Acta of Shoulder and Elbow Surgery | Volume 2 | Issue 2 | July-Dec 2017 | Page 12-15 | Federico Alfano
Authors: Federico Alfano .
 Spanish Hospital of Buenos Aires
Address of Correspondence
Dr. Federico Alfano
Spanish Hospital of Buenos Aires
Introduction: 2-part non-union of the surgical neck fracturesof the humerus after conservative treatment may result from initial displacement, secondary disimpaction,interposition of soft tissue, synovia fluid at the site of fracture, aggressive rehabilitation, bad patient compliance, and many other intrinsic causes. A wide variety of treatments for this condition have been proposed. They include conservative treatment, ORIF (with or without bone grafting), hemiarthroplasty and reverse arthroplasty. Most reports emphasize possible treatment options and their results. Nonetheless, it is hard to address conservative treatment since it is a very disabling disease. The aim of the present study is to evaluate the results achieved with conservative treatment for surgical neck non-unions in elderly patients. Although we advocate for surgical treatment for 2-part non-union of the surgical neck fractures, the group of patients included in the study didn’t accept our surgical indication or surgery was contraindicated because of increased operative or anesthetic risks.
Materials and Method: Retrospectively, 13 shoulders with a 2-year follow-up period were included in the study. 9 of the 13 patients were female. The mean age of the patients was 83.3 years (range 75–91 years). The dominant arm was affected in 4 patients. In the current study it was found that bone cavitation may occur early in the course of the disease, even in cases of hypertrophic non-union. It seems clear that 2-part surgical neck fractures can develop non-union in distinct manners. We found an association between hypertrophic non-union andgleno-humeral arthritis. In these cases, it looks like the limited range-of-motion in the gleno-humeral joint causes fracture instability and continuous movement between fragments, leading to hypertrophic non-unions. As stabilization of a fracture provides the essential mechanical component to allow calcification of the fibrous cartilage,on the contrary, early active mobilization exercises of a stiff joint leads to early mobilization of the fracture sitebefore bone healing had occurred.
Results: All patients complained of pain and functional impairment within the first year (with a mean Constant Score of 13.1, 15.1, 17.2 at 3, 6 and 12 months respectively). After that period most patients complained mainly about poor active range of motion (with a mean Constant Score of 24.7 and25.6 at 18 and 24 months respectively). The mean pain score improved from 8.4 at 6 months to 4.1 at the time of follow-up (p < 0.05).Mean active elevation didn´t improve although home-based exercises or supervised strengthening was carried out. All patients had internal and external rotation lag signs. At the time of last follow-up, the average active shoulder range of motion was 73° of total elevation, 20° of external rotation; on internal rotation, the ipsilateral thumb could reach the ipsilateral buttock. The two patients with combined preexisting gleno-humeral arthritis and hypertropic non-unions had worse outcome in terms of pain and range of motion.
Conclusions: Pain relief after 12 months was associated to three anatomical changes during the natural course of the disease. These are the development of a capsule-like formation of connective tissue in the non-union site, a varus cephalic displacement and bone cavitation process interruption (which was represented by the proximal humerus metaphyseal region and subcapital head sclerosis). In cases of preexisting gleno-humeral arthritis we advocate for reverse arthroplasty. If the hypertropic non-unions had occurred we would advocate for surgical stability and earlier mobilization. In all other cases, we still prefer the surgical indication if the patient has an unacceptable pain. If surgery is not possible, we can still expect reduction of pain but any improvement in terms of range of motion after 12 months of conservative treatment.
Key words: Conservative treatment, humeral surgical neck non-unions, elderly patients.
1. Handoll HHG, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database of Syst. Rev. 2003; Cd000434.
2. Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury 1998; 29: 349–52.
3. Martin C, Guillen M, Lopez G. Treatment of 2- and 3-part fractures of the proximal humerus using external fixation: a retrospective evaluation of 62 patients. ActaOrthop. 2006; 77: 275–8.
4. Neer CS II. Displaced proximal humeral fractures: part I. Classification and evaluation. J. Bone Joint Surg 1970; 52-A: 13.
5. Neer CS II. Displaced proximal humeral fractures: part II. Treatment of three-part and four-part displacement. J. Bone Joint Surg. 1970; 52-A: 1090–103.
6. Sorensen KH. Pseudarthrosis of the surgical neck of the humerus. ActaOrthop. Scand 1964; 34: 132–8.
7. Duralde XA, Flatow EL, Pollock RG, Nicholson GP, Self EB, Bigliani LU. Operative treatment of nonunions of the surgical neck of the humerus. J. Shoulder Elbow Surg. 1996; 5: 169–80.
8. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop. Clin. North Am. 2008; 39: 475–82.
9. Healy WL, Jupiter JB, Kristiansen TK, White RR. Nonunion of the proximal humerus: a review of 25 cases. J. Orthop. Trauma 1990; 4: 424–31.
10. Galatz LM, Iannotti JP. Management of surgical neck nonunions. Orthop. Clin. North Am. 2000; 31: 51–61.
11. Antuna SA, Sperling JW, Sanchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral nonunions. J. Shoulder Elbow Surg. 2002; 11: 114–21.
12. Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J. Shoulder Elbow Surg. 2009; 18: 612–21.
13. Neer CS II. Nonunion of the surgical neck of the humerus. Orthop Trans. 1983; 7:389.
14. Court-Brown CM, McQueen MM. Nonunions of the proximal humerus: their prevalence and functional outcome. J Trauma. 2008 Jun;64(6):1517-21.
15. Coventry MB, Laurnen EL. Ununited fractures of the middle and upper humerus. Special problems in treatment. ClinOrthopRelat Res. 1970 Mar-Apr; 69:192-8.
16. Krackow KA, Thomas SC, Jones LC. A new stitch for ligament-tendon fixation. Brief note.J Bone Joint Surg Am. 1986 Jun;68(5):764-6.
17. Leach RE, Premer RF. Nonunio of the surgical neck of thehumerus. Method of internal fixation.Minn Med. 1965 Mar;48:318-22.
18. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg. 2001 Jul-Aug;10(4):299-308.
19. Walch G, Badet R, Nov´e-Josserand L, Levigne C. Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elbow Surg. 1996 May-Jun;5(3):161-8.
20. Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the proximal humerus: malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elbow Surg. 1993;2: 11-21.
21. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. OrthopClin North Am. 2008 Oct;39(4):475-82, vii.
22. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):527-40.
23. Duquin TR, Jacobson JA, Sanchez-Sotelo J, Sperling JW, Cofield RH. Unconstrained shoulder arthroplasty for treatment of proximal humeral nonunions. J Bone Joint Surg Am. 2012 Sep 5;94(17):1610-7.
24. Raiss P, Edwards TB, da Silva MR, Bruckner T, Loew M, Walch G. Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type-3 fracture sequelae). J Bone Joint Surg Am. 2014 Dec 17;96(24):2070-6.
25. Jacobson JA, Duquin TR, Sanchez-Sotelo J, Schleck CD, Sperling JW, Cofield RH.Anatomic shoulder arthroplasty for treatment of proximal humerus malunions. J Shoulder Elbow Surg. 2014 Aug;23(8):1232-9.
|How to Cite this article: Alfano F .Conservative treatment for humeral surgical neck non-unions. Acta of Shoulder and Elbow Surgery July – Dec 2017;2(2):12-15.|