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Injury, Int. J.

Care Injured 32 (2001) 115 121


www.elsevier.com/locate/injury

The results of internal fixation of three- and four-part proximal


humeral fractures with the Polarus nail
A.O. Adedapo, J.O. Ikpeme *
Department of Trauma and Orthopaedic Surgery, Harrogate District Hospital, Lancaster Park Road, Harrogate, HG2 7SX, UK

Accepted 15 July 2000

Abstract

Twenty-three patients with acute displaced three- and four-part fractures of the proximal humerus, including seven patients with
associated shaft involvement, were treated with the Polarus intramedullary interlocking nail using a closed technique.
At the 1-year follow up, the median Neer scores were 89 and 60 for the three- and four-part fractures, respectively.
Three patients (13%), all of whom were in the four-part group, continued to have significant pain at final review.
We found the implant to be extremely satisfactory and particularly useful in the treatment of combined neck and shaft fractures
of the humerus. 2001 Elsevier Science Ltd. All rights reserved.

1. Introduction the current trend for displaced three- and especially


four-part fractures. Conflicting results have been re-
Proximal humeral fractures remain a difficult man- ported for this method [3,4].
agement problem, even with the advent of modern The different outcomes in the various papers on the
internal fixation devices. The reported incidence of treatment of these injuries arise from the difficulty in
these fractures varies from 48 to 142 per thousand of selection of patients for surgery, the poor inter- and
the population in some series. [1,2]. These studies also intra-observer reliability in fracture classification and
documented an exponential increase in the fracture the clinical variability of the patients that are subjected
incidence from the fifth decade, with the female exceed- to surgery. Thus, the quest continues for answers to this
ing the male by a ratio of over two to one and predict most difficult fracture.
a rise in the number of these fractures because of the We report the results of our pilot study on the
increasing age of the population. The economic conse- treatment of these fractures and in particular, those
quences of these fractures are often underestimated, combined with humeral shaft fractures, using the Po-
especially in the elderly. The injuries often make the larus intramedullary nails (Acumed Inc. of Oregon,
patients dependent partially or wholly on others for distributed by Ostek Ltd., Andover, Hampshire, UK).
their activities of daily living. The subsequent effects of
this on the social services and health care budget are
obviously serious. 2. Patients and methods
There have been numerous attempts to improve the
outcome of these fractures by using different forms of 2.1. Description of nail
internal fixation. These have ranged from wires to
plates and screws in various combinations and the The Polarus nail is a standard 150 mm cannulated
results have been far from satisfactory. The use of and tapered device with four 5-mm proximal and two
prostheses to replace the humeral head appears to be distal interlocking holes (Fig. 1). It is designed for
fractures that are confined to the proximal humerus.
* Corresponding author. Present address: 4 Hookstone Oval, Har-
The Polarus Plus is a longer device with various lengths
rogate, HG2 8QE, UK. of 200, 220, 240 and 260 mm and is designed for
E-mail address: jikpeme@bigfoot.com (J.O. Ikpeme). proximal fractures that also involve the shaft.

0020-1383/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 1 5 4 - 6
116 A.O. Adedapo, J.O. Ikpeme / Injury, Int. J. Care Injured 32 (2001) 115121

2.2. Study group The study also contained patients with combined
neck and shaft fractures; that is, a combined AO 11 and
Thirty-four patients admitted to the trauma service AO 12 fractures. There were no anatomical neck or
of Harrogate District Hospital between March 1997 intra-articular fractures, (Neer Group II; AO 11-C) and
and February 1999 with displaced fractures of the no isolated greater tuberosity fractures (AO 11-A1).
proximal humerus as described by Neer [5] were treated The Polarus Plus nail was used for proximal fractures
with the Polarus intramedullary nail. combined with shaft fractures. There were two kinds of
One patient was excluded from the final results as he these complex types, namely, a neck fracture combined
had severe dementia and could neither respond to with a metaphyseal and diaphyseal fracture in continu-
questions nor co-operate with the physical examination. ity and a neck fracture with a completely separate
Five patients had pathological fractures and were ex- diaphyseal fracture.
cluded from the final analysis. Five other patients, two
with two-part fractures, were excluded, as their follow
up was B 1 year. 2.4. Operati6e technique

The senior surgeon (JOI) performed all operations


2.3. Fracture types under general anaesthesia with the affected shoulder
elevated on a sandbag and the arm on a side table. The
These patients belonged to Neer Groups III, IV and fractures were manipulated and a satisfactory reduction
V and consisted of two-, three- and four-part fractures. confirmed by image intensifier. Using an antegrade
These corresponded to AO 11-A3, B1, B2 and B3. It approach through a 1-cm stab incision just medial to
was sometimes very difficult to estimate the number of the greater tuberosity, the humeral canal was reamed
segments involved when using only conventional radio- and a short Polarus nail inserted into the medullary
graphs. The use of computerized tomography proved cavity for fractures confined to the neck (Fig. 2a,b.).
beneficial in a few cases. Proximal locking was performed via drill sleeves with
5-mm cancellous screws into the humeral head. The
position of each screw is determined by the position of
the reduced fragments in a multi-directional pattern to
ensure firm fixation. Cortical screws for distal locking
for the Polarus nail were inserted into the upper shaft
via targeting sleeves using cortical screws. Distal lock-
ing for the Polarus Plus nail was by the free-hand
method under image intensifier control, with 3.5 mm
cortical screws into the distal humerus (Fig. 3a,b).

2.5. After-care

Mobilization of the limb was started soon after re-


covery from anaesthesia within the confines of a broad
arm sling. All patients were referred for physiotherapy
at the 3-week appointment after sutures were removed.
They were followed up at 3 and 6 weeks, 3 and 6
months and 1 year after surgery. Radiographs of the
humerus were taken at each visit to assess union and
implant complications.

2.6. Methods of assessment

At the 1-year follow up, we assessed the patients


shoulder function using the criteria of pain, range of
motion and power in the shoulder. The Neer [5] and
Constant Murley [28] shoulder scoring systems were
Fig. 1. The Polarus jig assembly showing the template location and
used in the final assessment. The radiographs were also
position for the different sleeves. (Illustration by kind permission of assessed for evidence of union and of implant or frac-
Ostek Ltd.). ture complications.
A.O. Adedapo, J.O. Ikpeme / Injury, Int. J. Care Injured 32 (2001) 115121 117

Fig. 2. (a) Comminuted proximal fracture of the humerus. (b) Post-operative position after fixation with a Polarus nail.

3. Results relief and another third had some mild discomfort at


follow-up. Only three out of 23 (13%) patients were
Twenty-three patients were available for the final incapacitated by shoulder pain at 1 year (Table 2).
review. There were ten patients (43.5%) with three-part
fractures, six (26.1%) with four-part fractures and seven 3.1. Range of mo6ement
(30.4%) with three- or four-part fractures combined
with shaft fractures. The range of motion after 1 year for three-part
The average age of all patients was 68.7 years (range: fractures had, in 95% of cases, returned to normal in all
27 100). Patients with three-part fractures were aged directions. The four-part fractures with or without shaft
61.6 years (range: 27 90); patients with four-part frac- involvement had less motion than the three-part group,
tures were aged 76.3 years (range: 60 100); and pa- although the overall range of flexion and abduction of
tients with three- or four-part with shaft involvement between 80 and 170 suggested a good functional range.
were aged 74 years (range: 39 99) (Table 1). Fifty The range of internal and external rotation gained was,
percent of all patients had complete pain relief and of however, only half of that achieved by the three-part
these, half had three-part fractures. No one with a fracture group (Table 3).
three-part fracture was left with severe or disabling
pain. It is interesting to note that four out of seven 3.2. Neer score
( \ 50%) patients with three- or four-part fractures with
shaft involvement obtained complete pain relief, while The functional results were very good for the three-
only a third of the four-part group had complete pain part fractures with a median Neer score of 89 (range:
118 A.O. Adedapo, J.O. Ikpeme / Injury, Int. J. Care Injured 32 (2001) 115121

Fig. 3. (a) A complex three-part fracture with a combined shaft involvement. (b) Position after closed nailing with a Polarus Plus nail.

33 100). Similar scores for the four-part and the three- 4. Discussion
and four-part fractures with shaft involvement, were 60
(range: 4187) and 73 (range: 31 91), respectively, The natural history following a three- and four-part
reflecting the greater severity of this injury. All patients, displaced proximal humeral fracture is reasonably well
except one in the three-part group, could perform their documented. Rasmussen et al. [6] studied 42 patients
activities of daily living independently. Two patients with proximal humeral fractures at a median follow-up
each in the other two groups found combing their hair of 2 years. All patients were treated non-operatively
difficult (Table 4). and the Neer protocol, based on the number of fracture
fragments and their degree of separation, was used to
3.3. Complications evaluate the results.
Two-, three- and four-part fractures had respectively
The complications we noticed in our series consisted reducing Neer scores, but the patients satisfaction eval-
of proximal screw loosening and extrusion that caused
uation was better than the score would indicate. Other
pain in three patients. This finding was unexpected
investigators [79] also appeared to suggest a satisfac-
because the deep cancellous screws were thought to be
tory outcome for these fractures. Unfortunately, these
ideal for the cancellous humeral head as opposed to a
similar problem that was found with the cortical screws Table 1
used in the Russell Taylor humeral nail system [26]. Age distribution of patients
These loose screws were removed with complete relief
of symptoms. One patient had avascular necrosis and Type of fracture Mean Median Range
collapse of the humeral head that led to nail protrusion
Three-part 61.6 64 2790
and sub-acromial impingement. The entire device was
Four-part 76.3 80 60100
removed, a procedure that proved to be extremely Three- and four-part with shaft 74 81 3999
traumatic because any cancellous screw head that was fracture
over-grown with bone was difficult to locate.
A.O. Adedapo, J.O. Ikpeme / Injury, Int. J. Care Injured 32 (2001) 115121 119

Table 2
Level of pain at 1-year

Pain level Three-part fracture Four-part fracture Three- and four-part plus shaft fracture Total

None/slight 6 2 4 12
Mild 3 2 0 5
Moderate 1 0 2 3
Severe 0 2 1 3
Total 10 6 7 23

Table 3
Range of shoulder movement in degrees at 1 yeara

Three-part fracture Four-part fracture Three- and four-part and shaft fracture

Flexion 170 (80170) 100 (80170) 115 (80170)


Abduction 155 (80170) 120 (100180) 90 (80170)
Internal rotation 90 (3090) 50 (3070) 40 (3090)
External rotation 60 (1060) 30 (1060) 30 (1060)
Extension 45 (1545) 30 (1545) 40 (1545)

a
Median and (range in brackets).

Table 4
Functional score at 1 year

Three-part fracture Four-part fracture Three- and four-part and shaft fracture

Neer score
Mean 83.6 62.5 69.14
Median 89 60 73
Range 33100 4187 3691
Constant score
Mean 88.4 67 69
Median 91.5 67 71
Range 40100 5091 4094

and other similar studies suffer from the twin problems wiring with non-operative treatment found no signifi-
of lack of uniform system of evaluating outcome and cant difference in outcome at 1, 3 and 5 years. The
inadequate separation of the different fracture patterns Constance Murley score at the 5-year review of 60919
when presenting and analyzing the results. in surgically and 659 15 in non-surgically treated pa-
Recent studies have questioned the reliability and tients did not improve after 1 year. Surgery improved
reproducibility of the Neer classification [10 13]. The the position of the fracture at union but not necessarily
addition of more complicated modalities, e.g. computer- the function [17]. Retrospective studies by other workers
ized tomography, was associated with a slight increase reached a similar conclusion [18].
in inter/intra observer reliability but not reproducibility Esser [27] recommended the use of open reduction
[14,15]. However, this classification continues to be used, and internal fixation with AO T-plates or cloverleaf
as there is, at this time, no other that has proved to be plates as an initial treatment for three- and four-part
more useful. fractures, but this method is unsatisfactory where there
There is uniformity of agreement on the satisfactory is osteoporosis and has a complication rate of :40%
outcome for undisplaced fractures with non-operative [19,20].
treatment. The difficulty arises in the osteoporotic bones Hemiarthroplasty has become a common method of
in the elderly and with displaced three- and four-part treatment for displaced four-part fractures in the elderly.
fractures. Closed manipulation almost invariably fails as Goldman [4], in a series of 23 patients and Moeckel et
the fracture almost always displaces again [7,9,16]. al. [21] using a bipolar prosthesis on a group of 22
There are many methods of fixation of these fractures. patients obtained pain relief in 73 and 90% of cases,
The most common has been tension band wiring. A respectively. Function and range of motion were far less
randomised controlled trial comparing tension band predictable than pain relief.
120 A.O. Adedapo, J.O. Ikpeme / Injury, Int. J. Care Injured 32 (2001) 115121

Wrentberg et al. [22], reporting on 18 patients at an suffering in patients who have often been treated in
average follow up of 3.5 years, mentioned 11 patients as slings or collar and cuff or undergone major open
being pain free but with a poorer range of motion surgery. It has enabled the old, a group in which this
compared with the other studies quoted above. type of injury is common, to resume earlier joint move-
Zyto and Wallace [3], in their series of 27 patients, ment and return to independent existence. The possibil-
quoted a median Constant score at follow up of 51 for ity of stabilising combined neck and shaft fractures
the three-part fractures and 46 for the four-part frac- with the Polarus Plus nail is a major step forward in the
tures following hemiarthroplasty. Eight patients contin- treatment of this injury.
ued to have moderate to severe pain and disability.
Hartsock et al. [23] reported an overall complication
rate of up to 35% in some hemiarthroplasty series and Acknowledgements
suggested a marginal improvement in the results with
earlier surgery, but with up to 22% needing additional The authors wish to thank R.J. Newman, Consultant
operations. Orthopaedic Surgeon, Harrogate District Hospital for
We have found very little in the literature that looks recommending the trial and use of the Polarus nail in
specifically at the usefulness of a locked intramedullary our trauma unit and also Bob Cradduck, Managing
device in the management of these fractures and noth- Director, Ostek Ltd., for permission to use Fig. 1 as an
ing that addressed the problem of combined neck and illustration.
shaft fractures. Lin [24] reported on 21 nailed proximal
humeral fractures. These were a heterogeneous group
of patients varying from two- to four-part and patho-
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