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References - Two-Part surgical neck fractures of the humerus

Two-Part and Three-Part Fractures: Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Pinning.

Williams Jr GR, Wong KL
Orthop Clin North Am 2000 Jan;31(1):1-21
Associate Professor, Shoulder and Elbow Service, Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Surgical management of two-part and three-part proximal humerus fractures is difficult and requires familiarity with more than one method of fixation. Poor bone quality, comminution, and the deforming forces of the rotator cuff on the tuberosities influence the choice of operative approach and fixation techniques. Closed reductions and percutaneous pinning offer the potential advantage of minimal soft-tissue dissection; however, good bone quality and minimal comminution are prerequisites. Selected two-part surgical neck fractures and valgus-impacted fractures lend themselves well to this technique. Open reduction and internal fixation is indicated in two-part surgical neck fractures with poor bone quality or extensive comminution, two-part greater tuberosity or lesser tuberosity fractures, and most three-part fractures. The choice of surgical approach is dictated by the fracture pattern and includes an extended deltopectoral approach and a superior deltoid-splitting approach. Fixation techniques are myriad and are dependent on the fracture pattern. Potential fixation methods include intramedullary rods, interfragmentary sutures or wires, and extramedullary plates and screws or blade plates. Successful results are predicated on obtaining adequate enough fixation to allow early passive motion. Results also are influenced by the quality of the reduction and patient compliance.

Percutaneous pinning of proximal humerus fractures: a biomechanical study.

Naidu SH, Bixler B, Capo JT, Moulton MJ, Radin A
Orthopedics 1997 Nov;20(11):1073-6
Department of Orthopedic Surgery, Pennsylvania State University, Hershey, Pa., USA.

Mechanical testing of two-part surgical neck fractures fixed with four different pin configurations was performed. Ten fresh, frozen, unembalmed humeri stripped of all soft tissues were used; the surgical neck was osteotomized perpendicular to the humerus long axis. Terminally threaded 2.5-mm AO pins were used to fix the fracture. Humeri then were tested in both torsion and bending on a custom-made jig using Instron 1331 to assess the rigidity of pinning constructs. In torsion, two lateral pin construct was significantly less rigid than all other pin configurations. The addition of an anterior pin to two lateral pins did not increase bending rigidity, but significantly increased torsional stiffness . The addition of two bicortical tuberosity pins or two bicortical tuberosity pins and one anterior pin to two lateral pins significantly increased rotational and bending rigidity . Results confirm clinical data, and the authors conclude that multiplanar pins are needed to augment torsional stiffness, and that the addition of two bicortical tuberosity pins enhances bending rigidity.
The influence of intramedullary fixation on figure-of-eight wiring for surgical neck fractures of the proximal humerus: a biomechanical comparison.

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