Conservative Treatment of Proximal Humeral Fractures: Prognostic Factors and Outcome

Our study identified four main fracture types including 90 % of fractures (Fig. 17.2):

Fig. 17.2

Diagrams of some fracture patterns identified. (a) Posteromedial impaction fracture. (b) Posteromedial impaction fracture with fracture of both tuberosities. (c) Lateral neck valgus impaction fracture with involvement of the greater tuberosity. (d) Lateral neck impaction fracture with involvement of both tuberosities. (e) Fracture of the greater tuberosity. (f) Anteromedial impaction fracture (Reproduced with permission and copyright © of the British Editorial Society of Bone and Joint Surgery [5])

1.

Posteromedial varus impaction with or without tuberosities involvement—54 %

2.

Valgus impaction —14 %

3.

Isolated fractures of the greater tuberosity —16 %

4.

Anteromedial impaction—9 %

A miscellanea group included the rest of the fractures. We found that different fracture patterns had different outcome (Fig. 17.3). Fifty-four percent of valgus impacted fractures had an unsatisfactory result, as well as 25 % of posteromedial varus impacted fractures. The great majority of isolated greater tuberosity and anteromedial impacted fractures had excellent results.

Fig. 17.3

Graphs showing the correlation with the patterns of fracture. (a) The visual analog scale for pain. (b) The visual analog scale for satisfaction. (c) The Disabilities of the Arm, Shoulder, and Hand (DASH) score loss. (d) The American Shoulder and Elbow Society (ASES) score loss. (e) The elevation loss. (f) The external rotation loss. GT greater tuberosity, LT lesser tuberosity (Reproduced with permission and copyright © of the British Editorial Society of Bone and Joint Surgery [5])

When analyzing fragment displacement in the posteromedial varus impacted fractures with or without tuberosity displacement, we were able to verify that specific fragment displacements correlated with loss of specific outcome parameters (Table 17.1). Motion loss was related to the change of orientation of the cephalic segment and the interference between fragments surrounding structures: the greater the varus impaction, the greater the elevation loss; the greater the posterior greater tuberosity displacement, the greater the loss of external rotation because of impingement with the posterior glenoid rim; the greater the retroversion, the lesser the loss of external rotation. Finally, multivariate analysis defined prognostic models for the loss of motion and function based on combinations of measurements of displacement (Table 17.2).

Table 17.1

Clinical value and statistical signification of correlations between measurements performed in CT triplane reconstructions and outcome variables in all patients (N = 93)

Measurement variable	Measured displacement	Univariate linear regression parameter*/P value
Measurement variable	Measured displacement	ASES change (points)	DASH change (points)	Elevation change (degrees)	External rotation change (degrees)	Internal rotation change (spinal levels)
Axial CT
AS to Gle angle^a	>45° retroversion	−15.2 p = 0.008	+8.7 p = 0.05	−14.6 p = 0.009	−14.9 p = 0.02	−2.1 p = 0.05
% GT to AS superposition	20 %	−11.0 p < 0.001	+8.4 p < 0.001	−9.4 p = 0.002	−12.8 p < 0.001	p = 0.06
Intertuberosity distance	10 mm	−4.3 p = 0.007	+4 p = 0.001	−3.3 p = 0.03	−4.3 p = 0.01	−0.8 p = 0.009
GT medial displacement	10 mm	−8.8 p < 0.001	+5.6 p = 0.005	−6.6 p = 0.008	−11.0 p < 0.001	p = 0.09
%LT-AS superposition	20 %	p = 0.65	p = 0.22	p = 0.47	p = 0.39	−6.2 p < 0.001
Coronal CT
Increase AS-AC distance	10 mm	−29.7 p < 0.001	+20.9 p < 0.001	−26.2 p < 0.001	−21.7 p < 0.001	−3.1 p = 0.002
GT-AS distance (GT above AS)	10 mm	−10.9 p < 0.001	+7.8 p = 0.002	−15.5 p < 0.001	−8.8 p = 0.02	−1.5 p = 0.02
Medial impaction	10 mm	−4.0 p = 0.04	p = 0.09	−7.5 p < 0.001	p = 0.11	p = 0.94
AS-shaft (varus) angulation	20°	p = 0.32	p = 0.81	−4.6 p = 0.003	p = 0.50	p = 0.84
Sagittal CT
Extension surgical neck	20°	p = 0.11	+3.6 p = 0.02	−5.6 p = 0.003	p = 0.13	p = 0.44
Posterior neck impaction	10 mm	p = 0.07	p = 0.07	−8.6 p < 0.001	−5.9 p = 0.02	p = 0.50

*Model parameters represent change in outcome from baseline to follow-up for the given displacement (independent variable). Model parameters are not reported for nonsignificant associations

AS articular surface, Gle glenoid, GT greater tuberosity, LT lesser tuberosity, AC acromion, Post posterior

^aAngle between the articular surface axis and the perpendicular line to the glenoid face, greater than 45°

Table 17.2

Outcome multivariable models

Outcome variable	Measurement variables to use	Increase in measurement variable displacement	Resultant change in outcome	P	R ²
Posteromedial impaction fracture pattern (N = 50)
Change ASES (points) Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Percutaneous Fixation: When and How Radial Palsy and Humerus Fractures External Fixation: When and How Operating Theater Setup Treatment of the Sequelae The Malunion and Nonunion of Distal Humerus Fractures Stay updated, free articles. Join our Telegram channel Tags: Simple and Complex Fractures of the Humerus May 22, 2017 \| Posted by admin in ORTHOPEDIC \| Comments Off on Conservative Treatment of Proximal Humeral Fractures: Prognostic Factors and Outcome Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access