|Year : 2013 | Volume
| Issue : 2 | Page : 99-102
External fixation by Joshi's external stabilizing system in cases of proximal humerus fractures in elderly subjects
Soumya Ghosh1, Debasis Ghosh1, Soma Datta2, Arunima Chaudhuri3, Debasis Singha Roy1, Arnad Chowdhury1
1 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
2 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
|Date of Web Publication||23-Jul-2013|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Fracture of the proximal humerus is a common and debilitating injury occurring mainly in elderly females and accounts for 4-5% of all adult fractures. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. Objectives: To study the effect of using Joshi's external stabilizing system (JESS) for the management of fractures of proximal humerus in elderly. Materials and Methods: This prospective study was conducted in a tertiary care hospital in West Bengal on 28 subjects with proximal humerus fractures. As per Neer's classification, 3- and 4-part fractures were included and prepared for JESS fixation. The results of the treatment were evaluated as per Neer's criteria. Patients were followed up for 10 − 12 months. Results: Among 18 females and 10 males, 22 had 3-part fracture and 6 had 4-part fracture. Mean duration of JESS application was 10 weeks. Among patients with 3-part fractures 4 cases had excellent result, 12 had satisfactory result, 4 had unsatisfactory result and treatment failed in 2 cases. With 4-part fractures, 2 cases had unsatisfactory result and 4 cases were failures. Conclusion: JESS is an alternative option for the treatment of proximal humerus fractures, especially in elderly patients with osteoporosis, showing excellent to good results in cases of Neer's type 3-part fracture.
Keywords: Humerus fracture, Management, JESS
|How to cite this article:|
Ghosh S, Ghosh D, Datta S, Chaudhuri A, Roy DS, Chowdhury A. External fixation by Joshi's external stabilizing system in cases of proximal humerus fractures in elderly subjects. J Sci Soc 2013;40:99-102
|How to cite this URL:|
Ghosh S, Ghosh D, Datta S, Chaudhuri A, Roy DS, Chowdhury A. External fixation by Joshi's external stabilizing system in cases of proximal humerus fractures in elderly subjects. J Sci Soc [serial online] 2013 [cited 2019 Oct 13];40:99-102. Available from: http://www.jscisociety.com/text.asp?2013/40/2/99/115490
| Introduction|| |
Fracture of the proximal humerus is a common and debilitating injury occurring mainly in elderly females and accounts for 4-5% of all fractures. Typical age of fracture is between 65 and 75 years.  There is a marked gender deference with 70-80% of fractures occurring in females. These fractures are due to low energy trauma in elderly persons and risk increases in sedentary individuals with low mineral density, family history of osteoporotic fractures, frequent falls, and evidence of impaired balance. ,
The proximal humerus is uniquely adapted to allow wide range of motion of the shoulder. Mobility is gained at the expense of stability. In fracture of the proximal humerus, biomechanics of this joint is disturbed if fracture fragments are not properly reduced and fixed, as greater tuberosity is attached to supraspinatus muscle and lesser tuberosity to subscapularis muscle. Thus, these muscles try to pull fracture fragments away with them, so close reduction is difficult. Ultimately joint stability and movement is compromised. ,,
Neer's classification scheme is most widely accepted and classifies fractures based on the number of parts and their displacement. ,,,
The bone density of the proximal humerus is relevant to fracture fixation and, generally, the bone density of the subchondral bone just underneath the articular surface is strongest, while the bone of the central humeral head and neck is more porous. In general, the proximal undisplaced or minimally displaced humerus fractures are treated conservatively. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. ,, Primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation program are important factors.
Displaced fractures are treated surgically by various methods like percutaneous pin or screw fixation, open reduction, and internal fixation with plate and screw, locking plate and screw fixation, and intramedullary nailing and external fixation. Joshi's external stabilizing system (JESS) is an external fixation device developed by Dr. B. B. Joshi, which is cost effective, easily applicable, light weight, and needs minimum number of instruments for application. ,,
The present study was conducted to study the effect of using JESS for the management of 3-part and 4-part fractures of proximal humerus in elderly, so that, in a developing country like India, it can be popularized for the benefit of the population at a large.
| Materials and Methods|| |
This prospective study was conducted in a tertiary care hospital in West Bengal after taking permission from ethical committee and consents from the patients. Inclusion criteria: All patients attending orthopedic outpatient or emergency department with proximal humerus fractures (3-part and 4-part), open or closed without any neurovascular deficit were included. Exclusion criteria: Patients with other varieties of fracture of proximal humorous, patients with previous injuries that has already compromised function, movement of shoulder, and subjects having neurovascular deficit were excluded. A total of 28 patients were included in this study. Among them, 18 were females (mean age: 60 years) and 10 were males (mean age: 65 years). Among them, 22 patients had 3-part fractures and 6 had 4-part fractures. Patients were operated within 2 weeks from the date of trauma after proper clinical and laboratory investigations and pre-anesthetic assessment. Road traffic accident was the commonest mode of injury in <60 years age group and fall on the ground in patients >60 years age group.
All patients were evaluated on admission. As per Neer's classification, 3- and 4-part fractures were included and prepared for JESS fixation. The results of the treatment were evaluated as per Neer's criteria.
It is a simple, light, highly modular mini external fixator system that systematically addresses a wide range of complex problems in the management of fracture of humerus, forearm, and hand. This system has high safety profile and unparalleled ease of application. It can be applied easily by any surgeon with minimum instrumentation. It allows minimum invasive techniques.
The operations were performed under regional or general anaesthesia with the patient in supine position. The whole upper limb was properly draped, and, under image intensifier, the shoulder joint and fracture fragments were delineated. Also, 3-part or 4-part fractures were reduced with traction and manipulation, and reduction was confirmed in anteroposterior, lateral, and axillary views. Whenever there was difficulty in realignment of the displaced fragments, Steinman pin was used to manipulate the fracture fragments at an acceptable level. Reduction was rechecked with the help of image intensifier in antero-posterior, lateral, and axillary views. During this procedure, the position of the shoulder was kept static and the c-arm was manipulated to see the reduction. Aim of the reduction was to reduce fragment distance to <45° or decrease displacement to <1 cm. Then, two 2.5-mm K-wires were inserted through the greater tuberosity to engage proximal and distal fractures in such a way that distal cortex was engaged. These two pins were kept almost parallel to each other or within 30° inclination. Now, in the proximal part, again two K-wires were inserted to fix any fracture fragment near the greater tuberosity. Extra fragment, if any, was held with a separate k-wire in the proximal part. In distal part of the humerus, three K-wires of 2.5-mm size were introduced to engage both the cortices. First k-wire was given 2 cm away from the fracture line. While all these K-wires were used, injury to axillary nerve and accompanying vessels were avoided. With the help of 3-4-mm connecting rod, these K-wires were attached using link joints. Two connecting rods were used in mirror image position or parallel to each other. Pre-operatively, shoulder joint stability was checked by running c-arm in all views. The limb was hanged in cuff and collar sling and arm bag was used. Patients were encouraged to do shoulder mobilising exercises as early as possible. Chest X-rays were taken on next postoperative day, after 7 days, after 4 weeks, and at 6-8 weeks for evaluation of results and then at 4 weeks.
Neer's criteria for assessment of post-operative cases
It includes pain, function, range in motion, and anatomy. ,,,
| Results|| |
A total of 22 patients had 3-part fracture and 6 patients had 4-part fracture. Mean interval between injury and surgery was 10 days. Mean duration of JESS application was 10 weeks. Mean time of radiological union was 10 weeks. Follow-up period ranged from 10 weeks to 11 months. Also, 4 of the 4-part fractures had nonunion and 2 had unsatisfactory shoulder function after fracture union as per Neer`s criteria, one had pin tract infection and pin loosening. Two of the 3-part fractures had frank non-union. All other 20 3-part fractures united. Two of them had pin loosening and 2 had pin tract granuloma formation and infection. Remaining 7 cases had pin tract infection. All these cases were treated with regular dressing. Granuloma was scraped and dressed. All pin tract infection and granuloma healed after removal of JESS within 1 week. Postoperative restriction of movement was treated with immediate mobilizing exercises in all cases, and shoulder mobility was satisfactory. All cases were estimated according to Neer's criteria. Thus, it was found that, among patients with 3-part fractures, 4 cases had excellent result, 12 had satisfactory result, 4 had unsatisfactory result, and the treatment failed in 2 cases. With 4-part fractures, 2 cases had unsatisfactory result and 4 cases were failures. So, 57% with 3-part fractures had excellent to satisfactory results. In 4-part fractures, treatment results were not satisfactory [Table 1].
|Table 1: Result as per Neer's criteria in 3-part and 4-part fracture of humerus|
Click here to view
| Discussion|| |
Treatment of proximal humerus fractures may be conservative or operative. Each procedure has some limitations and complications. A major disadvantage of non-operative treatment is failure to obtain early mobilization, which results in a high rate of shoulder stiffness and pain and malunion or nonunion is likely with certain fracture types. , JESS fixator application in this study allowed sound fracture union with functional mobility in type 3 cases.  Disadvantage of open internal fixation is difficulty in achieving rigid fixation in the osteoporotic cancellous bone of proximal humerus. Cortical bone in osteoporosis constitutes only a thin shell of bone and provides weak purchase for the screws. Presence of comminution offers difficulty in internal fixation. Internal fixation has been reported to have increased complication rates in these patients due to hardware loosening and pullout of the screws. In addition, the use of internal fixation device prolongs the operative time, increases intraoperative blood loss, and increases the risk of avascular necrosis of humeral head. ,,,, Postoperative adhesions further limit the range of motion as a result of extensive dissection needed in cases of open reduction and internal fixation. However, recent studies have shown good long-term results of proximal humerus fractures managed by PHILOS plate. 
The use of external fixators in the management of proximal humeral fractures has become popular in the past decade. The idea of minimal fixation now lends to the fact that the blood supply to the head of the humerus is preserved. Hoffmann's external fixators were used for this type of fractures, but their use was hindered by bulky Steinman pins, increasing the risk of injury to soft tissue and limiting the space for application of multiple pins in different planes. ,,,, The smaller K-wires used in JESS have lesser risk of soft tissue, neural, and vascular injury. Multiple K-wires used in different planes add to the rotational stability to reduced fractures. The principles of management for complex proximal humeral fractures are minimal soft tissue dissection to avoid the occurrence of avascular necrosis of the humeral head, adequate fixation to provide good stability for early rehabilitation, and an intact rotator cuff for an optimal functional outcome. Closed reduction and the use of JESS achieve these principles adequately. 
Complications encountered by external fixation by JESS of fractures of proximal humerus are K-wire loosening, pin tract infection, malunion, and shoulder stiffness. The use of partially threaded K-wire increases the pullout strength. The undue tension on skin should be avoided to prevent pressure necrosis. 
| Conclusion|| |
Thus, in this study, it was found that JESS is an alternative option for the treatment of proximal humerus fractures, especially in elderly patients with osteoporosis, showing excellent to good results in many cases of Neer's type 3-part fracture.
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