Management of Proximal Humerus Fractures by JESS

Introduction

The upper end humerus fractures (UHFs) have a dual age distribution, occurring either in young people following high-energy trauma or in elderly people with trivial trauma.1 Amongst all the fractures, the upper end of humerus fractures account for 4-5%.¹ Among them, the displaced and comminuted fractures fare poorly with non-operative treatment and are to be treated with surgical intervention. Because of anatomy and comminution, both reduction and fixation encounter difficulties. The aim of treatment in UHFs is to achieve a good anatomical reduction and stable fixation, and thus achieve a good functional shoulder. The result depends on the age, anatomy of the fracture, fracture comminution, associated pathological conditions, quality of the bone, and expectations of the patient, method of surgery i.e., closed reduction-internal fixation (CRIF) or open reduction-internal fixation (ORIF), soft tissue stripping, type of implant. While undisplaced fractures are managed by non-operative treatment,^2,3 the treatment of displaced/comminuted UHFs is challenging and controversial and various operative modalities can be used, like transosseous suture fixation, tension band wiring, percutaneous wiring and different types of plates and screws fixations, and hemiarthroplasty.^4,5 Despite latest developments of surgical techniques and implants, the surgical treatment of these fractures continue to remain challenging. In Neer’s original research, where he treated the upper end of humerus fractures, he could only achieve excellent / satisfactory results up to 50 to 60%. Therefore, a method was needed which does not require expertise, is less invasive, gives good reduction and stable fixation without much soft tissue damage. Therefore, we had used closed reduction-internal fixation (CRIF) with Joshi’s External Stabilization System (JESS) for the management of upper end of humerus fractures. The objective of using JESS was to stabilize the fracture fragments as much in the best reduced position as possible, leaving the joint free for mobilization by CRIF, so as to start early mobilization, thereby to achieve a good and functional shoulder.

Methodology

This was a two-year prospective study (from 2017 to 2019) involving patients (25- 70 years, of both sexes) who had sustained upper end humerus fractures presenting at the Department of Orthopaedics. The inclusion criteria were unstable upper end humerus (UEH) fracture with displacement, displaced fractures ≥1 cm, angulated or rotated proximal fragment ≥ 45°, two-part fractures UEH, three-part fractures UEH, four-part fractures UEH and split head fractures of upper end humerus.

The following patients were excluded: impacted and undisplaced fracture, fracture dislocation – irreducible by close method and fracture presenting after two weeks. Neer’s classification was used to classify the fractures: six patients had 2-part fractures, six patients had 3-part fractures and six patients 4-part fractures, two patients had split head fractures of humerus. The surgery was done under interscalene block or general anaesthesia under C-ARM guidance.

Under anaesthesia, one K-wire was passed from the lateral aspect of the proximal fragment to lever the proximal fragment. Then two to three K-Wires were passed in the proximal fragment parallel to each other. If 3rd or 4th fragments were present, then K-wires were passed through 3rd or 4th fragment to proximal fragment and fixed to proximal fragment. Then two K-wires were passed in the distal fragment, usually parallel to proximal fragment K-wires. Depending on the number of fragments, K-wires were used to fix them to the proximal fragment. Then these K-wires were connected to each other with connecting rods and JESS clamps, after holding the proper reduction under C-ARM. Then the stability of fractures was checked under C-ARM. Post-operatively, a cardboard box was applied over the fixator and a shoulder arm pouch was given. After 3-4 days, when the soft tissue pain was reduced, shoulder movements were initiated. Dressing was done once in 3-4 days to prevent pin tract infection. After 3-4 months when the union was confirmed, JESS was removed in OPD. Neer’s criteria was used for postoperative analysis of cases (based on anatomy, pain, range of movements, and function).^6,7

Results

Totally there were six patients who had 2-part fracture, six patients with 3-part fracture, six patients with 4-part fracture and two patients with split head fracture humerus. Between injury and surgery, the mean interval was seven days. JESS application mean duration was nine weeks. Radiological union mean duration was 10 weeks. Patient’s follow-up was from 6 months to 1 year. All the patients had regular dressings. Neer’s criteria was used to analyse all the cases. Accordingly, among patients having 2-part fractures, five showed excellent results and it was satisfactory in one. Similarly, among patients having 3-part fractures, excellent results were found in four and two showed satisfactory results. In patients having 4-part fractures, excellent results were found in four and two had satisfactory results. In patients with split head fracture humerus, one showed excellent result while one had a satisfactory result (Table.1).

Discussion

The present modalities in the management of UHFs range from non-operative treatment with physical therapy to fracture fixation using percutaneous fixation, open techniques to arthroplasty reconstructions. However, it is still an ongoing research to find the best treatment possible. Undisplaced fractures of the UHF are most commonly managed conservatively. The basis for Neer’s Classification (Figure 1), which is the most common classification used for UHF is the relationship of the four anatomic parts: anatomic neck, surgical neck, greater tuberosity, and lesser tuberosity, which are considered a separate part if there is displacement of > 1 cm or 45° angulation.⁸

Recent studies have concluded that the functional outcome is poor in displaced UHFs, when such fractures are not managed operatively.9 Complications of these fracture fixations include stiffness of shoulder, non-union, periarthritis shoulder, loss of reduction, malunion, humeral head AVN, impingement syndrome, and compromised shoulder function.^10,11

The past decade has seen a rise in the usage of external fixators in UHF management. That the humeral head blood supply should be preserved, lends credence to the theory while using minimal fixation. The disadvantage in using Hoffman’s external fixators is that the Steinman pins are bulky, which increases the soft tissue injuries risk and also limits the space while applying multiple pins, loosening of pins, and pin tract infection.¹²

JESS, developed by Dr. B.B. Joshi in 1987, gives a good anatomical reduction, stable fixation and an excellent functional outcome in the UHF management.¹³ The advantage of using K-wires is that there is decreased risk of soft tissue injuries as well as neurovascular injury. Also, it can be used in multiple planes leading to an increase in the stability of the reduced fracture fragments. Therefore, the principles of complex UHF management are maintained. In this technique, there is no dissection of the soft tissue, so union chances are increased, and chances for non-union and AVN are decreased. Therefore, early rehabilitation is possible due to stable fixation and uninjured rotator cuff, leading to a good functional outcome.¹⁴ UHF treated with closed reduction and JESS fixation achieves these principles adequately.¹⁴

In our study, all had excellent-to-satisfactory results (Figure 2). Advantages of JESS are many. It avoids stripping of soft tissues, thus keeping the blood supply intact. With an intact fracture- haematoma, stable osteosynthesis without immobilizing the surrounding joint, minimal invasive procedure, minimum implants are used. Early mobilization reduces oedema and fibrosis of the capsule. If necessary, fracture readjustment on a later date can be done without anesthesia. Implant removal is also possible without anaesthesia. Implants are cheap and the procedure is economical and less time consuming. Most importantly, it is a simple technique and can be done by any Orthopaedic surgeon, inexperienced to experienced. Even compound fractures are easy to dress and manage. Although it can lead to pin tract infection, it can be managed by an empirical therapy with antibiotics, analgesics and regular dressings. One more advantage is that it is inexpensive.

CRIF with JESS is an easy, inexpensive, less space occupying, highly modular external stabilization system that has many advantages and manages the difficult problems associated with the treatment of upper end humerus fractures very easily. It requires no expertise, is very safe to apply and requires very little instrumentation. It is a minimum invasive technique and can be done by any Orthopaedic surgeon and it also does not require the classification for the management of fractures.

Conclusion

For any upper end humerus fracture, CRIF with JESS can be recommended as it is an easy, good, effective, less time-consuming and cost effective procedure. It gives good anatomical reduction, stable fixation, leaves the shoulder joint free for mobilization, thus giving a good anatomical and functional outcome and it can be done very easily even by an inexperienced surgeon.

Conflict of interest

Nil.

Financial support

Nil.