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Internal fixation of fractures of the proximal humerus with the MultiLoc nail

Innere Fixation proximaler Humerusfrakturen mit dem MultiLoc-Nagel

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Abstract

Objective

Anatomical reduction of two- to four-part fractures of the proximal humerus using indirect reduction techniques. Intramedullary fixation with a short humerus nail. Restoration of a stable bone-implant construct that enables early functional after-treatment.

Indications

Displaced and unstable two- to four-part fractures of the proximal humerus. Fractures of the proximal humerus extending in the humeral diaphysis (use a long nail). Ipsilateral combined lesions of the proximal humerus and the humeral diaphysis (use a long nail).

Contraindications

Poor physical and/or mental status. Critical soft tissue conditions in the area near the surgical site. Local soft tissue infection. Pre-existing severe osteoarthritis of the shoulder joint; severe shoulder stiffness. Head-split fractures of the humerus head that cannot be reduced.

Surgical technique

Exposure of the fracture using an anterior acromial approach and determination of the correct nail entrance point. Anatomic fracture reduction using indirect reduction techniques. Stable fixation using an intramedullary MultiLoc® nail. Determination of the proximal locking configuration depending on the fracture morphology. Distal locking with angle-stable option.

Post-operative treatment

Post-operative radiographs for documentation of the surgical result and implant position. Use of an arm sling for 7–10 days. Active and passive exercises of the shoulder joint starting on day 1. Shoulder abduction limited to 60° for 2 weeks. Subsequent abduction to 90° until the 4th week. Subsequent active mobilisation without restrictions. Weight bearing and sporting activities after 3 months. Radiological evaluation after 2, 6 and 12 weeks.

Results

During a 6-month period, 160 patients were documented in a prospective clinical multicentre study. According to the AO classification, there were 36% A-type fractures, 41% B- and 23% C-type injuries. A 6-month follow-up was available for 17 patients. The mean age of these patients was 67 years. One patient had an A-type fracture. There were ten B- and six C-type fractures. At the time of follow-up, the mean Constant score was 66 points. Radiographically, all fractures had healed. Intra-articular screw penetration and loss of reduction were both observed once.

Zusammenfassung

Operationsziel

Anatomiegerechte Reposition der 2- bis 4-Fragment Humeruskopffraktur unter Anwendung von indirekten Repositionstechniken. Fixation mit einem kurzen intramedullären Humerusnagel. Herstellen eines stabilen Knochen-Implantat-Verbunds, welcher eine frühfunktionelle Nachbehandlung ermöglicht.

Indikationen

Dislozierte und instabile 2-, 3- und 4-Fragment-Frakturen des Humeruskopfes. Proximale Humerusfrakturen, ausstrahlend in die Diaphyse (Verwendung eines langen Nagels). Ipsilaterale Kombinationsverletzungen von Humeruskopffrakturen und diaphysären Humerusschaftfrakturen (Verwendung eines langen Nagels).

Kontraindikationen

Schlechter physischer und/oder psychischer Allgemeinzustand. Lokal kritische Weichteilverhältnisse im Zugangsbereich. Lokale Weichteilinfektion. Vorbestehende fortgeschrittene Omarthrose und Einsteifung des Schultergelenks. Nicht rekonstruierbare Head-split-Frakturen des Humeruskopfes.

Operationstechnik

Darstellen der Fraktur über einen vorderen akromialen Zugang und Bestimmen der korrekten Nageleintrittstelle. Anatomiegerechte Frakturreposition unter Verwendung von indirekten Repositionstechniken. Stabile Fixation mit einem intramedullär eingebrachten MultiLoc® Humerusnagel. Wahl der proximalen Verriegelungskonfiguration in Abhängigkeit von der Frakturmorphologie. Distale Verriegelung mit winkelstabiler Option.

Weiterbehandlung

Postoperative Röntgenkontrolle zur Dokumentation der Reposition und Implantatlage. Benutzung einer Armschlinge für 7–10 Tage. Ab dem 1. postoperativen Tag passive und aktiv-assistive Bewegungsübungen des Schultergelenks bis 60° Abduktion für 2 Wochen. Danach Abduktion bis 90° bis Ende 4. Woche. Anschließend Freigabe der Beweglichkeit. Belastung und Sport nach 3 Monaten. Röntgenkontrollen nach 2, 6 und 12 Wochen.

Ergebnisse

In einem Zeitraum von 6 Monaten wurden in einer prospektiven multizentrischen Studie 160 Patienten prospektiv erfasst. Nach der AO-Klassifikation handelte es sich um 36% Typ-A-, 41% Typ-B- und 23% Typ-C-Verletzungen. Siebzehn Patienten konnten nach 6 Monaten untersucht werden. Durchschnittsalter der Patienten war 67 Jahre. Frakturmorphologisch fanden sich 1 Typ-A-, 10 Typ-B- und 6 Typ-C-Verletzungen. Der durchschnittliche Constant-Score lag bei 66 Punkten. Radiologisch waren alle Frakturen geheilt. Eine intraartikuläre Schraubenperforation und ein Repositionsverlust wurden in jeweils einem Fall beobachtet.

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Conflict of interest

On behalf of all authors, the corresponding author states the following: consulting performed for the company Synthes.

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Authors and Affiliations

  1. Department of Orthopedics and Trauma Surgery, Academic Teaching Hospital Fulda, Pacelliallee 4, 36043, Fulda, Germany

    M.H. Hessmann & V. Winkelbach

  2. Department of Trauma Surgery, University Hospitals Leuven-Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium

    S. Nijs

  3. Department of Trauma and Reconstructive Surgery, University Rostock, Schillingallee 35, 18057, Rostock, Germany

    T. Mittlmeier

  4. Department of Traumatology, Hospital Ceské Budejovice, B. Nemcove, Ceské Budejovice, Czech Republic

    M. Kloub

  5. Department of Trauma Surgery, Sint Antonius Hospital, 3730, EM Nieuwegen, The Netherlands

    M.J.M. Segers

  6. Department of Trauma Surgery, University Hospital Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria

    M. Blauth

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  1. M.H. Hessmann
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  6. V. Winkelbach
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Correspondence to M.H. Hessmann.

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Hessmann, M., Nijs, S., Mittlmeier, T. et al. Internal fixation of fractures of the proximal humerus with the MultiLoc nail. Oper Orthop Traumatol 24, 418–431 (2012). https://doi.org/10.1007/s00064-011-0085-z

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  • DOI: https://doi.org/10.1007/s00064-011-0085-z

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