wboacon24siligurimedalpaper-kaustav copy.pptx

Ppt

1. Radiological and clinical outcome of treating proximal humerus simple head split fractures by internal fixation- A case series Dr. Kaustav Mukherjee MBBS,MS Ortho, DNB, MNAMS, Dip.SICOT (Belgium) Executive member SICOT EDUCATION COMMITTEE 2023-25 Executive member WORLD ORTHOPAEDIC CONCERN (WOC)-India Chapter ( Senior Resident, Dept. of Orthopaedics, JNM medical college & Hospital, Kalyani, India)

2. Introduction Humerus head split fractures represent a rare subgroup of coronal plane proximal humerus fracture( 2 % incidence of all proximal humerus #) Isolated simple head splits are often missed at initial presentations. Treating simple head splits lacks a clear algorithm ( minimal fixation vs screw-augmented-plate fixation) We AIM to bring forward the challenges in diagnosing these rare isolated simple head splits, principles and mode of treatment of these fractures.

3. Materials & Methods A retrospective study from 2010 to 2020, with pts in age group of 20 to 50 years were included in the study. All pathological & severely comminuted(>4 fragments) fractures were excluded X-rays & CT Scans/ MRI were done for all patients included in the study. 2 subgroup of patients- cancellous screw fixation & plate augmented screw construct. All operated by standard Delto-pectoral approach . Pts followed up over next 12 months , at regular intervals. Radiological follow-up included serial shoulder AP/Lat x-rays. Clinical outcome by Oxford Shoulder Score & Visual Analogue Scale ( VAS ) . Mean time to Radiological union on X-rays was assessed by 2 blinded analysers.

4. Case example-1

5. Follow-up clinical outcome at 16 weeks , operated by anterior-posterior screw augmented by plate

6. Case example 2

7. Case example 3 A gentleman in mid 30s admitted with left shoulder pain post trauma. AP xrays were reported to be normal from outside clinic. Ct scans were done which revealed a head split fracture. Screw fixation was done. 20 weeks x-rays revealed good union. (operated in 2012)

8. Results A total of 7 patients were included. 4 fixed with screws alone. 3 by plate augmented screw construct. Mean age group- 34.5 years, with 85% male preponderance. N=4 N=3

9. All fractures went on to unite on its own . No incidence of non union/ osteonecrosis. 1 patient had SSI . Was managed later with implant removal at 11 months post-op.

10. Discussion Simple head splits are difficult to identify on simple AP xrays . Y view / axillary Y view s can be difficult in acute trauma setting. However a Velpau Axillary view should be taken whenever a doubt. Resch et al suggested CT scans for all patients with h/o trauma & inability to lift shoulder with signs of possible fracture/subluxation. Griewe et al stated that even with CTs almost 50% of head splits are missed . Missed diagnosis patients presenting late often land up with shoulder stiffness/ bony ankylosis. [Our case series had 3 patients with missed diagnosis of head split , referred with only standard AP radiographs ] How often do we miss it ?

11. AO has classified all head splits as 11C2-3 . However, a clear classification on its subtypes and treatment algorithm is still deficient. Mora Guix et al , Hertel et al have described on x-rays. However, the most comprehensive CT based classification have been proposed by Scheibel et al . [ We had 5 cases of type 1 and 2 cases of Type 2 Scheibel.] Robinson et al mentioned a prognostic classification – type 1 ( humeral head retained capsular attachment, >2cm in length, with arterial bleed) , type 2 (head detached from capsular attachments, <2cm in length, with no demonstrable arterial bleed. [ All our cases had good posteromedial bone spike and in Robinson Type 1 ] How to classify ?

12. Simple head splits in young adults demands prompt diagnosis , adequate fixation and early mobilisation. Head preservation should be given utmost priority . Minimal fixation techniques, with good soft tissue handling reap excellent results. Sperling et al recommends open anatomic reduction and internal fixation in all proximal humerus fractures in patients younger than 50 years. Chesser et al described good results with internal fixation using cancellous screws alone. Gavaskar et al mentioned antero- posterior screws along with PHILOS plate in treatment of these fractures. [ we treated all simple head splits by a combination of minimal cancellous screw fixation & plate augmented screw fixation ] How to plan your treatment ?

13. Limitations…. Only simple head splits fractures were included in the study. All cases had only mild displacement without any major subluxation/ displacement. Limited cases , not adequate to compare between the 2 groups of fixation.

14. Conclusion Diagnosing these subtle head split fractures is important and a clinician needs to be aware of it. Primary internal fixation in Type 1 & 2 Schiebel yields good functional outcome. Minimal internal fixation with cancellous screws alone has better functional outcome with lesser chance of hardware irritation. Minimal fixation also doesn’t require the need of prolonged physiotherapy & rehabilitation usually associated with more complex constructs.

15. References Bailie, A. G., & McAlinden , M. G. (2006). Complex head-splitting fracture-dislocation of the proximal humerus successfully treated with minimal internal fixation: a case report and discussion. Injury , 37 (2), 82-85. Resch , H., Tauber , M., Neviaser , R. J., Neviaser , A. S., Majed , A., Halsey, et al. (2016). Classification of proximal humeral fractures based on a pathomorphologic analysis. Journal of shoulder and elbow surgery , 25 (3), 455-462. Gokkus , K., Agar, E., Sagtas , E., & Aydin, A. T. (2014). Proximal humerus head-splitting fracture associated with single-part anterior dislocation. Case Reports , 2014 , bcr2013202188 . Shrader , M. W., Sanchez-Sotelo, J., Sperling , J. W., Rowland, C. M., & Cofield , R. H. (2005). Understanding proximal humerus fractures: image analysis, classification, and treatment. Journal of shoulder and elbow surgery , 14 (5), 497–505. Scheibel , M., Peters, P., Moro, F., & Moroder , P. (2019). Head-split fractures of the proximal humerus. Obere Extremität , 14 (2), 93-102. Dawson, J., Rogers, K., Fitzpatrick, R., & Carr, A. (2009). The Oxford shoulder score revisited. Archives of orthopaedic and trauma surgery , 129 (1), 119-123. Lind, T., Krøner , K., & Jensen, J. (1989). The epidemiology of fractures of the proximal humerus. Archives of orthopaedic and trauma surgery , 108 (5), 285-287. Chesser , T. J. S., Langdon, I. J., Ogilvie, C., Sarangi, P. P., & Clarke, A. M. (2001). Fractures involving splitting of the humeral head. The Journal of bone and joint surgery. British volume , 83 (3), 423-426. Greiwe , R. M., Vargas-Ariza , R., Bigliani , L. U., Levine, W. N., & Ahmad, C. S. (2013). Hemiarthroplasty for head-split fractures of the proximal humerus. Orthopedics , 36 (7), e905-e911. Hertel , R., Hempfing , A., Stiehler , M., & Leunig, M. (2004). Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. Journal of shoulder and elbow surgery , 13 (4), 427-433. Guix , J. M. M., Pedrós , J. S., & Serrano, A. C. (2009). Updated classification system for proximal humeral fractures. Clinical Medicine & Research , 7 (1-2), 32-44. Gavaskar , A. S., & Tummala , N. C. (2015). Locked plate osteosynthesis of humeral head–splitting fractures in young adults. Journal of shoulder and elbow surgery , 24 (6), 908-914. Ogawa , K., Yoshida, A., & Inokuchi , W. (1999). Posterior shoulder dislocation associated with fracture of the humeral anatomic neck: treatment guidelines and long-term outcome. The Journal of trauma , 46 (2), 318–323. Robinson, C. M., Khan, L. A., & Akhtar , M. A. (2006). Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. The Journal of bone and joint surgery. British volume , 88 (4), 502–508. Sperling , J. W., Cofield , R. H., & Rowland, C. M. (1998). Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. The Journal of bone and joint surgery. American volume , 80 (4), 464–473. Schai , P., Imhoff , A., & Preiss , S. (1995). Comminuted humeral head fractures: a multicenter analysis. Journal of shoulder and elbow surgery , 4 (5), 319–330. Swamy, G., & Schemitsch , E. H. (1998). Humeral head fracture dislocation: case report and review of the literature. The Journal of trauma , 44 (2), 377–380. Jost, B., Spross , C., Grehn , H., & Gerber, C. (2013). Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. Journal of shoulder and elbow surgery , 22 (4), 542-549.  

16. Acknowledgements Prof. R Dorai Kumar Prof. M Mohan Kumar Dr Tarun Prashanth Dr Thirunthaiyan

17. THANK YOU