EFFECTS OF PROXIMAL HUMERAL FRACTURE TREATMENTS ON POSTOPERATIVE OUTCOMES

1. Introduction

Proximal humeral fractures (PHFs) are common, accounting for 4–5% of all fractures and 50% of all humeral fractures.^1,2,3 People over 60 years of age, especially women, account for approximately three-quarters of all PHF cases, mostly related to osteoporosis. PHFs are primarily secondary to high-energy injuries for younger people, such as injuries from car accidents, electric shock, and epilepsy. Therefore, the fracture comminution degree is also higher in the younger population.^4,5 Furthermore, the PHF incidence rate has risen with the aging population and expansion of the transportation and construction industries, with a projected three times increase over the next 30 years.⁵

Conservative treatment is effective for most PHFs with mild displacement. However, severe PHF injuries with obvious displacement require surgical treatment. The primary surgical methods are conventional open reduction and plate fixation. Internal fixation, artificial replacement, and closed reduction combined with percutaneous needle fixation are also common and have good clinical effect, but the surgeries are complicated. Regardless, PHF treatment has greatly improved in recent years with continuous developments and improvements to internal fixation. For example, a proximal humeral anatomical locking plate and a new type of intramedullary needle have been introduced. Open reduction and plate fixation⁶ is the most traditional and accurate surgical method to restore the original calcaneal structure. Thus, it is often the first choice for clinicians and patients. However, clinical case reviews have provided doctors with a deeper understanding of the surgical treatments, and medical devices have developed accordingly.

The degree of postoperative adverse reactions differs among the surgical methods. For example, open reduction and plate fixation have long operation times, considerable interoperative blood loss, and skin tissue necrosis and infection during the healing process. Therefore, less traumatic orthopedic surgeries with faster recovery are a superior choice.⁷ One such method is fracture reduction and internal fixation,^8,9 which is less traumatic and has a faster recovery time, fewer complications, and lower medical costs than open reduction and plate fixation. However, for PHFs with comminuted fracture and obvious displacement, exposure, reduction, and fixation of the fracture site is more difficult owing to the anatomical characteristics of the proximal humerus. This is especially true for those with less experience managing this kind of fracture, making it challenging to achieve good fracture reduction and fixation. Poor fracture reduction and fixation, especially of large and small nodule bone blocks as the rotator cuff attachment point, considerably negatively affect the surgical outcome.

Systematic comparative studies exploring newer technologies have always lacked. Therefore, we compared two types of complex PHF treatments, namely intramedullary nail fixation and plate internal fixation, to evaluate their therapeutic effects.

2. Patients and Methods

2.1. Patient selection

We included 60 patients with complex PHFs admitted to the People’s Hospital of Zhongjiang County, China, from May 2016 to May 2017. Patients with confirmed complex PHFs by computed tomography or X-ray examination were included and randomly divided into group A (intramedullary nail fixation) or group B (plate internal fixation). The patients and their families were informed of the study and signed a letter of understanding. Furthermore, the research proposal and study design were approved by the ethical review committee of the People’s Hospital of Zhongjiang County.

2.2. Surgical methods

2.2.1. Preoperative measures

The patients underwent preoperative laboratory, heart function, and lung function examinations. Furthermore, the injured limb was immobilized in a forearm sling with an ice bag cold compress in all cases. The patients were advised on their permitted activities before the operation based on the injury. Furthermore, patients with hypertension or diabetes were prescribed antihypertensive or insulin-regulating medication to control blood pressure or blood sugar, respectively, to ensure the patient’s physical status met the surgical requirements.

2.2.2. Intramedullary nail fixation (group A)

Patients in group A were treated with intramedullary nail fixation. Under general anesthesia, the patient was placed in the beach chair surgical position. The anterolateral acromial approach was used to cut the skin, subcutaneous tissue, fascia, then the deltoid muscle while protecting the axillary nerve; the proximal humerus was completely exposed. The long head tendon of the biceps brachii and the intertubercular sulcus were closed and reduced under fluoroscopy using the C-arm X-ray machine, and the distal and proximal locking nails were placed in order. High-strength sutures were used to fix the large and small nodules, and then fluoroscopy was used to determine where the fracture ended and the internal fixation position. Next, the rotator cuff tissue was cut open, rinsed, and repaired. Finally, the deltoid muscle was repaired, and the initial incision was sutured.

2.2.3. Plate internal fixation (group B)

Patients in group B were treated with plate internal fixation. Under general anesthesia, the patient was placed in the beach chair surgical position. The deltopectoral approach was used to cut the skin, subcutaneous tissue, and fascia while protecting the cephalic vein; the proximal humerus was completely exposed. The large and small nodules were sutured through the rotator cuff as a traction thread, and the proximal humerus was reset and temporarily fixed with Kirschner wire. The anatomical locking plate for the proximal humerus was placed outside the intertubercular sulcus, and then the screw was screwed in for fixation. At the same time, the Kirschner wire was removed. Next, the large and small nodule sutures were threaded through the steel plate hole, knotted, and fixed. C-arm X-ray fluoroscopy was used to determine where the fracture ended and the internal fixation position. After flushing the area, the initial incision was sutured.

2.3. Outcome measures

The surgical outcomes were scored using Neer’s scoring system six weeks after surgery.^3,4 The maximum outcome score is 100 points: 90–100-point scores are excellent, 80–89-point scores are good, 70–79-point scores are acceptable, and less than 78-point scores are poor. Furthermore, we calculated the “excellent rate” using the following equation: Excellent rate = (excellent + good + acceptable) × 100.0%. The patient’s pain was also scored based on the following point system: no pain: 0 points, slight pain: 1–3 points, moderate pain: 4–6 points, and severe pain: 7–10 points.

2.4. Statistical analyses

All study data were input into Excel (Microsoft Corporation, Redmond, WA, USA) by the same person, then verified by another to ensure accuracy. All statistical analyses based on the Excel data were performed using SPSS version 19.0 (IBM Corp., Armonk, NY, USA). Counting data in the variables were expressed as% by $x^2$ test. A $P$-value of $<0.05$ was considered statistically significant.

3. Results

3.1. Patient demographics

Group A included 30 patients (17 men and 13 women) with an average age of $60\pm 5.1$ (range: 48–72) years. Group B included 30 patients (16 men and 14 women) with an average age of $59\pm 4.8$ (range: 46–72) years. The basic demographic data did not differ between the groups ($P>0.05$).

3.2. Postoperative outcomes

Table 1 details the surgical outcomes.^6,10 Groups A and B had acceptability ratios of 80.0% and 93.3%, respectively; the ratios did not differ between the groups ($P>0.05$).

3.3. Pain scores

Table 2 presents the pain outcomes. Overall, 56.7% and 50% of the patients in groups A and B were pain-free, respectively; the pain scores did not differ between the groups ($P>0.05$).

4. Discussion

Humeral fractures are common, especially among women over 60 years, and usually involve the large and small nodules, humeral head, and anatomical neck. The proximal humerus is located where cancellous bone transitions to dense bone. Thus, it is anatomically weak, making it a frequent fracture site.⁵ Approximately 4–5% of patients with systemic fractures suffer from humeral fractures, which are usually treated surgically. The main surgical methods include conventional open reduction and plate fixation, internal fixation, artificial replacement, and closed reduction combined with percutaneous needle fixation, some of which have good clinical outcomes but are complex surgeries.

This study compared the surgical outcomes of two techniques to repair complex PHFs using Neer’s scoring system: intramedullary nail fixation and plate internal fixation. The outcome acceptability ratio was 80.0% for intramedullary nail fixation and 93.3% for plate internal fixation ($P>0.05$). Moreover, 56.7% and 50% of patients were pain-free after healing from the intramedullary nail fixation and plate internal fixation procedures, respectively ($P>0.05$).

4.1. Limitations and future directions

The small number of cases limited this study. Limited medical resources in the primary hospitals and the small number of cases due to coronavirus disease (2019) prevented us from including more patients. Therefore, to verify our results, we plan to continue collecting data for relevant cases and strive to achieve a case-control analysis of more than 300 patients. We also performed physical rehabilitation analyses (data not reported), finding differences in the rehabilitation effects based on occupation and physical qualities. Therefore, our future study will focus on this aspect related to these surgical procedures.

5. Conclusion

Intramedullary nail fixation and plate internal fixation for complex PHFs have good and comparable outcomes. However, in practice, surgeons should select the most suitable treatment method based on the patient’s actual fracture to ensure the best postsurgical outcome with the least amount of pain.

Acknowledgments

This work is supported by the Foundation of Ph.D. Scientific Research of Neijiang Normal University under grant No. 18B19, the Sichuan applied psychology research center of Chengdu Medical College Funded Projects under grant No. CSXL-21103 and the Innovative Team Program of the Neijiang Normal University under grant No. 2021TD02.