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Objective: To explore the clinical outcomes of anteromedial combined with lateral locking plate for complex proximal humeral fractures in the eldery., Methods: From June 2018 to October 2020, 30 patients who underwent surgical treatment for Neer grade 3 to 4 proximal humeral fractures, including 8 males and 22 females, aged from 51 to 78 years old with an average of (61.5±7.5) years old. Of them, 15 patients had fractures fixed with anteromedial combined with lateral locking plate(ALLP group), whereas 15 received internal fixation with proximal humerus locking plate only(PHLP group). The clinical data, simple shoulder test (SST), humeral head height loss, varus angle and shoulder range of motion were compared between the two groups., Results: All fractures were healed. The follow-up time ranged from 12 to 24 months, with an average of(14.3±2.9) months. The operation time of ALLP group was longer than that of PHLP group ( P <0.05). There was no significant difference in intraoperative blood loss between the two groups ( P >0.05). There was no significant difference in SST score between the two groups at 1, 3 and 12 months after operation ( P >0.05). In terms of radiographic measurement, there was no significant difference in humeral head height loss and varus angle between the two groups at 1 and 3 months after operation ( P >0.05). At 12 months after operation, the height loss and varus angle of humeral head in ALLP group were lower than those in PHLP group ( P <0.05). In shoulder range of motion, the range of forward elevation in ALLP group was larger than that in PHLP group 1 year after operation( P <0.05). There was no significant difference in external rotation between the two groups., Conclusion: Anteromedial combined with lateral locking plate in the treatment of complex proximal humeral fractures in the elderly can increase the stability of the medial column and obtain a good fracture prognosis. But there are also disadvantages such as longer operation time, so it should be individualized according to the fracture type of the patient.

Objective: To investigate the effectiveness of limited open reduction via "door-shaft method" and internal fixation with locking plate for two- and three-part fractures of the proximal humerus., Methods: The clinical data of 64 patients with proximal humeral fractures who were admitted between January 2013 and December 2016 and met the selection criteria were retrospectively analyzed. There were 23 males and 41 females, with an average age of 68.0 years (range, 50-89 years). The injuries were caused by falling in 57 cases, traffic accident in 5 cases, and falling from height in 2 cases. The interval between injury and operation was 1-7 days (mean, 2.1 days). According to Neer classification, there were 28 cases of two-part fractures and 36 cases of three-part fractures. According to the angulation direction of the proximal humeral neck shaft angle, there were 21 cases of adduction fractures and 43 cases of abduction fractures. The fractures were treated with limited open reduction via "door-shaft method" and proximal humerus internal locking systems for internal fixation. The operation time, intraoperative blood loss, number of fluoroscopy, hospital stay, and complications were recorded. The fracture healing was reviewed by X-ray film and the healing time was recorded. The shoulder joint function was evaluated by Neer score standard., Results: The operation time was 45-127 minutes, with an average of 82.3 minutes. The intraoperative blood loss was 30-125 mL, with an average of 62.7 mL. Intraoperative fluoroscopy was performed 30-69 times, with an average of 37.0 times. The hospital stay was 6-23 days, with an average of 10.3 days. All incisions healed by first intention. All patients were followed up 12-37 months, with an average of 18.3 months. X-ray film re-examination showed that all fractures healed, the healing time was 12-21 weeks, with an average of 14.3 weeks. After operation, 3 cases had shoulder stiffness and 1 case had fracture malunion. At last follow-up, the Neer score of shoulder joint function was 49-97, with an average of 83.1. Among them, 38 cases were excellent, 13 cases were good, 10 cases were fair, and 3 cases were poor. The excellent and good rate was 79.7%. The excellent and good rate of patients with two-part fractures was 82.1% (23/28), and the excellent and good rate of patients with three-part fractures was 77.8% (28/36)., Conclusion: The "door-shaft method" not only reduces the difficulty of the Joystick technique in the reduction of proximal humerus fractures, but also provides auxiliary stability. It is used for limited open reduction and internal fixation with locking plate to treat the two- and three-part fractures of the proximal humerus, which can achieve good effectiveness.

Objective: To observe the influence of different humeral neck-shaft angle on the efficacy in the treatment of proximal humeral fractures with locking plate., Methods: A total of 106 patients with proximal humeral fractures were treated by locking plate between March 2009 and March 2013, and the clinical data were retrospectively analyzed. Of 106 cases, 58 were male and 48 were female, aged from 26 to 71 years (mean, 52.3 years). The causes were traffic accident injury in 54 cases, falling injury from height in 23 cases, falling injury in 21 cases, and others in 8 cases. According to the Neer classification, there were 32 cases of two-part fractures, 65 cases of three-part fractures, and 9 cases of four-part fractures. The time from injury to operation was 1-7 days (mean, 2.7 days). According to neck-shaft angle by X-ray measurements at 1-3 days after operation, the patients were divided into 3 groups: valgus group (> 145°), normal group (126-145°), and varus group (< 126°) to observe the influence of neck-shaft angle on efficacy., Results: According to postoperative humeral neck-shaft angle, there were 10 cases in valgus group, 75 cases in normal group, and 21 cases in varus group. There was no significant difference in general clinical data among 3 groups (P > 0.05). The patients were followed up 6-12 months. The X-ray results showed fracture healing, and no significant difference was found in fracture healing time among 3 groups (P>0.05). After 6 months, the varus angle of femoral head and visual analogue scale (VAS) score of normal group were significantly lower than those of valgus group and varus group (P < 0.05). The excellent and good rate of Constant-Murley score was 78.67% (59/75) in normal group, and it was significantly higher than that in valgus group (60.00%, 6/10) and varus group (42.86%, 9/21) (P < 0.05), but there was no significant difference between valgus group and varus group (P > 0.05). The complication rate was 28.57% (6/21) in varus group, was 10.67% (8/75) in normal group, and was 20.00% (2/10) in valgus group, showing no significant difference among 3 groups (χ2 = 4.31, P = 0.12)., Conclusion: Reconstruction of normal neck-shaft angle is the key to good shoulder function and clinical efficacy in the treatment of proximal humeral fracture.

Objective: To investigate the effectiveness of limited internal fixation combined with hinged super-articular external fixator to treat type C3 fracture of the distal humerus., Methods: Between September 2007 and November 2012, 37 cases of type C3 fracture of the distal humerus were treated. There were 22 males and 15 females with an average age of 43.6 years (range, 22-66 years). The causes were accident injury in 24 cases, falling injury in 5 cases, falling from height in 4 cases, heavy crush injury in 2 cases, machine injury in 1 case, and other injury in 1 case. There were 22 cases of open injury and 15 cases of closed injury. The time from injury to operation was 3-46 hours (mean, 18 hours)., Results: Needle tract reaction and incision infection occurred in 3 cases and 1 case respectively, healing of incision by first intension was obtained in the other cases. Thirty-six patients were followed up 9-48 months (mean, 25.4 months). Heterotopic ossification occurred in 3 cases after operation and no recurrence was found by release after fracture healing. Fractures healed in the other patients after 6-14 months (mean, 9 months) of operation except 1 patient who suffered chronic osteomyelitis. One patient had delayed ulnar neuritis at 12 months after operation, and the nerve function returned to normal after the ulnar nerve transposition. There was no bone ischemic necrosis, elbow joint instability, or loosening of internal fixation. At last follow-up, the average range of motion of injured elbow was 105.0° in flexion, -25.0° in extension, 69.2° in pronation, and 75.6° in supination. According to Mayo elbow joint function score (MEPS) and disability of arm shoulder and hand (DASH) score, the results were excellent in 22 cases, good in 8 cases, fair in 4 cases, and poor in 2 cases with an excellent and good rate of 83.3%; and according to Cassebaum elbow joint function score, the results were excellent in 21 cases, good in 7 cases, fair in 5 cases, and poor in 3 cases with an excellent and good rate of 77.8%., Conclusion: A combination of limited internal fixation and hinged super-articular external fixator has satisfactory clinical curative effect for type C3 fractures of the distal humerus, relatively few complications.

Objective: To evaluate the effectiveness of titanium elastic nails for severe displaced proximal humeral fractures in older children., Methods: Between April 2009 and July 2012, 31 cases of severe displaced proximal humeral fractures were treated with closed or open reduction and fixation with 2 titanium elastic nails, and the clinical data were retrospectively analyzed. There were 23 boys and 8 girls, aged from 10 to 15 years (mean, 12.8 years). The causes of injury were sports injury (16 cases), traffic accident (11 cases), and falling from height (4 cases). The interval from injury to operation was 6 hours to 7 days (mean, 72 hours). According to Neer-Horwitz classification, 17 cases were rated as type III fracture and 14 cases as type IV fracture. There were 21 cases of metaphyseal fractures and 10 cases of epiphyseal fractures., Results: Satisfactory reduction of fracture and stable fixation were obtained in all patients (closed reduction in 23 cases and open reduction in 8 cases). Primary healing was achieved in all incisions; no infection and neurovascular injury occurred. All patients were followed up 12-36 months with an average of 20 months. X-ray films showed that all fractures healed at 7-10 weeks (mean, 8 weeks). During follow-up, no disturbance of development or angulation deformity caused by premature physeal closure or bone bridge formation was observed. At last follow-up, the average Neer score of the shoulder was 95.7 (range, 83-100). The appearance and motion of the shoulder were normal. There was no significant difference in the upper extremity length between affected side and contralateral side [(67.68 +/- 2.56) cm vs. (67.61 +/- 2.54) cm; t = 1.867, P = 0.072]., Conclusion: Titanium elastic nails for severe displaced humeral fractures in older children is a safe and effective method with a low complication incidence.

Objective: To investigate the clinical results of locking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation., Methods: Between January 2011 and August 2012, 16 patients with proximal humeral fractures (AO type C2) were treated by locking-plate with an intramedullary fibular allograft. The clinical data were retrospectively analysed. There were 5 males and 11 females with an average age of 64 years (range, 55-70 years). The injury causes were falling injury in 12 cases, traffic accident injury in 3 cases, and sports injury in 1 case. The duration between injury and operation ranged from 2 to 6 days (mean, 4.5 days). The imaging data were used to judge the fracture healing, and to measure the neck-shaft angle and the height of humeral head; the disability of arm, shoulder, and hand (DASH) score, short-form 36 health survey scale (SF-36), and Neer score were used to evaluate the function of the shoulder after surgery., Results: Primary healing of incision was obtained in all patients; no complication of vascular and nerve injury occurred. Sixteen cases were followed up 12-24 months (mean, 18 months). All fractures healed at 18-24 weeks (mean, 20 weeks). No complication occurred as follows: re-displacement, necrosis, rejection reaction, and loosening or extraction of screws. At last follow-up, the neck-shaft angle was 126.6-136.9 degrees (mean, 132.5 degrees), showing a little lost when compared with intraoperative angle (130.5-138.0 degrees, 134.0 degrees on average). At 12 months after surgery, the height loss of humeral head was 1.8-4.6 mm (mean, 2.0 mm); the passive anteflexion of the shoulder was 130-160 degrees (mean, 148 degrees); the active anteflexion was 120-145 degrees (mean, 136 degrees); the external rotation was 30-65 degrees (mean, 56 degrees); the internal rotation was 15-25 degrees (mean, 19 degrees). And the DASH score was 2-53 (mean, 12); the SF-36 score was 50-95 (mean, 89). According to Neer score for shoulder function, the results were excellent in 10 cases, good in 4 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 87.5%., Conclusion: Locking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation has satisfactory clinical results because of stable fixation, high clinical outcome scores, and low internal fixation failure.

Objective: To compare therapeutic effects of locking plates for the treatment of Neer 3-and 4-part proximal humerus fractures., Methods: From January 2009 to June 2011, 64 patients with Neer 3-and 4-part proximal humerus fractures were treated with locked plate fixation. There were 39 patients in the 3-part group including 16 males and 23 females, with an average age of (55.12 +/- 12.52) years old; and 25 patients in the 4-part fractures group including 9 males and 16 females,with an average age of (57.92 +/- 13.14) years old. The American Shoulder and Elbow Surgeons score (ASES), visual analogue scale (VAS) and complications were documented for analysis before and after treatment., Results: All the patients had incision healing at the first stage. All the patients were followed up, and the duration ranged from 12 to 30 months, with a mean of 16.5 months. Comparably better shoulder function recovery was achieved in the 3-part fractures group with regard to the ASES (76.14 +/- 14.10 in the 3-part fractures group vs. 65.93 +/- 11.82 in the 4-part fractures group, P < 0.05). Moreover,a statistical difference (P < 0.05) was observed regarding the VAS pain score (2.12 +/- 1.63 in the 3-part fractures group vs. 3.90 +/- 2.21 in the 4-part fractures group). For the complications rate,no statistical difference was noted between 3-part fractures group and 4-part fractures group (20.51% vs. 36.00%)., Conclusion: The clinical outcomes of the 3-part proximal humerus fractures is better than the 4-part fractures proximal humerus fractures treated with locking plate. Complex proximal humeral fractures treated with locking plates can be achieved a satisfactory outcome when attention is paid to anatomic reduction, stable fixation, proper screws and plate placement, and reasonable functional exercise postoperative.

Objective: To investigate the comparison of curative effects in treating proximal humerus fractures' patients between minimally invasive locking plate internal fixation and open reduction with internal fixation, and to provide guidance for the operation method of the proximal humerus fracture patients., Methods: In the study, 157 patients of proximal humerus fractures from May 2006 to December 2012 in Peking University Third Hospital were analyzed retrospectively, of whom 78 were followed up, including 19 males and 59 females. They were from 15 to 90 years old, with the mean age of 60.5 years. According to Neer classification, there were 53 cases of two-part fractures, 19 cases of three-part fractures and 6 cases of four-part fractures. According to AO classification, there were 49 cases of type A,21 cases of type B and 8 cases of type C. There were 24 cases treated with minimally invasive locking plate internal fixation operation and 54 cases treated with open reduction with internal fixation operation. The patients were followed up with postoperative physical examinations and X ray examinations. Postoperative shoulder pain after 1 week and more than 6 months was assessed using the VAS score. Postoperative shoulder joint function with the use of Constant-Murley score and ASES score were evaluated after 3 months and more than 6 months. The results were analyzed by SPSS 18.0., Results: The follow-up time was 6 to 85 months, with the mean time of 33.8 months. According to the rank sum test: there were significant differences in operation time (P=0.002), postoperative hospital day (P=0.001), the satisfaction of patients (P=0.029), postoperative shoulder pain after 1 week (P=0.024), postoperative Constant-Murley score after 3 months (P=0.012) and postoperative ASES score after 3 months (P=0.001) between minimally invasive group and non-minimally invasive group. There weren't significant differences in clinical union time of bone (P=0.446), postoperative shoulder pain after more than 6 months (P=0.894), postoperative Constant-Murley score after more than 6 months (P=0.122) and postoperative ASES score after more than 6 months (P=0.351) between minimally invasive group and non-minimally invasive group. There were no breakage of the internal fixation and humeral head osteonecrosis. Minimally invasive group had 2 cases with internal fixation loosening (8.3%) and 1 case with complete limitation of abduction (4.2%). Non-minimally invasive group had 1 case with tracture nonunion (1.9%), 1 case with internal fixation loosening (1.9%) and 1 case with complete limitation of abduction (1.9%)., Conclusion: The operation method of proximal humerus fractures is an important factor affecting the recovery of shoulder joint function. Minimally invasive locking plate internal fixation operation in early stage (1 week) of pain control, early (3 months) functional recovery, operation time, postoperative hospital day and patient satisfaction are better than those of traditional operation.

Objective: To evaluate the effectiveness of locking plates for Neer 3- and 4-part proximal humerus fractures., Methods: A retrospective analysis was made on the clinical data of 77 patients with 3- or 4-part proximal humerus fractures, who underwent open reduction and internal fixation of locking plates and were followed up more than 12 months between July 2008 and May 2011. There were 39 males and 38 females with an average age of 54.2 years (range, 18-81 years). Fractures were caused by falling in 47 cases, by traffic accident in 16 cases, by falling from height in 4 cases, by sporting in 5 cases, and by other reasons in 5 cases. The time between injury and operation was 2-16 days (mean, 4.5 days). According to Neer classification, there were 54 cases of 3-part fracture and 23 cases of 4-part fracture. The Constant scores, visual analogue score (VAS), and the complications were evaluated during follow-up., Results: After operation, healing of incisions by first intention was obtained in 76 cases and healing by second intention in 1 case. All patients were followed up 12-36 months (mean, 18.5 months). At last follow-up, the Constant score was 71.1 +/- 11.9; the results were excellent in 18 cases, good in 24 cases, fair in 25 cases, and poor in 10 cases with an excellent and good rate of 54.5%. The VAS score was 2.8 +/- 2.2. Bone nonunion occurred in 2 cases; the other patients had bone union within 2-6 months (mean, 3.2 months). The complications occurred in 25 cases (32.5%). Revision surgery was performed in 15 patients (19.5%)., Conclusion: The treatment of Neer 3- and 4-part proximal humerus fractures remains challenging. Anatomic reduction, stable fixation, and reduced humeral head blood supply disruption may lead to a satisfactory outcome.

Objective: To evaluate the treatment effect of three and four-part fractures of proximal humerus in elder patients using indirect reduction combined with locking proximal humeral plate (LPHP) fixation., Methods: From November 2004 to May 2008, 24 cases of proximal humeral three and four-part fracture were treated with percutaneous plate fixation using LPHP included 6 males and 18 females with an average age of 70 years old ranging from 55 to 88 years. The surgery was performed through antrolateral transdeoltoid approach. After extra articular capsule indirect reduction, the plate was inserted through the incision, and then an incision was made distal to previous incision to expose distal plate. The proximal fragments were fixed with 4 to 6 screws, and distal fragments were fixed with 3 screws. Shoulder exercises were performed at the 2nd to 3rd day after operation. Two weeks after operation, active shoulder exercise was done, which was gradually intensified 3 weeks after operation. The functional outcomes of the shoulder were assessed according to Constant score., Results: All the fractures united clinically and radiologically. The mean healing time was 10.5 weeks (8 to 21 weeks). The mean Constant score was 81.6 points (49 to 92 points). A total of 20 patients had excellent or satisfactory result, with only one scored as poor., Conclusion: The technique of extra articular capsule indirect reduction combined LPHP internal fixation has the advantages of stable, easy to operate, less vascular damage and so on. It can effectively treat the proximal humerus three-and four-part fractures, especially to elder patients.

Objective: To investigate a method to distinguish avulsion fracture from sesamoid, accessory bone, and permanent osteoepiphyte., Methods: Fourteen cases of suspicious avulsion fractures of articular portion of tubular bones were reviewed. Direct/indirect signs and the injury mechanism of avulsion fractures were analyzed and compared with permanent osteoepiphyte, sesamoid and accessory bones for their morphological characteristics., Results: There are two cases of permanent osteoepiphytes, three cases of sesamoids, and three cases of accessory bones. These cases were characterized by smooth edges, contiguous bony cortex, without swelling of the surrounding soft tissue or obvious image changes after consecutive radiography., Conclusion: It is fundamental in image analysis to distinguish avulsion fracture from physiological small osteoepiphyte, sesamoid bone, and aberrant accessory bone.