r e v b r a s o r t o p . 2 0 1 8;5 3(3):350–356

SOCIEDADE BRASILEIRA DEORTOPEDIA E TRAUMATOLOGIA

www.rbo.org .br

Original Article

Posterior four-part fracture-dislocations of theproximal humerus: clinical and functionalevaluation of osteosynthesis treatment�

Carla Teresa Barbosa de Oliveiraa,∗, Elpídio da Gracaa, Vânia Aparecida Fanelli b

a Universidade de Ribeirão Preto, Ribeirão Preto, SP, Brazilb Clínica Ortohealth, Ribeirão Preto, SP, Brazil

a r t i c l e i n f o

Article history:

Received 1 February 2017

Accepted 6 April 2017

Available online 5 April 2018

Keywords:

Humeral fractures

Shoulder dislocation

Internal fracture fixation

a b s t r a c t

Objective: To evaluate patients diagnosed with posterior four-part fracture-dislocations of

the proximal humerus, that were surgically treated with osteosynthesis, regarding their

clinical and functional outcomes.

Methods: A prospective observational study of eight patients from the same hospital insti-

tution in the interior of São Paulo State (Brazil), through individual interviews using the

UCLA, DASH, and Constant international scores. The active movements included in the

scores plus the range of motion of the affected and non-affected limb were measured. The

affected shoulder’s radiographs were requested to verify bone conditions and the fixation

of the osteosynthesis.

Results: The rating of eight patients by the international scores indicated that seven of the

eight patients presented good clinical and functional evolution of the affected limb; this

represents 87.5% of the evaluated individuals.

Conclusion: Surgical treatment with osteosynthesis performed during the acute period (<four

weeks) leads to good results in most cases.

© 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora

Ltda. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Fraturas-luxacões posteriores do úmero proximal em quatro partes:avaliacão clínico-funcional do tratamento por osteossíntese

r e s u m o

Palavras-chave:

Fraturas do úmero

Luxacão do ombro

Fixacão interna de fraturas

Objetivo: Avaliar os pacientes com diagnóstico de fratura-luxacão posterior da extremidade

proximal do úmero em quatro partes que foram tratados cirurgicamente com osteossínte-

ses, do ponto de vista clínico e funcional.

� Study conducted at Hospital Santa Lydia, Ribeirão Preto, SP, Brazil.∗ Corresponding author.

E-mail: carla.teresa@hotmail.com (C.T. Oliveira).https://doi.org/10.1016/j.rboe.2018.03.0102255-4971/© 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access articleunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

r e v b r a s o r t o p . 2 0 1 8;5 3(3):350–356 351

Métodos: Estudo observacional prospectivo de oito pacientes de um mesmo servico de

ortopedia e traumatologia do interior do Estado de São Paulo, por meio de entrevistas

individuais, com os scores internacionais de UCLA, DASH e Constant. Mediram-se os movi-

mentos ativos incluídos nos scores e a amplitude de movimentos do membro acometido e do

não acometido. Solicitaram-se radiografias do ombro acometido para verificar as condicões

ósseas e de fixacão dos materiais de síntese.

Resultados: A avaliacão de oito pacientes por meio dos scores usados indicou que sete apre-

sentaram uma boa evolucão clinico-funcional do membro acometido, ou seja, 87,5% dos

avaliados.

Conclusão: O tratamento cirúrgico com osteossínteses feito no período agudo (< quatro

semanas) apresenta bons resultados na maioria dos casos.

© 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier

Editora Ltda. Este e um artigo Open Access sob uma licenca CC BY-NC-ND (http://

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ntroduction

he shoulder joint is prone to dislocation due to its anatomi-al structure and its biomechanics, which allow an extensiveange of movement.1 It is believed that, among the majoroints of the human body, the shoulder suffers most disloca-ions, with an incidence of 8.2 to 23.9 per 100,000 inhabitants.2

According to Cooke and Hackney,3 of all dislocations, 4%re posterior and only 1% are associated with fractures. Frac-ures of the proximal humerus account for 4% to 10% of allractures; the most common trauma mechanism is a fall fromhe patient’s own height.4

Posterior fracture-dislocation of the shoulder (PFDS) isn uncommon orthopedic entity,5–10 and bilateral PFDS isven rarer, initially described by Mynther in 1902.5,11,12 Theost frequent causes described in the literature are epilepsy,

xtreme trauma, and electric shock, hence it is known as triple syndrome. The imbalance of muscle strength between theedial and lateral rotator groups accounts for the traumaechanism, attributed to adduction and medial rotation

MR) of the affected limb.5,13 In addition to the high-energyrauma, the intense muscle contraction forces the humeralead against the glenoid edge, causing fracture with possibleomminution.5

The infrequent diagnosis of PFDS and its non-specificymptoms, such as pain and limitation of movement with theimb in MR and adduction, contribute to the underdiagnosisnd delayed treatment of this condition. This may increasehe number of complications, including osteonecrosis and col-apse of the humeral head, inverted Hill-Sachs injury, posteriornstability, and the inevitable arthrosis.6 The diagnosis of PFDSan be made through imaging tests, such as shoulder radio-raphs, in anteroposterior, scapulary, and especially lateralxillary views.14

Moreover, dislocation and PFDS have been described sincehe last century, but to date, the literature features few articlesith a sufficient numbers of cases.15

In the present study, the authors evaluated patients diag-osed with PFDS classified according to Neer as four-part

ractures, that were surgically treated with osteosynthesisaterial, all of whom were followed-up by the same surgeon

creativecommons.org/licenses/by-nc-nd/4.0/).

at an orthopedics and traumatology unit in the interior of SãoPaulo State (Brazil).

Material and methods

Between July 2001 and June 2013, eight patients were diag-nosed with posterior fracture of the proximal humerus,classified as four-part fractures by the Neer classification.Posterior fracture-dislocations of the proximal humerus inthree or less parts, anterior fracture-dislocation, and poste-rior four-part fracture-dislocation of the proximal humerustreated conservatively or with arthroplasty were not included.Patients were diagnosed and treated by the staff of an ortho-pedics and traumatology unit in the interior of São Paulo,State (Brazil), and are currently in outpatient follow-up. Eightshoulders were treated in eight patients (seven males andone female), with mean age of 47 years (range: 37–59). Fivepatients reported motorcycle accident as cause of the injury,one reported seizure crisis, and two reported electric shock.Four patients presented injury to the dominant limb, and fouron the non-dominant side (Table 1). All patients in the studywere diagnosed and treated in the acute phase (up to fourweeks after the event), �t of 11.5 days (range: 1–28 days).Five patients presented injuries associated with blunt forcetrauma in the contralateral hand, compound fracture of ipsi-lateral leg bones, contralateral patellar fracture and ipsilateralthird-finger fracture, and posterior contralateral shoulder dis-location.

For all eight patients, radiographs of the affected shoulderwere made in anteroposterior (AP; Fig. 1), scapular profile (P;Fig. 2), and lateral axillary views (Fig. 3); in four cases, com-puted tomography (CT) scans were performed (Fig. 4A andB).

Patients were treated through open surgery and internalfixation with osteosynthesis. In one patient, Ethibond sutureswere used, and in the other, fixation with Kirschner wire (KW)and securing sutures were used. Six shoulders were securedwith locking plate (LP) and screws associated with securing

sutures (Fig. 5A–C). All patients were immobilized with a lat-eral rotation (LR) thoraco brachial (TB) plaster cast for 45 days,followed by outpatient and radiological follow-up. No patientevolved with acute complications. Four patients underwent

352 r e v b r a s o r t o p . 2 0 1 8;5 3(3):350–356

Table 1 – Patient profile.

Patient Age Gender Dominant side Affected side Cause Associated lesion

1 59 M R L Convulsion Posterior Right shoulder dislocation2 49 M R L Motorcycle accident3 48 M R R Motorcycle accident Left hand wound4 38 M R L Motorcycle accident Compound Left leg fracture5 51 M R R Motorcycle accident Left patellar fracture6 37 M R L Electric shock7 56 M R R Motorcycle accident Fracture of the 3rd and 5th fingers8 40 F R L Motorcycle accident

Fig. 1 – Radiograph of the left shoulder on an

limb.

anteroposterior view.

physical therapy and four, home exercises under medicalsupervision. One patient admitted to not adhering to the phys-ical therapy or exercises with the prescribed frequency, givingpreference to the treatment of associated injuries (Table 2).

For clinical and functional assessment, a prospectiveobservational study was conducted through individual inter-views. The UCLA, Disabilities of the Arm, Shoulder and Hand(DASH), and Constant scored were used; the active movementsincluded in the Constant score were performed under thesupervision of a physical therapist. The range of motion ofactive movements of the affected and contralateral limb weremeasured with the use of a goniometer, considering elevation,LR, and MR as comparative parameters. The modified UCLAscore evaluates pain, function, range of active flexion, ante-rior flexion strength of the shoulder, and patient satisfaction.Pain and function are graded on a scale of up to 10 points each.Active flexion, anterior flexion strength, and patient satisfac-tion range from 0 to 5, totaling 35 points. A score from 34 to 35points is considered excellent; from 28 to 33, good; from 21 to27, fair; and 0 to 20, poor, according to Oku et al.16

The DASH score measures the symptoms and physicalfunction of individuals with musculoskeletal disorders in theupper limbs. The assessment of functional status is subdi-vided into physical, social, and psychological categories. Thereare 30 items, whose scores range from 1 to 5 each; and a min-

imum of 27 of the 30 items must be answered. In the socialcategory, two areas are optional: musical and sports perfor-mance or work. Each area includes four items, whose scores

Fig. 2 – Radiograph of the left shoulder on a lateral view.

also range from 1 to 5. In these areas, all questions must beanswered.

To calculate the functional status score, the following for-mula should be used:[(

sum of answersNo. of items answered

)− 1

]× 25

To obtain the score of the optional areas, a similar formulashould be used:[(

sum of answers4

)− 1

]× 25

In both scores, a total of 100 points will be obtained; thehigher the value, the greater the degree of dysfunction of the

17

The last score evaluates the functional ability of theaffected shoulder through the Constant-Murley clinical proto-col, which scores four parameters: pain, performance in daily

r e v b r a s o r t o p . 2 0 1 8

Fig. 3 – Radiograph of the left shoulder on lateral axillaryv

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ctivities, joint mobility, and isometric muscle strength. To cal-ulate the score, the protocol must be applied bilaterally. Theaximum score is 100 points; the closer to 100, the better the

unctional capacity.18

The interviews were scheduled at the institution itself,ccording to the patients’ availability. Radiographs of theffected shoulder were requested to assess the bone and fix-tion of the osteosynthesis material. The study was approvedy the institution’s Ethics Committee under CAAE No.2955113.3.0000.5440 – opinion No. 774166. All eight patientsttended the reassessment consultation. An Informed Con-ent Form was signed by all participants.

esults

n the UCLA score, two patients presented excellent results;hree, good; and three, fair.

In the DASH score, four patients had scores of 0 or <1; twoatients, <20; and two patients, between 24 and 50 points.

In the Constant score, five patients scored above 90, whichs interpreted as an excellent result. Two patients scored 73nd 77 points, interpreted as fair results; and one obtained acore of 61 points (Table 3).

iscussion

his study evaluated patients who suffered posterior fracture-islocation of the proximal humerus, classified as four-partractures by the Neer classification, who were surgically

reated with open reduction and internal fixation withsteosynthesis material. This pathology is a rare group amonglenohumeral injuries19; of all dislocations, 1.7% to 4.3% areosterior and only 0.9% are associated with fractures.8–10

;5 3(3):350–356 353

Fukuda et al.8 also indicated that PFDS is an extremely rareinjury, accounting for 0.9% of proximal humeral fractures,occurring annually in 0.6/100,000 people. Thus, in 13 years,only eight patients from an orthopedic and traumatology unitin the interior of São Paulo State met the inclusion criteriaadopted.

The patients studied presented triple E syndrome as thetrauma mechanism. The causes for these types of injuries areforced MR, flexion, and adduction of the shoulder joint.7 In2012, O’Neil et al.11 reported that 50% of all cases are causedby seizures, 45% by trauma, and less than 5% by electric shock.

Robinson19 describes the profile of patients as relativelyyoung and middle-aged, and predominantly male. Likewise,the mean age of the patients in the present study was 42years, and 87.5% were male. Therefore, they represent patientswith good bone quality, capable of sustaining osteosynthesismaterial.

The internal fixation with LP and screws offers greaterstability, favoring early mobility of the affected limb.4 How-ever, various other methods of osteosynthesis are also capableof providing stability and allowing early mobility.20 Differentosteosynthesis methods provide different degrees of stability,but show similar functional clinical results.21

It is important to have the possibility of partial arthroplastyin the surgical therapeutic arsenal for cases where a satisfac-tory reduction and stabilization of the bone fragments is notpossible, due to fracture comminution.22

In the present study, different osteosynthesis techniqueswere used, such as securing sutures,23,24 KW and tension-band,25 and LP,4 depending of the material available for eachcase, which is related to financial cost. However, all patientsunderwent surgical treatment in accordance with the con-cepts of minimally invasive osteosynthesis, i.e., early surgicalintervention, minimal soft tissue injury, careful manipu-lation of the fragments, fracture stabilization, and earlyrehabilitation.8,26

Among the assessed patients, seven presented a goodlong-term evolution, while one presented scores that charac-terized mild to moderate musculoskeletal dysfunction. Thispatient admitted to not having undergone physical ther-apy nor performed domestic rehabilitation of the upperlimb due to giving preference to treatment of associatedinjuries.

Vastamaki and Solonem9 state that early reduction is ofextreme importance, and that the primary results of latetreatment are good; however, in the long term, it leads topainful post-traumatic arthrosis. Cooke and Hackey3 reportthat good outcomes depend not only on early diagnosis andtreatment, but also on early and continuous physical ther-apy. The authors insist on and draw attention to the factthat diagnosis and treatment should be made early in orderto prevent complications and to recover joint mobility andfunction.14

According to Oakes and McAllister,10 the possible compli-cations of PFDS include the development of osteonecrosis ofthe humeral head. Anatomic neck fractures are associatedwith a high risk of avascular necrosis and four-part fracture-

dislocations; the risk can be as high as 90%.3

Conservative treatment presents an incidence of avascularnecrosis of between 3% and 14% in cases with three fragments

354 r e v b r a s o r t o p . 2 0 1 8;5 3(3):350–356

Fig. 4 – (A) Computed tomography in axial section; (B) computed tomography in sagittal section.

Fig. 5 – (A) Radiograph on anteroposterior view showing consolidated fracture treated with fixation with a locking plate; (B)radiograph lateral view showing consolidated fracture treated with fixation with a locking plate; (C) radiograph on axial

th a

view showing consolidated fracture treated with fixation wi

and between 13% and 34% in cases with four fragments. This

rate increases in the presence of dislocated fractures. Plateosteosynthesis may also lead to avascular necrosis, presentingrates above 35% in complex joint fractures.27

locking plate.

According to Robinson,19 complications include

osteonecrosis of the humeral head and tubercles, pseu-doarthrosis, malunion, infections, neurological lesions,movement limitation, and complications related to the

r e v b r a s o r t o p . 2 0 1 8;5 3(3):350–356 355

Table 2 – Treatment data.

Patient �t (days) Type of osteosynthesis Type of immobilization Rehabilitation

1 01 Securing sutures TB in LR Yes2 03 KW and securing sutures TB in LR Yes3 03 PB and Ethibond suture TB in LR Yes4 06 PB and Ethibond suture TB in LR No5 05 PB and Ethibond suture TB in LR Yes6 01 PB and Ethibond suture TB in LR Yes7 09 PB and Ethibond suture TB in LR Yes8 28 PB and Ethibond suture TB in LR Yes

Table 3 – Result of the scores.

Patient UCLA DASH Constant ROM affected side ROM non-affected side

1 34 0.83 92 180 1800 40◦ 35◦

0 T10 Gluteus

2 29 6.6 73 150◦ 180DNA 45◦ 60◦

0 L1 T10

3 27 0 96 140◦ 160◦

DNA 45◦ 60◦

0 T7 T7

4 21 24.16 61 90◦ 170◦

50 20◦ 60◦

43.75 L4 T10

5 35 0 98 180 180DNA 90◦ 90◦

0 T3 T10

6 33 0 96 180 180DNA 45◦ 90◦

0 T7 T10

7 30 13.33 92 115◦ 1806.25 45◦ 60◦

12.5 T7 T7

8 26 42.5 77 110◦ 180DNA 20◦ 60◦

DNA L2 T7

Interpretation: Constant, the closer to 100, the better the function; DASH, the closer to 100, the greater the dysfunction; UCLA, excellent, 34–35;good, 28–33; fair, 21–27; poor, 0–20.

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steosynthesis material. In case of movement limitation,he initial treatment is conservative, with rehabilitationith stretching exercises. If conservative treatment fails,

reatment with hydraulic distension is indicated to promoteapsular stretching and rupture.

To date, the only complication presented by the patientstudied was the reduction in the range of some movements;owever the patients declared to be satisfied with the results.his complication did not lead to disabilities, and all patientsere able to adapt to their limitation.

onclusion

n general, the final results of the evaluation of the eightatients using the three scores indicated that seven of them

(87.5%) had a good clinical-functional evolution of the affectedlimb.

Conflicts of interest

The authors declare no conflicts of interest.

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