Abstract
Percutaneous fixation offers many advantages (low risk of avascular necrosis, fibrosis and stiffness, improved cosmesis, low costs). However, it has been criticized because of the risk of pin migration, the loss of reduction and pin-site infection, a quite long learning curve, and a revision rate around 10 %. With the aim of reducing these complications, we use pins with a longer thread, to engage both the lateral cortex and the subchondral bone, and we stabilize the pins with an external fixator (the so-called hybrid technique) to increase the resistance to pullout and to reduce the importance of pin configuration in implant stability. The patient resting position depends on whether closed reduction (supine position) or open reduction (beach-chair position) is going to be performed. In the case of a two-fragment fracture, we use four retrograde pins; in three- and four-fragment fractures, two more antegrade pins are needed. We believe the majority of fractures can be treated with pins: in fact, in cases of complex fractures, the surgeon can perform an open reduction followed by percutaneous fixation. Percutaneous pinning is contraindicated in cases of fractures without a good lateral cortex, splitting of the humeral head, and highly comminuted tuberosities. The great advantage of this technique over other surgical treatments is the complete absence of hardware around the shoulder after the treatment has been completed.
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References
Bohler J (1962) Percutane osteosynthese mit dem rontgenbildverstarker. Wien Klin Wochenschr 74:485–487
Hawkins RJ, Kiefer GN (1987) Internal fixation techniques for proximal humeral fractures. Clin Orthop Relat Res 223:77–85
Angehrn F, Schultheiss HR (1986) Percutaneous drill wire osteosynthesis of fractures of the proximal humerus. Z Unfallchir Versicherungsmed Berufskr 79:155–160
Hagg O, Lundberg B (1984) Aspects of prognostic factors in comminuted and dislocated proximal humerus fractures. In: Bateman JE, Welsh PR (eds) Surgery of the shoulder. BC Decker, Philadelphia
Kristiansen B, Kofoed H (1988) Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. A controlled clinical trial. J Bone Joint Surg Br 70:821–824
Kristiansen B, Barfod G, Bredesen J et al (1987) Epidemiology of proximal humeral fractures. Acta Orthop Scand 58:75–77
Neer CS II (1984) Fractures about the shoulder. In: Rockwood CA Jr, Green DP (eds) Fractures in adults, vol I, 2nd edn, Neer CS II. JB Lippincott, Philadelphia
Court-Brown CM, Garg A, McQueen MM (2001) The epidemiology of proximal humeral fractures. Acta Orthop Scand 72:365–371
Harrison AK, Gruson KI, Zmistowski B et al (2012) Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am 94:1223–1228
Monga P, Verma R, Sharma VK (2009) Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong) 17:142–145
Chen CY, Chao EK, Tu YK, Ueng SW, Shih CH (1998) Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma 45:1039–1045
Jaberg H, Warner JJ, Jakob RP (1992) Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am 74:508–515
Misra A, Kapur R, Maffulli N (2001) Complex proximal humeral fractures in adults – a systematic review of management. Injury 32:363–372
Neer CS (1970) Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 52:1077–1089
Resch H, Povacz P, Fröhlich R, Wambacher M (1997) Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 79:295–300
Bogner R, Hübner C, Matis N, Auffarth A, Lederer S, Resch H (2008) Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients. J Bone Joint Surg Br 90:1602–1607
Cuny C, Scarlat MM, Irrazi M et al (2008) The Telegraph nail for proximal humeral fractures: a prospective four-year study. J Shoulder Elbow Surg 17:539–545
Frangen TM, Müller EJ, Dudda M, Arens S, Muhr G, Kälicke T (2007) Proximal humeral fractures in geriatric patients. Is the angle-stable plate osteosynthesis really a breakthrough? Acta Orthop Belg 73:571–579
Herscovici D, Saunders DT, Johnson MP, Sanders R, DiPasquale T (2000) Percutaneous fixation of proximal humeral fractures. Clin Orthop Relat Res 375:97–104
Qidwai SA (2001) Treatment of proximal humeral fractures by intramedullary Kirschner wires. J Trauma 50:1090–1095
Smith AM, Mardones RM, Sperling JW, Cofield RH (2007) Early complications of operatively treated proximal humeral fractures. J Shoulder Elbow Surg 16:14–24
Greiner S, Kääb MJ, Haas NP, Bail HJ (2009) Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury 40:186–191
Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P (2009) Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg 18:837–844
Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF (2010) Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 19:489–494
Südkamp N, Bayer J, Hepp P et al (2009) Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 91:1320–1328
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S (1992) The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am 74:491–500
Boileau P, Walch G (1997) The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br 79:857–865
Harrold F, Wigderowitz C (2012) A three-dimensional analysis of humeral head retroversion. J Shoulder Elbow Surg 21:612–617
Rowles DJ, McGrory JE (2001) Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am 83-A:1695–1699
Burkhead WZ, Scheinberg RR, Box G (1992) Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1:31–36
Kamineni S, Ankem H, Sanghavi S (2004) Anatomical considerations for percutaneous proximal humeral fracture fixation. Injury 35:1133–1136
Burkhart SS, Nassar J, Schenck RC, Wirth MA (1996) Clinical and anatomic considerations in the use of a new anterior inferior subaxillary nerve arthroscopy portal. Arthroscopy 12:634–637
Resch H, Hübner C, Schwaiger R (2001) Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head. Injury 32(Suppl 1):SA25–SA32
Calvo E, de Miguel I, de la Cruz JJ, López-MartÃn N (2007) Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results. J Shoulder Elbow Surg 16:774–781
Kocialkowski A, Wallace WA (1990) Closed percutaneous K-wire stabilization for displaced fractures of the surgical neck of the humerus. Injury 21:209–212
Yu Z, Zheng L, Wang Y, Zhang Y, Zhang X, Ma B (2010) Functional and radiological evaluations of unstable displaced proximal humeral fractures treated with closed reduction and percutaneous pinning fixation. Eur Surg Res 45:138–145
Koval KJ, Blair B, Takei R, Kummer FJ, Zuckerman JD (1996) Surgical neck fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques. J Trauma 40:778–783
Wheeler DL, Colville MR (1997) Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation. J Orthop Trauma 11:363–367
Swiontkowski MF, Harrington RM, Keller TS, Van Patten PK (1987) Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res 5:433–444
Lill H, Hepp P, Korner J et al (2003) Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens. Arch Orthop Trauma Surg 123:74–81
Williams GR, Wong KL (2000) Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. Orthop Clin North Am 31:1–21
Soete PJ, Clayson PE, Costenoble VH (1999) Transitory percutaneous pinning in fractures of the proximal humerus. J Shoulder Elbow Surg 8:569–573
Fenichel I, Oran A, Burstein G, Perry Pritsch M (2006) Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus: a retrospective study. Int Orthop 30:153–157
Aschauer E, Resch H, Hübner C (2007) Percutaneous osteosynthesis of humeral head fractures. Oper Orthop Traumatol 19:276–293
Brunner A, Weller K, Thormann S, Jöckel JA, Babst R (2010) Closed reduction and minimally invasive percutaneous fixation of proximal humerus fractures using the Humerusblock. J Orthop Trauma 24:407–413
Jöckel JA, Brunner A, Thormann S, Babst R (2010) Elastic stabilisation of proximal humeral fractures with a new percutaneous angular stable fixation device (ButtonFix(®)): a preliminary report. Arch Orthop Trauma Surg 130:1397–1403
Brunner A, Resch H, Babst R et al (2012) The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation. Arch Orthop Trauma Surg 132:985–992
Jiang C, Zhu Y, Wang M, Rong G (2007) Biomechanical comparison of different pin configurations during percutaneous pinning for the treatment of proximal humeral fractures. J Shoulder Elbow Surg 16:235–239
Naidu SH, Bixler B, Capo JT, Moulton MJ, Radin A (1997) Percutaneous pinning of proximal humerus fractures: a biomechanical study. Orthopedics 20:1073–1076
Kralinger F, Gschwentner M, Wambacher M, Smekal V, Haid C (2008) Proximal humeral fractures: what is semi-rigid? Biomechanical properties of semi-rigid implants, a biomechanical cadaver based evaluation. Arch Orthop Trauma Surg 128:205–210
Castoldi F, Bonasia DE, Blonna D et al (2010) The stability of percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am 92(Suppl 2):90–97
Magovern B, Ramsey ML (2008) Percutaneous fixation of proximal humerus fractures. Orthop Clin North Am 39:405–416
Clifford PC (1980) Fractures of the neck of the humerus: a review of the late results. Injury 12:91–95
Roberts VI, Komarasamy B, Pandey R (2012) Modification of the Resch procedure: a new technique and its results in managing three- and four-part proximal humeral fractures. J Bone Joint Surg Br 94:1409–1413
Stableforth PG (1984) Four-part fractures of the neck of the humerus. J Bone Joint Surg Br 66:104–108
Svend-Hansen H (1974) Displaced proximal humeral fractures. A review of 49 patients. Acta Orthop Scand 45:359–364
Keener JD, Parsons BO, Flatow EL, Rogers K, Williams GR, Galatz LM (2007) Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg 16:330–338
Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R (1991) Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 73:295–298
Resch H, Beck E, Bayley I (1995) Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg 4:73–80
Robinson CM, Page RS (2003) Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am 85-A:1647–1655
Carbone S, Tangari M, Gumina S, Postacchini R, Campi A, Postacchini F (2012) Percutaneous pinning of three- or four-part fractures of the proximal humerus in elderly patients in poor general condition: MIROS® versus traditional pinning. Int Orthop 36:1267–1273
Hertel R (2005) Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 16(Suppl 2):S65–S72
Bastian JD, Hertel R (2008) Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg 17:2–8
Zhang J, Ebraheim N, Lause GE (2012) Surgical treatment of proximal humeral fracture with external fixator. J Shoulder Elbow Surg 21:882–886
Kristiansen B (1989) Treatment of displaced fractures of the proximal humerus: transcutaneous reduction and Hoffmann’s external fixation. Injury 20:195–199
Ebraheim NA, Patil V, Husain A (2007) Mini-external fixation of two- and three-part proximal humerus fractures. Acta Orthop Belg 73:437–442
Seyhan M, Kocaoglu B, Nalbantoglu U, Aydin N, Guven O (2012) Technique of Kirschner wire reduction and fixation of displaced two-part valgus angulated proximal humerus fractures at the surgical neck. J Orthop Trauma 26:e46–e50
Kristiansen B, Kofoed H (1987) External fixation of displaced fractures of the proximal humerus. Technique and preliminary results. J Bone Joint Surg Br 69:643–646
Kristiansen B (1987) External fixation of proximal humerus fracture. Clinical and cadaver study of pinning technique. Acta Orthop Scand 58:645–648
Martin C, Guillen M, Lopez G (2006) Treatment of 2- and 3-part fractures of the proximal humerus using external fixation: a retrospective evaluation of 62 patients. Acta Orthop 77:275–278
Blonna D, Castoldi F, Scelsi M, Rossi R, Falcone G, Assom M (2010) The hybrid technique: potential reduction in complications related to pins mobilization in the treatment of proximal humeral fractures. J Shoulder Elbow Surg 19:1218–1229
Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ (2006) Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg 15:675–678
Handoll HH, Ollivere BJ, Rollins KE (2012) Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev (12):CD000434
Mazet R Jr (1943) Migration of a Kirschner wire from the shoulder region into the lung – report of two cases. J Boint Joint Surg Am 25:477–483
Blonna D, Rossi R, Fantino G, Maiello A, Assom M, Castoldi F (2009) The impacted varus (A2.2) proximal humeral fracture in elderly patients: is minimal fixation justified? A case control study. J Shoulder Elbow Surg 18:545–552
Glauser F, Kremens V (1956) Unusual sequela following pinning of medial clavicular fracture. Am J Roentgenol Radium Ther Nucl Med 76:1066–1069
Tristan TA, Daughtridge TG (1964) Migration of a metallic pin from the humerus into the lung. N Engl J Med 270:987–989
Lyons FA, Rockwood CA (1990) Migration of pins used in operations on the shoulder. J Bone Joint Surg Am 72:1262–1267
Freund E, Nachman R, Gips H, Hiss J (2007) Migration of a Kirschner wire used in the fixation of a subcapital humeral fracture, causing cardiac tamponade: case report and review of literature. Am J Forensic Med Pathol 28:155–156
Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 13:427–433
Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK (2002) Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 84-A:1919–1925
Gerber C, Hersche O, Berberat C (1998) The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg 7:586–590
Shabtai L, Dolkart O, Chechik O et al (2013) Incidence and severity of infections after closed reduction and external fixation of proximal humeral fractures. J Orthop Trauma 27:e81–e86
Blonna D, Barbasetti N, Banche G, Cuffini AM, Bellato E, Massè A, Marenco S, Battiston B, Castoldi F (2014) Incidence and risk factors for acute infection after proximal humeral fractures: a multicenter study. J Shoulder Elbow Surg 23(4):528–35
Kralinger F, Irenberger A, Lechner C, Wambacher M, Golser K, Sperner G (2006) Comparison of open versus percutaneous treatment for humeral head fracture. Unfallchirurg 109:406–410
Bellato E, Scelsi M, Marini E, Mortera S, Marenco S, Blonna D, Assom M, Castoldi F (2011) Protesi versus sintesi nelle fratture complesse del terzo prossimale d’omero. Minerva Ortop Traumatol 62:19–27
Murray IR, Amin AK, White TO, Robinson CM (2011) Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Joint Surg Br 93:1–11
Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20:1025–1033
Moonot P, Ashwood N, Hamlet M (2007) Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Br 89:1206–1209
Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R (2005) A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 430:176–181
Ricchetti ET, Warrender WJ, Abboud JA (2010) Use of locking plates in the treatment of proximal humerus fractures. J Shoulder Elbow Surg 19:66–75
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. J Shoulder Elbow Surg 22:542–549
Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20:747–755
Zyto K, Ahrengart L, Sperber A, Törnkvist H (1997) Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br 79:412–417
Fjalestad T, Hole M, Hovden IA, Blücher J, Strømsøe K (2012) Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 26:98–106
Sanders RJ, Thissen LG, Teepen JC, van Kampen A, Jaarsma RL (2011) Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. J Shoulder Elbow Surg 20:1118–1124
Solberg BD, Moon CN, Franco DP, Paiement GD (2009) Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma 23:113–119
Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S (2012) Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury 43:153–158
Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS (2011) Predicting failure after surgical fixation of proximal humerus fractures. Injury 42:1283–1288
Darder A, Sanchis V, Gastaldi E, Gomar F (1993) Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band. J Orthop Trauma 7:497–505
Neer CS (1970) Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 52:1090–1103
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Assom, M., Bellato, E. (2015). Percutaneous Fixation: When and How. In: Castoldi, F., Blonna, D., Assom, M. (eds) Simple and Complex Fractures of the Humerus. Springer, Milano. https://doi.org/10.1007/978-88-470-5307-6_6
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