Abstract
Abstract
Fourteen elderly patients with a two-part fracture, in osteopenic
bone, of the surgical neck of the humerus were treated with a valgus
impaction osteotomy and tension band fixation—that is,
the parachute technique. Thirteen patients were followed, and all
were able to perform activities of daily living without difficulty
and were satisfied with the result of the surgery. The average age
of these thirteen patients was sixty-eight years, and the average
duration of follow-up was 18.5 months. Union was achieved in all
patients, at an average of 45.5 days. No patient demonstrated osteonecrosis
of the humeral head. This technique of valgus impaction osteotomy with
Dacron-tape tension band fixation leads to rapid union. Patient
satisfaction and function were excellent.
Proximal humeral fractures are a common problem seen by most
orthopaedic surgeons. The majority of these fractures can be treated
nonoperatively with closed reduction and immobilization with a sling.
However, in elderly patients with osteopenic bone, displaced proximal
humeral fractures may require operative stabilization. Fixation
techniques are technically difficult and often have unsatisfactory
results due to poor bone quality, comminution, and deforming forces.
Stiffness from immobilization and lack of compliance in this patient
population often compromise the results.
We propose a method of operative stabilization of displaced two-part
fractures of the surgical neck of the humerus in patients with osteopenic
bone. An osteotomy of the distal fragment reduces the diameter of
the bone so that it can be impacted into the medullary canal of
the proximal fragment. Dacron-tape tension bands (Deknatel, Coventry,
Connecticut) maintain the impaction, control rotation, and resist
the tendency of the fracture to deform into varus and retroversion. This
technique is well tolerated by the soft osteopenic bone, and it
eliminates the need for hardware and its potential complications.
Fractures of the surgical neck of the humerus in the elderly most
often are oblique, extending from proximal-lateral to distal-medial
on the distal fragment, and often they are comminuted. Those that
are unstable following closed reduction require open reduction and
internal fixation. The deforming forces on the fracture fragments
most often result in the proximal fragment becoming aligned in varus
and retroversion (Fig. 1). The distal fragment migrates
proximally and anteriorly, contributing to anterior angulation (retroversion)
at the fracture site (Fig. 2). The unopposed rotator cuff (supraspinatus)
rotates the proximal fragment into varus. The pectoralis and deltoid
pull the distal fragment proximally, creating anterior angulation
at the fracture site, and contribute to retroversion of the proximal fragment.
Any internal fixation device must counteract these deforming forces
successfully if fixation is to be maintained. Our new technique
takes into account all of the deforming forces on this fracture.
Medial-lateral and anterior-posterior stability is achieved by osteotomizing
the proximal spike of the distal fragment, thus narrowing the circumference
of the distal fragment, and then impacting it into the medullary
canal of the proximal fragment (Fig. 3). Tension bands from the proximal
fragment to the distal fragment maintain the impaction and control
rotation. The tension band over the greater tuberosity counteracts
the forces that tend to deform the fracture into varus. Eliminating
the proximal spike of the distal fragment allows the tension band over
the greater tuberosity to overreduce the deformity into a slight
valgus alignment (Fig. 4). The tension band over the lesser
tuberosity counteracts the forces that tend to deform the fracture
into retroversion and anterior angulation (Fig. 5).
The tension bands are driven through the rotator cuff tendons, which
are stronger than the adjacent bone in the proximal fragment, and
through drill-holes placed on either side of the bicipital groove,
which is the most dense cortical bone in the distal fragment. Dacron
tapes have a broad surface area and are very pliable, making them
less prone to cut through bone than round or wire suture.
The surgical neck is located approximately 2 cm distal to the anatomic
neck. The majority of fractures in this area are minimally displaced.
It has been estimated that approximately 85% can be treated
with sling immobilization and early exercise1-3.
The remaining 15% of these fractures require operative
treatment. Many different techniques have been described in the literature.
Closed reduction is usually attempted first, but it can be challenging
because of soft-tissue interposition. The shaft of the humerus is
usually displaced anteromedially secondary to the pull of the pectoralis
major. If reduction is achieved, it is often difficult to maintain.
Closed reduction in the operating room followed by percutaneous
pinning offers the advantage of maintaining reduction of the fracture
fragments if reduction is achieved. However, this procedure is technically
demanding and pin fixation in osteopenic bone is insecure4.
Plate-and-screw fixation is a poor option in patients with osteopenic
bone. Also, with this method the plates and screws often impinge
under the acromion3. Osteonecrosis
is more frequent with this technique because the ascending branch
of the anterior circumflex artery is often compromised by the surgical
dissection5,6.
Antegrade intramedullary fixation with Ender nails or Rush rods
may be used. However, these devices do not provide rotational stability
and they injure the rotator cuff insertion. Retrograde migration
is also a common complication, requiring a second operation for
removal7.
Cornell et al.8 described a
tension band technique similar to our proposed method, except that
a 6.5-mm cancellous screw is placed through the humeral shaft into
the center of the head. This procedure produced excellent results,
with union achieved in all patients in the study. However, the hardware
may need to be removed at a later date, and the 6.5-mm screw could
split the osteoporotic head. Cornell et al. reported one case of
wire breakage.
The charts of fourteen patients who underwent valgus impaction
osteotomy with Dacron-tape fixation for the treatment of a two-part
fracture of the surgical neck of the humerus were retrospectively
reviewed. All patients were operated on by the senior author between
1989 and 1997. There were thirteen fresh fractures, and one patient
was treated for a nonunion. The average age of the thirteen patients
who were followed was sixty-eight years, with an age range of forty-six
to eighty-seven years. The duration of follow-up averaged 18.5 months, with
a range of 1.5 to 61.5 months. At each follow-up examination, patients
were evaluated both radiographically and clinically.
Radiographic union was defined as the formation of callus and
the loss of fracture lines as seen on the axillary, scapular "Y" lateral,
and anteroposterior internal and external rotation radiographs of
the proximal part of the humerus. Clinical union was defined as
the time, in the surgeon’s judgment and based on radiographic
and clinical examination, that the patient could participate in
an aggressive passive-range-of-motion exercise program without restriction.
Range of motion was evaluated by comparison with that of the contralateral shoulder.
The patient is placed in the beach-chair position. A standard deltopectoral
approach is made to the fracture site. The biceps tendon is identified
and used as the guide for orientation. The fracture is mobilized
to clearly identify the configuration of the distal fragment. In
most cases, this is an oblique fracture with a prominence laterally
(Figs. 1 and 2). A portion of the
prominence (~1 cm, enough so that the circumference of the distal
fragment can be impacted into the medullary canal of the proximal
fragment) is removed with a rongeur (Fig. 3).
Next, the biceps tendon is mobilized to the rotator interval. This
interval is opened so that an index finger can be passed inside
the joint and the surgeon can thus appreciate the intra-articular
relationship of the rotator cuff and tuberosities relative to the
articular surface. Two drill-holes are placed approximately 1 in
(2.5 cm) distal to the fracture, in the distal fragment immediately
adjacent to the bicipital groove; one drill-hole is placed medial
to the groove and one, lateral to it. This area is selected as it
is the best-quality bone in the metaphyseal area and will provide
the proper orientation of pull for the sutures that will be placed
through it.
It should be made certain that there are no undisplaced fracture
lines in the area of the drill-holes so that they will not propagate
after placement of the sutures. If the bone is not of good quality,
the drill-holes should be placed more distal from the fracture site.
Only two drill-holes in the metaphyseal region are utilized. The
more holes that are drilled, the greater the potential for fracture
propagation.
Three-millimeter, double-armed, Cottony Dacron tape and a large,
curved cutting needle are used. The two lateral tapes are splayed
over the greater tuberosity and through the supraspinatus insertion.
The two medial tapes are driven similarly from inside out through
the anterior aspect of the anatomic neck and the subscapularis tendon
at its insertion on the lesser tuberosity. These arms are splayed
approximately 2 cm apart.
The fracture is then reduced by placing the distal fragment inside
the medullary canal of the proximal fragment. The distal fragment
is then pushed up inside the proximal fragment with pressure on
the elbow. Care must be taken to achieve rotational alignment relative
to the biceps tendon as this process is accomplished. The Dacron
tapes are then tied under tension. The two lateral tapes over the
greater tuberosity are tensioned so that there is a slight valgus
configuration to the fracture alignment (Fig. 4). This will counter the forces
tending to create a varus deformity. The two anterior-medial tapes
over the lesser tuberosity are tensioned to eliminate the potential
to retrovert the proximal fragment and to create an anterior angulation
at the fracture site (Fig. 5). The humerus is then moved about
to check for stability. If the tension is not proper, the tapes
can be untied and the tension can be adjusted.
Additional tapes can be utilized if necessary. Several throws of
a Dacron tape will result in a relatively bulky knot, and three
throws with a stick tie to secure the tails should help to reduce
the size of the knot. If the procedure has been done properly, the
tapes behave as tension bands compressing the fracture. This compression
within the medullary canal controls rotation. The fixation is not
rigid, but it adequately controls the fracture fragments to allow
for an early range of motion and exercise while the patient is awaiting
early union. The broad-based tapes are preferable to round suture,
which tends to cut through osteopenic bone. As fracture-healing seems
to progress rapidly with this technique, the fixation needs to hold
only temporarily.
The configuration of the splayed tapes under tension coming down
to the common fixation site in the distal fragment and going up
to the rounded articular surface gave the illusion, to a previous
resident, of a parachute; therefore we called the procedure the parachute
technique.
Union was achieved at a mean of 45.5 days in all thirteen patients
who were evaluated (Table I). There was a mean loss of 18.6°
of forward flexion and of 7.7° of external rotation; internal rotation
was decreased by a mean of 2.2 spinal levels.
There were no cases of malunion, infection, impingement, neurovascular
injury, avascular necrosis, or post-traumatic arthritis. All thirteen
patients had returned to their activities of daily living and were
pain-free.
Thirty to forty percent of all humeral fractures are proximal9. It has been estimated that approximately
65% of these fractures involve the surgical neck7,10. The prevalence has been increasing
steadily as a result of the increasing age of the population and
the prevalence of osteoporosis. It has been estimated that, after
the age of fifty years, these fractures occur at a rate of 3.7 per
1000, which is greater than the published rate of hip fractures11,12.
Displaced two-part proximal humeral fractures present a challenge
to the orthopaedic surgeon. The fracture is commonly found in elderly
patients with osteopenic bone. Because of the poor bone quality
and the degree of comminution in the elderly, stable fixation is
difficult to achieve.
Nonunion of proximal humeral fractures is uncommon, and the true
prevalence is not known. Displaced two-part fractures of the surgical
neck, however, have a higher prevalence of nonunion13. Few reliable techniques have been
described for fixation of displaced two-part fractures of the surgical
neck in patients with osteopenic bone.
Tension band suture fixation (the parachute technique) of two-part
surgical neck fractures in osteopenic humeri resulted in union and
good function, with minimal symptoms, in all thirteen of our patients
at an average of 45.5 days. This technique creates a stable fracture
pattern and eliminates the morbidity of hardware implantation in
elderly patients with osteopenic bone.
Neer CSII. Displaced proximal humeral fractures. I. Classification
and evaluation. J Bone Joint Surg Am,1970;52: 1077-89. 521077
1970
[PubMed]
Rockwood CA Jr, Green DP, Bucholz
RW, Heckman JD, editors. Rockwood and Green’s fractures
in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996
SchlegelTF,Hawkins RJ. Displaced proximal humeral fractures: evaluation and treatment. J Am Acad Orthop Surg,1994;12: 54-78. 1254
1994
HawkinsRJ,Kiefer GN. Internal fixation techniques for proximal humeral fractures. Clin Orthop,1987;223: 77-85. 22377
1987
[PubMed]
JupiterJB,Mullaji AB. Blade plate fixation of proximal humeral non-unions. Injury,1994;25: 301-3. 25301
1994
[PubMed]
LaingPG. The arterial supply of the adult humerus. J Bone Joint Surg Am,1956;38: 1105-16. 381105
1956
[PubMed]
SzyszkowitzR, Seggl W, Schleifer P,Cundy PJ. Proximal humeral fractures. Management techniques and expected
results. Clin Orthop,1993;292: 13-25. 29213
1993
[PubMed]
CornellCN, Levine D,Pagnani MJ. Internal fixation of proximal humerus fractures using
the screw-tension band technique. J Orthop Trauma,1994;8: 23-7. 823
1994
[PubMed]
HawkinsRJ. Displaced proximal humeral fractures. Orthopedics,1993;16: 49-53. 1649
1993
[PubMed]
WeseleyMS, Barenfeld PA,Eisenstein AL. Rush pin intramedullary fixation for fractures of the
proximal humerus. J Trauma,1977;17: 29-37. 1729
1977
[PubMed]
HorakJ,Nilsson BE. Epidemiology of fractures of the upper end of the humerus. Clin Orthop,1975;112: 250-3. 112250
1975
[PubMed]
KristiansenB, Barfod G, Bredesen J, Erin-Madsen J, Grum B, Horsnaes MW,Aalberg JR. Epidemiology of proximal humeral fractures. Acta Orthop Scand,1987;58: 75-7. 5875
1987
[PubMed]
NayakNK, Schickendantz MS, Regan WD,Hawkins RJ. Operative treatment of nonunion of surgical neck fractures
of the humerus. Clin Orthop,1995;313: 200-5. 313200
1995
[PubMed]