed to compare the biomechanical effects of removing screws and blade of a fixed angle locking plate and hybrid blade plate, on a two-part fracture model. METHODS: Forty-five synthetic humeri were divided into nine groups where four were implanted with a hybrid blade plate and the remaining with locking plate, to treat a two-part surgical neck fracture. Plates' head screws and blades were divided into zones based on their distance from fracture site. Two groups acted as a control for each plate and the remaining seven had either a vacant zone or blade swapped with screws. For elastic cantilever bending, humeral head was fixed and the shaft was displaced 5 mm in extension, flexion, valgus and varus direction. Specimens were further loaded in varus direction to investigate their plastic behaviour. RESULTS: In both plates, removal of inferomedial screws or blade led to a significantly larger drop in varus construct stiffness than other zones. In blade plate, insertion of screws in place of blade significantly increased the mean extension, flexion valgus and varus bending stiffness (24.458%/16.623%/19.493%/14.137%). In locking plate, removal of screw zones proximal to the inferomedial screws reduced extension and flexion bending stiffness by 26-33%. CONCLUSIONS: Although medial support improved varus stability, two inferomedial screws were more effective than blade. Proximal screws are important for extension and flexion. Mechanical consequences of screw removal should be considered when deciding the number and choice of screws and blade in clinic.

CT metal artefact reduction for internal fixation of the proximal humerus: value of mono-energetic extrapolation from dual-energy and iterative reconstructions.

AIM: To assess the value of dual-energy computed tomography (DECT) and an iterative frequency split-normalized metal artefact reduction (IFS-MAR) algorithm compared to filtered back projections (FBP) from single-energy CT (SECT) for artefact reduction in internally fixated humeral fractures. MATERIALS AND METHODS: Six internally fixated cadaveric humeri were examined using SECT and DECT. Data were reconstructed using FBP, IFS-MAR, and mono-energetic DECT extrapolations. Image analysis included radiodensity values and qualitative evaluation of artefacts, image quality, and level of confidence for localizing screw tips. RESULTS: Radiodensity values of streak artefacts were significantly different (p < 0.05) between FBP (-104 ± 222) and IFS-MAR (73 ± 122), and between FBP and DECT (32 ± 151), without differences between IFS-MAR and DECT (p < 0.553). Compared to FBP, qualitative artefacts were significantly reduced using IFS-MAR (p < 0.001) and DECT (p < 0.05), without significant differences between IFS-MAR and DECT (p < 0.219). Image quality significantly (p = 0.016) improved for IFS-MAR and DECT compared to FBP, without significant differences between IFS-MAR and DECT (p < 0.553). The level of confidence for screw tip localization was assessed as best for DECT in all cases. CONCLUSION: Both IFS-MAR in SECT and mono-energetic DECT produce improved image quality and a reduction of metal artefacts. Screw tip positions can be most confidently assessed using DECT.

Trends in epidemiology and patho-anatomical pattern of proximal humeral fractures.

PURPOSE: Proximal humeral fractures are common and frequently associated with osteoporosis. Little is known about the association between the patho-anatomical fracture pattern of proximal humeral fractures and patient characteristics. The purpose of this six year longitudinal registry analysis of proximal humeral fractures was to study overall numbers, certain predefined pathoanatomical patterns and distribution compared with specific patient characteristics. METHODS: Data of patients treated between 2006 and 2011 in a country hospital that provides care >95 % of the city's hospitalised patients with fractures was retrospectively reviewed. Data were analysed according to patient characteristics of age, gender, comorbidity, accompanying injuries and radiological analysis of pathoanatomical fracture patterns based on Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. RESULTS: Eight hundred and fifteen proximal humeral fractures (67% women/33% men; mean age 66 years, range 19-99) were analysed. During the study period, an overall increase of 42.5% was found: according to AO classification, 46% were type A, 22% type B and 32% type C. Based on the Neer classification, 86% were displaced, and 49% were complex with more than three parts. Of complex fractures, 57% were female patients >60 years. The number of complex fractures was five times higher in women >60 years than in men of the same age group. CONCLUSIONS: An overall increase of inpatients with displaced proximal tibial fractures was documented. Interestingly, complex displaced proximal humeral fractures, especially in older women with comorbidities, accounted for the majority of cases. These results suggest that health-care planning and hospital-based therapeutic strategies should focus on this patient group.

[Multiplanar reconstruction with mobile 3D image intensifier. Surgical treatment of proximal humerus fractures]. / Multiplanare Rekonstruktion mit mobilem 3D-Bildwandler. Operative Versorgung proximaler Humerusfrakturen.

PURPOSE: The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures. MATERIALS AND METHODS: In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications. RESULTS: In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients. CONCLUSION: Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.

Three-dimensional analyses of proximal humeral fractures using computed tomography with multiplanar reconstruction: early stability of fixation after osteosynthesis in relation to preoperative bone quality.

The purpose of this study was to evaluate the relationship between the bone quality of the humeral head measured by CT multiplanar reconstruction images (MPR) and the stability of nail or plate fixation and to compare the clinical outcomes of these procedures in patients with proximal humeral fractures. Thirty-six consecutive patients (nail group: n = 18, plate group: n = 18) were investigated. In nail group, 14 cases were classified as two-part fractures, three cases were classified as three-part fractures and one case was classified as four-part fractures. In plate group, three cases were classified as two-part fractures, nine cases were classified as three-part fractures and six cases were classified as four-part fractures. Both clinical and radiological outcomes were assessed. In addition, the percentage of trabecular bone volume of the humeral head was calculated using preoperative CT-MPR images. Three patients in the nail group underwent reoperation. In contrast, no patients in the plate group underwent reoperation. In nail group, six of 18 (33%) patients demonstrated poor results (three underwent reoperation, and three had varus displacements >10º) and had bone volume percentages (axial image) that were significantly lower than those observed in the patients with good results. The cutoff point of trabecular bone volume required to obtain satisfactory results after surgical treatment using intramedullary nail was 78%. The results of this study suggest that the bone volume of the humeral head calculated using CT-MPR images provides useful information, in addition to the type of fracture, when selecting fixation devices for osteosynthesis of proximal humeral fracture.

Hemiarthroplasty versus angle-stable locking compression plate osteosynthesis in the treatment of three- and four-part fractures of the proximal humerus in the elderly: design of a randomized controlled trial.

BACKGROUND: The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications. METHODS/DESIGN: A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, "head-split" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. TRIAL REGISTRATION NUMBER: The trial is registered in the Netherlands Trial Registry (NTR2461).

All-arthroscopic intramedullary nailing of 2- and 3-part proximal humeral fractures: a new arthroscopic technique and preliminary results.

PURPOSE: The most criticism of antegrade humeral nailing is the potentially deleterious effect on the shoulder function, which is caused by the trauma to the M. supraspinatus (SSP) at the nail insertion site. We describe a new technique of all-arthroscopical intramedullary nailing, which preserves the rotator cuff, and compare it with the conventional open procedure. METHODS: From 11/2009 to 12/2010 82 patients with unstable, displaced proximal humeral fractures were treated surgically. Twenty-one of these patients received an intramedullary nailing. Sixteen of 21 met the inclusion criteria. Based on the surgeon's arthroscopic experience, patients were assigned to the arthroscopic (group I, n = 8) or open group (group II, n = 8). Both groups were compared due to the replacement results, complications, time of surgery and fluoroscopy. Concomitant intraarticular pathologies were assessed (group I). First clinical results after a median follow-up of 13 months (group I) and 14 months (group II) were reported. RESULTS: Between group I and II, no significant differences were seen in patients age [77 years (range 45-90 years) vs. 76 years (range 65-92 years)], gender (6 female/2 male vs. 5 female/3 male) and fracture pattern (six 2-/two 3-part fractures vs. five 2-/three 3-part fractures). The reduction was evaluated by the caput-diaphysis-angle, which was median 137° (range 120-147°) in group I and 132° (range 120-158°) in group II (p = 0.959). Postoperatively, group I showed one varus-, group II two varus- and valgus deformities. Median time of surgery was 75 min (range 45-182 min) versus 70 min (range 40-146 min) (p = 0.442), fluoroscopy time 1.5 min (range, 0.6-3.7 min) versus 1.2 min (range 0.3-2.2 min) in group I and II (p = 0.336). Concomitant pathologies like one traumatic bicipital tendon-lesion and three partial lesions of the SSP were observed and treated in group I. Constant Scores and Visual Analogue Scale did not differ significantly between both groups at the time of follow-up. CONCLUSIONS: All-arthroscopical humeral nailing is possible, preserves the rotator cuff and provides equal replacement and functional results like the open technique. An arthroscopically visualized optimal nail insertion point provides less frequent head deformities. Level of evidence Level III.

Influence of trabecular microstructure and cortical index on the complexity of proximal humeral fractures.

OBJECTIVES: Poor bone quality increases the susceptibility to fractures of the proximal humerus. It is unclear whether local trabecular and cortical measures influence the severity of fracture patterns. The goal of this study was to assess parameters of trabecular and cortical bone properties and to compare these parameters with the severity of fractures and biomechanical testing. METHODS: Twenty patients with displaced proximal humeral fractures planned for osteosynthesis were included. Fractures were classified as either 2-part fractures or complex fractures. Bone after core drilling was harvested during surgery from the humeral head in each patient. Twenty bone cores obtained from nonpaired cadaver humeral heads served as nonfractured controls. Micro-CT (µCT) was performed and bone volume/total volume (BV/TV), connectivity density (CD), trabecular number (Tb.N), trabecular thickness (Tb.Th), trabecular spacing (Tb.Sp), and bone mineral density (BMD) were assessed. The cortical index (CI) was determined from AP plain films. Biomechanical testing was done after µCT scanning by axially loading until failure, and ultimate strength and E modulus were recorded. RESULTS: BV/TV, BMD and CD showed moderate to strong correlations with biomechanical testing (r = 0.45-0.76, all p < 0.05). No significant differences were detected between the 2-part and complex fracture groups and controls regarding µCT and biomechanical parameters. CI was not significantly different between the 2-part and complex fracture groups. CONCLUSIONS: In our study population local trabecular bone structure and cortical index could not predict the severity of proximal humeral fractures in the elderly. Complex fractures do not necessarily imply lower bone quality compared to simple fractures.

A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks.

BACKGROUND: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). METHODS: Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. RESULTS: In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). CONCLUSIONS: Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Physeal injuries of the proximal humerus: long-term results in seventy two patients.

PURPOSE: The aim of this study was to evaluate our treatment methods of proximal humeral physeal injuries retrospectively and elucidate the relationship between the trauma mechanism, the radiographic injury pattern, the consequent therapy and the functional outcome, and to further deduct and verify prognostic criteria. METHODS: At our Department of Trauma Surgery, 303 children and adolescent patients with fractures of the proximal humeral epiphysis were treated from 1992 to 2009. 72 cases were diagnosed as physeal fractures according to the Salter-Harris classification and were included in our study. RESULTS: 15 physeal fractures of the proximal humerus were reconstructed anatomically by open or closed reduction and produced 93.3% excellent results. 57 physeal fractures were treated in a conservative way and produced 94.7% excellent results. CONCLUSION: We state that epiphyseal injuries should to be treated depending on the age of the patient. This is the only way to decrease the rate of posttraumatic epiphysiodesis with consequent problems, including limb-length discrepancy and/or angular deformities.

Comparison between two classifications of humeral head fractures: Neer and AO-ASIF.

Our purpose was to verify if the Neer and AO-ASIF classifications for fractures of the proximal humerus satisfy the requisites of simplicity and reproducibility and if the parameters that they consider to establish the severity of the fracture are similar. Two of the authors classified the proximal humeral fractures of 227 patients based on plain radiographs, and they repeated the classification five years later. The reliability, reproducibility and coherence of the classifications were investigated. Inter-observer reliability was K = 0.77 (Neer) and K = 0.65 (AO-ASIF) while intra-observer reproducibility was K = 0.68 (examiner I) and K = 0.63 (examiner II). In 1/5 of the cases, disagreement led to a different classification of the same fracture. Furthermore, neither classification establishes a linear scale of gravity able to provide an indication for treatment. The Neer and AO-ASIF classifications have a low reproducibility and reliability when fractures, especially those with 3 or 4 parts, are assessed by means of plain radiographs. Therefore, patients with complex fractures should be submitted to CT to have a correct pre-operative diagnosis.

Double Hill-Sachs lesion: a report of two cases.

Hill-Sachs lesions are common after anterior dislocation of the shoulder. We present two cases of uncommon double Hill-Sachs lesions composed of a typical Hill-Sachs lesion and an atypical extra compression fracture with a rim of normal cartilage in between. Both patients had two anterior shoulder dislocations before surgery. These case reports show that recurrent posttraumatic anterior glenohumeral dislocations can result in increased damage to the humeral cartilage.

Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon): a multicenter randomized controlled trial.

BACKGROUND: Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent, impairment of function and quality of life. The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem, especially in the elderly. Locking plates appear to offer improved fixation; however, screw cut-out rates ranges due to fracture collapse are high. As this may lead to higher rates of revision surgery, it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively. Results from case series and a small-sample randomized controlled trial (RCT) suggest improved function and less pain after primary hemiarthroplasty (HA); however these studies had some limitations and a RCT is needed. The primary aim of this study is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture. Secondary aims include effects on functional outcome, pain, complications, quality of life, and cost-effectiveness. METHODS/DESIGN: A prospective, multi-center RCT will be conducted in nine centers in the Netherlands and Belgium. Eighty patients over 65 years of age, who have sustained a three-or four part, or split head proximal humeral fracture will be randomized between primary hemiarthroplasty and conservative treatment. The primary outcome is the Constant score, which indicates pain and function. Secondary outcomes include the Disability of the Arm and Shoulder (DASH) score, Visual Analogue Scale (VAS) for pain, radiographic healing, health-related quality of life (Short-form-36, EuroQol-5D) and healthcare consumption. Cost-effectiveness ratios will be determined for both trial arms. Outcome will be monitored at regular intervals over the subsequent 24 months (1, 3 and 6 weeks, and 3, 6, 12, 18, and 24 months). Data will be analyzed on an intention to treat basis, using univariate and multivariable analyses. DISCUSSION: This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. These data may support the development of a clinical guideline for treatment of these traumatic injuries. TRIAL REGISTRATION: Netherlands Trial Register (NTR2040).

Predictive value of valgus head-shaft angle in identifying Neer 4-part proximal humerus fractures. A radiographic and CT-scan analysis of 120 cases.

BACKGROUND AND AIM OF THE WORK: Understanding the fracture morphology and its relation to the expected outcome and risk of complications is fundamental for proximal humerus fractures (PHFs) management. Most Neer 3- and 4-part fractures may deserve surgical treatment. Unfortunately, plain x-rays may not be able to differentiate between a 3- or 4-part fractures unless an axillary or analogue projection is carried out. Aim of the present study is to evaluate whether a high valgus head-shaft angle degree is predictive of a Neer 4-part rather than a 3-part fracture. METHODS: The study included 120 3-(75 cases) and 4-(45 cases) part PHFs (valgus displaced in 98 cases), M:F ratio = 1:2.6, mean age 65.7 years, classified on CT scan images. The humeral head shaft angle was calculated on AP x-rays and statistically correlated with 3 and 4-part fractures to identify values predictive of 4-part fracture. RESULTS: Valgus head/shaft angle was significantly higher in 4-part fractures, especially in the valgus displaced group (p < 0.001). A cutoff value of 168.5° was identified as predictive of a 4-part fracture with a sensibility of 74% and specificity of 78%. Increasing by 1 degree the humeral head-shaft angle, the chance to have a 4-part fracture increases of 3% in the whole population and of 11% in the valgus sub-group. CONCLUSION: The severity of PHF can be predicted analysing valgus head shaft angle on AP x-rays with a sensibility of 74% and specificity of 78% in identifying a 4-part fracture with a cutoff value of 168.5°.

Continuous Paravertebral Nerve Block for Scapula Fracture Analgesia: A Case Report.

A 46-year-old man presented with severe refractory posterior shoulder pain due to a left scapular fracture sustained during a motor vehicle collision. Despite multimodal oral and intravenous analgesics, the patient's pain remained difficult to control. A continuous paravertebral nerve block was performed between the second and third thoracic vertebrae resulting in excellent analgesia of the scapular pain. This case suggests that a continuous thoracic paravertebral block placed between the second and third vertebrae may be considered as part of multimodal analgesia in patients with scapular fractures.

Bilateral posterior fracture-dislocation of the shoulders: Two rare case reports and literature review.

RATIONALE: Bilateral posterior fracture-dislocation of the shoulders occurs rarely and the diagnosis is often challenging. This injury is often missed or delayed on initial presentation, leading to continuous pain, disability, and rising medical costs. Timely diagnosis and proper treatment are very important to restore shoulder function. PATIENT CONCERNS: Here we report 2 rare cases. Case 1 was a 53-year-old physical worker with severe pain and limited shoulder movement after an unexpected fall. Case 2 was a 55-year-old man with pain in upper limbs and shoulders after an electric shock. DIAGNOSIS: Both of them were diagnosed as bilateral posterior fracture-dislocation of the shoulders by computed tomography (CT) scan. INTERVENTION: After systematic preoperative evaluation, both of them were treated with open reduction and internal fixation. OUTCOMES: After 16 months follow-up, case 1 was pain-free in both shoulders. He had returned to full activity and was satisfied with his level of function. At 24 months follow-up, both shoulders of case 2 were painless and stable with acceptable range of motion and he was able to carry out daily activities. LESSONS: Our case reports highlight that bilateral posterior fracture-dislocation of the shoulders is easy to be missed; one way to prevent missing diagnosis is to suspect cases with pain and limited external rotation, especially those with a history of seizures, electric shock, or severe trauma; appropriate history inquiry, physical examination, proper shoulder images are the key to correct diagnosis.

Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures.

BACKGROUND: Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. METHODS: The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. RESULTS: The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). CONCLUSIONS: The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients' prognosis than the conventional Neer classification.

Open Reduction and Long Locking Plate Fixation of Complex Proximal Humeral Metadiaphyseal Fractures.

BACKGROUND: A minority of proximal humeral fractures extend into the diaphysis and their optimal treatment remains controversial. We evaluated the outcomes and risk of complications in patients with these injuries, treated by a protocol of open reduction and long locking plate fixation (LPF). METHODS: Between 2007 and 2014, all locally resident patients with a proximal humeral fracture extending into the diaphysis were referred to a specialist shoulder clinic. Operative treatment using a protocol of open reduction and LPF was offered to medically fit patients. Those with 2-year radiographic follow-up were included in the study, and standardized assessments of clinical and radiographic outcomes were performed during the first 2 years postoperatively. At a mean of 8.8 years (range, 5 to 12 years) after LPF, the functional outcomes and satisfaction of surviving, cognitively intact patients were assessed with a questionnaire study. RESULTS: One hundred and two patients met the inclusion criteria; the majority were older women who had incurred the injury during a simple fall. Fractures were divided into 2 types depending on the pattern of diaphyseal extension. The pain levels, functional scores, and satisfaction with treatment were satisfactory both at the 2-year follow-up and at the longer-term follow-up at a mean of 8.8 years postsurgery. Complications were predominantly due to postsurgical stiffness (in 7 patients, with 3 undergoing additional surgery) and nonunion or fixation failure (in 7 patients, with 6 undergoing additional surgery). CONCLUSIONS: Proximal humeral fractures with diaphyseal extension are rare. The results of our study support the use of LPF in medically stable patients in centers with the expertise to perform these procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.