w w w . r b o . o r g . b r
Review
Article
Impacted
valgus
fractures
of
the
proximal
humerus
夽
Fabiano
Rebouc¸as
Ribeiro
∗,
Fernando
Hovaguim
Takesian,
Luiz
Eduardo
Pimentel
Bezerra,
Rômulo
Brasil
Filho,
Antonio
Carlos
Tenor
Júnior,
Miguel
Pereira
da
Costa
HospitaldoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil
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Articlehistory:
Received24January2015
Accepted30March2015
Availableonline2February2016
Keywords:
Humeralfractures
Shoulderfractures/classification
Fracturefixation
Humeralhead/surgery
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Impactedvalgusfracturesoftheproximalhumerusareconsideredtobeaspecialtype
fracture, sinceimpactionofthehumeralheadonthemetaphysiswith maintenanceof
theposteromedialperiosteumimprovestheprognosisregardingoccurrencesofavascular
necrosis.Thischaracteristiccanalsofacilitatethereductionmaneuverandincreasethe
consolidationrateofthesefractures,eveninmorecomplexcases.Thestudiesincluded
wereobtainedbysearchingtheBireme,Medline, PubMed,CochraneLibrary andGoogle
Scholardatabasesforthosepublishedbetween1991and2013.Theobjectiveofthisstudy
wastoidentifythemostcommondefinitions,classificationsandtreatmentmethodsused
forthesefracturesintheorthopedicmedicalliterature.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
Fratura
impactada
em
valgo
do
úmero
proximal
Palavras-chave:
Fraturasdoúmero
Fraturasdoombro/classificac¸ão
Fixac¸ãodefratura
Cabec¸adoúmero/cirurgia
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e
s
u
m
o
A fraturaimpactada em valgo doúmero proximal é considerada um tipoespecial de
fratura,poisaimpactac¸ãometafisáriada cabec¸aumeral,commanutenc¸ãodoperiósteo
póstero-medial,melhoraseuprognósticoquantoàocorrênciadenecroseavascular.Essa
car-acterísticapode,ainda,facilitaramanobradereduc¸ãoeaumentaroíndicedeconsolidac¸ão
dessasfraturas,mesmonoscasosmaiscomplexos.Osestudosincluídosforampesquisados
nasbasesdedadosBireme,Medline,PubMed,CochraneLibraryeGoogleScholarpublicados
de1991a2013.Oobjetivodesteestudofoiidentificaradefinic¸ão,classificac¸ãoeosmétodos
detratamentodessasfraturasmaisusadosnaliteraturamédicaortopédica.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora
Ltda.Todososdireitosreservados.
夽
WorkperformedintheShoulderandElbowGroup,HospitaldoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:fabianoreboucas@globo.com(F.R.Ribeiro).
http://dx.doi.org/10.1016/j.rboe.2016.01.004
Thesefractureshavereceivedattentionthatdifferentiates
themfromothercomplexfracturesoftheproximalhumerus,
becauseoftheirbetterprognosiswithregardtosurgical
reduc-tion,consolidationandoccurrencesofavascularnecrosis.1–14
Themechanismforthesefracturesconsistsofaxialtrauma
tothe abductedupperlimb,withdirectimpactionbetween
the humeral head and the glenoid cavity, and consequent
impactionandposteromedialdisplacement(dorsaltiltingof
thehead)becauseofitsphysiologicalanatomical
conforma-tioninretroversion.1,2,8,10,12 Inthis specifictypeoffracture,
withmetaphysealboneimpaction,theposteromedial
perios-teumofthehumeralhead(i.e.themedialhinge)maybe
main-tained.Consequently,theposteriorhumeralcircumflexartery
(whichpassesthroughthisregion)mayalsobemaintained.
The blood supply to the humeral head may be preserved
(Fig.2).1–3,6,8–13 Thismay giverisetoavoidanceofthemost
frequentcomplicationofcomplexfracturesofthe proximal
humerus:avascularnecrosis.Theincidenceofthis
complica-tionis21–75%infour-partfracturesand8–26%insituationsof
Fig.1–Radiographshowingmeasurementofthe cervicodiaphysealangleoftheproximalhumerus,i.e.the anglebetweentheanatomicalneckandtheaxisofthe humeraldiaphysis.
Fig.2–Anteroposteriorradiographoftherightshoulder showingvalgusimpactedfractureoftheproximal humerus.
valgusimpact.11Maintenanceofthismedialhingemayalso
helpinfracturereduction,sinceitservesasasupportpoint
(fulcrum) forthe humeralheadtoreturntoits varus
posi-tion,withoutlosingcontactwiththemetaphysealregionof
thediaphysis.1–3,6–8Thesecharacteristicfactorsmayleadtoa
higherconsolidationrateforthesefractures,comparedwith
othercomplexfracturesoftheproximalhumerus.1,2,6,7
Indecidingbetweenconservativeandsurgicaltreatment
forvalgusimpactedfracturesoftheproximalhumerus,the
followingimportantfactors needtobetaken into account:
physiologicalage,comorbidities,workactivities,sports
activ-ities, demand, smoking, osteoporosis, patient cooperation,
timeelapsedsincethefracture,surgeon’sexperienceandthe
fracture pattern described.1,2,5,11 Amongthe surgical
treat-ments, the options that have been described are: closed
reduction withpercutaneous fixation, open reductionwith
internalfixationusingalocked plate(Fig.3),screws,metal
wiresand/ornonabsorbablethreadsandarthroplasty.1–13
Furthermore, regarding surgical treatment, in reducing
theseimpactedfractures,significantbonefailuremayoccur
belowthehumeralhead.Thecavitythatthusformscanbe
filledwithrepositionedtuberclesfromthisboneorbymeans
ofanautologous,autogenousorsyntheticbonegraft,inorder
toavoidlossofreduction.1–3,7,11
The aim of this study was to identify the definitions,
classifications andtreatment methodsfor valgusimpacted
fracturesoftheproximalhumerusthathavebeenmostused
intheorthopedicmedicalliterature.
Methods
Areviewoftheorthopedicmedicalliteraturewasconducted
intheRegionalMedicalLibrary(BibliotecaRegionalde
Medi-cina,Bireme),Medline,PubMed,CochraneLibraryandGoogle
Scholar databases. This review covered articles published
between1991and2013,anditusedcombinationsofthe
fol-lowingsearchterms:fractureoftheproximalhumerus,valgus
Fig.3–(A)Anteroposteriorradiographoftherightshouldershowingvalgusimpactedfractureoftheproximalhumerus.(B) Intraoperativefluoroscopyshowingfracturereduction,syntheticgraftandprovisionalfixationwithmetalwires.(C)Fixation usinglockedplate.(D)Finalosteosynthesis.
iftheydealtwithvalgusimpactedfracturesoftheproximal
humerus,withdescriptionsintheEnglishorPortuguese
lan-guages.
Results
Jakob et al.7 considered valgus impacted fractures of the
proximalhumerustobeaspecifictypeoffracturethatwas
notmentionedinitiallyinNeer’sclassification.1Theydefined
themasfour-fragmentfractureswithvaryingdisplacement
ofthetuberositiesandvalgusimpactionofthehumeralhead.
TheyusedtheAO/ASIFclassificationandreportedthatthey
had16patientsin11C2.2andthreein11C2.1,whowereall
treatedsurgically.Theyfoundthat 74%ofthe resultswere
satisfactoryandconcludedthatthesevalgusimpacted
frac-tureswereangledandnottranslated,whichfavoredabetter
prognosis.Theirunsatisfactoryresultswereduetoavascular
necrosisofthehumeralhead.
Robinsonetal.1,2definedvalgusimpactedfracturesofthe
proximalhumerusassituationsinwhichthe
cervicodiaphy-sealanglewasgreaterthanorequalto160◦.Theyusedthe
NeerandAO/ASIFclassifications.Duringtheoperations,the
tubercleswereseparatedandthehumeralheadwasreduced
toitsoriginalposition.Inthecavityformedbyimpactionofthe
humeralhead,asyntheticgraftwasusedtoaidin
maintain-ingthesurgicalreduction.Thetubercleswerethenbrought
totheiranatomicalpositionsandwereboundupusing
non-absorbablethreads.Afixed-angleplatewasusedforfracture
62.5%ofthepatients.Theyfoundthefollowingpostoperative
complications:avascularnecrosis,infection,pseudarthrosis,
heterotopicossificationandadhesivecapsulitis.
Atalaretal.3definedvalgusimpactedfracturesofthe
prox-imalhumerusasthosewithacervicodiaphysealanglegreater
than170◦.TheyusedNeer’sclassification.Theydefinedthe
type of treatment during the operation, according to the
degree of blood reflux (backflow), after perforation of the
humeralhead.When bleedingoccurred intheperforations,
osteosynthesiswasperformed.Ifitdidnotoccur,arthroplasty
wasperformed.Theosteosynthesiswasperformedafteropen
reductionofthehumeralheadtoitsanatomicalpositionand
fixation of the tubercles using non-absorbable thread and
metalwires.Theyusedautologousorallogeneicbonegraftsin
alltheircases.Theyobservedthattherateofavascular
necro-sisofthehumeralheadinthesefractureswaslowerthanin
otherfour-partfractures,especiallywhenthedisplacementof
themedialhingewaslessthan2mm.
Reshetal.8usedNeer’sclassificationbutsubdividedthe
fracturesintovarus(duetoseparationorimpaction)and
val-gus,whichmightormightnothavelateraldisplacementofthe
humeralhead.INthevalgusimpactedfractures,thetubercles
couldbeintheiroriginalpositions,sincetheywereconnected
tothe diaphysisbytheperiosteum.Thehumeralheadwas
reducedwiththeaidofthemedialhingeasasupport,until
satisfactoryalignmentwiththetubercleswasachieved.
Fixa-tionwasdoneusingmetalwiresorscrews.
Herteletal.9developedanewbinaryclassificationsystem
(LEGO®),with12possibletypesoffracturesoftheproximal
humerus:sixthatdividedthehumerusintotwofragments,
fivethatdivideditintothreefragmentsandasinglefracture
patterninfourfragments.Fromthis,theydefinedsome
pre-dictorsofischemiaofthehumeralhead:fractureextentinthe
metaphysislessthan8mm,displacementofthemedialhinge
greaterthan2mm,basicpatternofjointfracture(anatomical
neckorheadsplit),angulardisplacementofthehumeralhead
greaterthan45◦,fracturesinthreeorfourparts,displacement
oftuberositiesgreaterthan1cmandglenohumeral
displace-ment.Theyobservedthattherewasa97%riskofavascular
necrosisofthehumeralheadwhenafractureofthe
anatom-icalneckoccurredinassociation withinjurytothe medial
hingeandacalcarwithmetaphyseallengthlessthan8mm.
Panagopoulosetal.10definedvalgusimpactedfracturesof
theproximalhumerusashumeraljointfragments
(anatom-ical neck) impacted against the metaphyseal region, with
separationofthetuberositiesandminimallateraldeviation
ofthe humeralhead.Themean cervicodiaphysealangleof
humeralimpactionamongthepatientsinvolvedintheirstudy
was42◦(range:37–48◦)andthemeanlateraldisplacementwas
of avascularnecrosis: the directionofthe displacement of
thehumeralhead(varusorvalgus)andthelengthof
meta-physeal continuation,whichcould bemeasured bymaking
comparisonswiththeintactcontralateralside,bymeansof
radiography ortomography.Theyconcludedthatwhenthis
metaphyseal lengthofthe humeralhead was greater than
2mm,therewould belower riskofavascularnecrosis.The
NeerandAO/ASIFclassificationswereused.Afterreduction
ofallofthecasesofvalgusimpactedfractures,afixed-angle
platewasused,withoutagraft.
Catalanoetal.5 definedvalgusimpactedfractures ofthe
proximal humerusasthose withacervicodiaphysealangle
greaterthan160◦.Thecriteriaforsurgicalindicationthatthey
usedwerethefracturepattern,degreeofdisplacement and
bonequality.Thetechniquesthattheyusedwereopen
reduc-tion,internalfixationwithmetalwiresandimplantationof
syntheticgrafts.
DeFranco etal.11 usedtheNeerandAO/ASIF
classifica-tionsanddefinedvalgusimpactedfracturesoftheproximal
humerusasthosethatwereclassifiedas11C2.1and11C2.2.
They used either conservative treatment or surgical
treat-ment consisting of open or percutaneous osteosynthesis
and arthroplasty. In implementing treatment consisting of
osteosynthesis,theyreported thatwhenthe humeralhead
wasreducedfromvalgustoitsoriginalposition,thetubercles
returnedtotheiranatomicalpositionbecauseofthepossible
integrityoftheperiosteuminthesefractures.Forfixation,they
usedSteinmannpins,cannulatedscrews,suturingwith
non-absorbablethreadand/orplatesandscrews.Whennecessary,
theyusedgraftstosupportthehumeralhead.
Neer12reviewedhisclassicalclassification,whichhadnot
prescribed treatmentsormadeprognoses.Inthis study,he
dividedtheevaluationoffracturesintothosewithtwoparts
(anatomicalneckorsurgicalneck),whichcouldbeimpacted,
non-impactedorcomminuted;thoseinwhichopenreduction
andinternalfixationorarthroplastywasperformed;andthose
withfourparts,whichcouldbetrueorhavevalgusimpaction.
Hereportedthatinfour-partfractureswithvalgusimpaction,
with a minimum inclination of 45◦, without displacement
or with minimal lateral displacement of the joint surface
inrelationtothehumeraldiaphysis,themedialperiosteum
remainedintact,whichcouldmaintainthevascularsupplyof
thehumeralhead,withbetterprognosisregardingavascular
necrosis.
Ogawa et al.13 studied four-part fractures of the
proxi-malhumeruswithvalgusimpactionandusedtheNeerand
AO/ASIFclassifications.Theydefinedthesefracturesastype
11C2.2,inwhichthehumeralheadpresentedvalgus
greatertuberositywashigherthanthevertexofthehumeral
head.Surgicaltreatmentwasindicatedforalltheirpatients.
Thereductionwasperformedwiththefirstmetalwirepassing
throughthehumeralheadfromalateraltoamediallocation
andthesecondmetalwireforcorrectingthevalgus.Inelderly
patients,athirdmetalwirewasalsoused,inaretrograde
man-ner,toaidinthereduction.Ifthereductionwasnotachieved,
tensionbands,screwsandnon-absorbablethreadswereused.
Court-Brown et al.14 analyzed 125 patients with valgus
impactedfracturesoftheproximalhumerusthatpresented
theAO/ASIFclassification11B1.1andforwhichconservative
treatmentwasused.Theyobservedthatallofthesefractures
thattheyfollowedup intheirstudy reachedconsolidation.
Theyreportedthatthesefracturespresentedabetter
prog-nosisalsowhentreatedconservatively,andthat80%ofthe
results were good. They also concluded that these results
dependeddirectlyontheinitialdegreeofdisplacementofthe
fractureandonthepatient’sage.
Discussion
Inthemainstudiesintheorthopedicmedicalliteraturethat
wereconsulted1–14regardingvalgusimpactedfracturesofthe
proximalhumerus,avarietyofdefinitions,classificationsand
treatmentmethodshavebeenused.
Mostofthesestudiesusedthedefinitionof
cervicodiaphy-sealanglegreaterthan160◦.Theyagreedthatimpactionofthe
metaphysealregionofthehumeralheadwasanimportant
characteristicofthesefractures,whichcould favor
mainte-nanceoftheintegrityoftheposteromedialperiosteumofthe
calcar.Thisparticularfeaturegaverisetoalowerrateof
avas-cularnecrosisofthehumeralheadandahigherconsolidation
rate,incomparisonwithothercomplexfracturesofthe
prox-imalhumerus.
Theclassificationsmostusedintheliteratureconsulted
wereNeerandAO/ASIF.
Thetreatment method mostused inthese studies was
surgical. The operations consisted of open reduction and
internalfixationusingmetalwires,lockedplatesand/or
non-absorbablethread.
Avarietyofgraftswereusedforfillingthespacethathad
formedinthe impacted region, comprisingsynthetic,
allo-geneicandautogenoustypes.Theindicationsforusinggrafts
thatweredescribedintheliteratureconsultedwerevariable
andremainedatthediscretionofeachsurgeon.
Final
remarks
Studiesonvalgusimpactedfracturesoftheproximalhumerus
presentvariationsindefinitions,classificationsandtreatment
methodsused,buttheyarealwaysconcordantwitheachother
regardingthebetterprognosisforthesefractures,in
compar-isonwithothercomplexfracturesoftheproximalhumerus.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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