“RETROSPECTIVE AND PROSPECTIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL OUTCOMES IN COMMINUTED PROXIMAL
HUMERUS FRACTURES TREATED BY LOCKING PLATE”
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
In Partial fulfillment of the Regulations
“RETROSPECTIVE AND PROSPECTIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL OUTCOMES IN COMMINUTED PROXIMAL
HUMERUS FRACTURES TREATED BY LOCKING PLATE”
Dissertation Submitted to
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI
In Partial fulfillment of the Regulations for the Award of the degree
M.S. DEGREE-BRANCH II ORTHOPAEDIC SURGERY
MADRAS MEDICAL COLLEGE CHENNAI
MAY - 2019
“RETROSPECTIVE AND PROSPECTIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL OUTCOMES IN COMMINUTED PROXIMAL
HUMERUS FRACTURES TREATED BY LOCKING PLATE”
CERTIFICATE
This is to certify that this dissertation “RETROSPECTIVE AND
PROSPECTIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL
OUTCOMES IN COMMINUTED PROXIMAL HUMERUS
FRACTURES TREATED BY LOCKING PLATE” is a bonafide record of
work done by DR.NADARAJAN.J, during the period of his Post graduate
study from March 2017 to September 2018 under guidance and supervision in
the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Madras
Medical College and Rajiv Gandhi Government General Hospital,
Chennai-600003, in partial fulfilment of the requirement for
M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamil Nadu
Dr. M.G.R. Medical University to be held in May 2019.
Prof. Jayanthi, Dean,
Rajiv Gandhi Govt. General Hospital, Madras Medical College,
Chennai – 600 003.
Prof. N.Deen Muhammad Ismail, M.S Ortho., D.Ortho.,
Director & Professor of Orthopaedics, Institute of Orthopaedics &Traumatology, Madras MedicalCollege,
DECLARATION
I declare that the dissertation entitled “RETROSPECTIVE AND
PROSPECTIVE STUDY OF FUNCTIONAL AND RADIOLOGICAL
OUTCOMES IN COMMINUTED PROXIMAL HUMERUS
FRACTURES TREATED BY LOCKING PLATE” submitted by me for the
degree of M.S ORTHO is the record work carried out by me during the period of
March 2017 to August 2018 under the guidance of Prof. N. DEEN MUHAMMAD
ISMAIL, M.S.Ortho., D.Ortho., Director, Professor of Orthopaedics, Institute of
Orthopaedics and Traumatology, Madras Medical College, Chennai. This dissertation
is submitted to the Tamil Nadu Dr.M.G.R. Medical University, Chennai,
in partial fulfilment of the University regulations for the award of degree of
M.S.ORTHOPAEDICS (BRANCH-II) examination to be held in May 2019.
Place: Chennai Signature of the Candidate
Date:
(Dr.J.NADARAJAN)
Signature of the Guide:
Prof.N. DEEN MUHAMMAD ISMAIL, M.S.Ortho., D.Ortho.,
Director, Professor of Orthopaedics,
Institute of Orthopaedics and Traumatology,
ACKNOWLEDGEMENT
I express my thanks and gratitude to our respected Dean Prof.R.JAYANTHI,
M.D., FRCP., Madras Medical College, Chennai – 3 for having given permission for
conducting this study and utilize the clinical materials of this hospital.
I have great pleasure in thanking Prof.N. DEEN MUHAMMAD ISMAIL
M.S. Ortho., D. Ortho., Director, Institute of Orthopaedics and Traumatology, for
being my guide and giving his valuable advice throughout this study.
My sincere thanks and gratitude to Prof.R. SELVARAJ, M.S. Ortho.,
D. Ortho., Professor, Institute of Orthopaedics and Traumatology, for his guidance
and constant advice provided throughout this study
My sincere thanks and gratitude to Prof.V.SINGARAVADIVELU, M.S.
Ortho., D. Ortho., Ph.D., Professor, Institute of Orthopaedics and Traumatology, for
his guidance and constant advice provided throughout this study.
My sincere thanks and guidance to Prof.A.PANDIASELVAM, M.S. Ortho.,
D. Ortho., Professor, Institute of Orthopaedics and Traumatology, for his valuable
advice and support.
I am very much grateful to Prof.M.SUDHEER, M.S. Ortho., D. Ortho., for
I sincerely thank Prof.NALLIRUVARAJ, M.S. Ortho., D. Ortho.,for his
advice, guidance and unrelenting support during the study.
I sincerely thank Prof.K.VELMURUGAN, M.S. Ortho., D. Ortho., for his
advice, guidance and unrelenting support during the study.
My sincere thanks and gratitude to my co guide Dr. P.KANNAN M.S.
Ortho., for his constant advice and guidance provided throughout this study.
I sincerely thank Dr.S.Senthilsailesh, Dr.Nalli.R.Gopinath, Dr.Kingsly,
Dr.J.Pazhani, Dr.Muthalagan, Dr.Hemanthkumar, Dr.Kaliraj, Dr.Saravanan, Dr.Rajganesh, Dr.Sarathbabu, Dr.Dhanasekar, Dr.Sureshanandhan, Dr.Karthick, Dr.Balasubramaniam, Dr.Jeffray Raj Assistant Professors of this
department for their valuable suggestions and help during this study.
I thank all anesthetest and anaesthetists and staff members of the theatre and
wards for their endurance during this study.
I am grateful to all my post graduate colleagues for helping in this study.
Last but not least, my sincere thanks to all our patients, without whom this study
CONTENTS
S.NO PARTICULARS PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 3
3. ANATOMY AND CLASSIFICATION 4
4. REVIEW OF LITERATURE 21
5. CLINICAL EVALUATION 40
6. MATERIALS AND METHODS 43
7. APPROACH 47
8. SURGICAL TECHNIQUE 49
9. CASE ILLUSTRATION 56
10. RESULTS AND OBSERVATION 66
11. DISCUSSION 81
12. CONCLUSION 87
13. BIBLIOGRAPHY 89
14. ANNEXURE
1
INTRODUCTION
The shoulder joint in the body has got the maximum range of
movements that provides high degree of mobility for diverse functions of the
upper extremity. The incidence of skeletal injuries among trauma victims has
increased in the recent years, of which proximal humerus fractures accounts to
approximately 4 – 5% of all the bony injuries.1 It is the third most common
fracture type among the elderly population with osteoporotic bone and the
incidence will increase further due to the increase in life expectancy with
better quality of life2.
The treatment of proximal humerus fractures is very challenging due to
the wide variety of fracture patterns seen in these injuries. The aim in treating
these fractures is to obtain a functional and pain-free shoulder. Multiple factors
govern the outcome of these fractures like age, activity level, professional
demands, co-morbidities and compliance with post-operative rehabilitation
protocol.3 Due to the complex anatomy and various fracture patterns the
reduction of displaced proximal humerus fracture is more challenging. Wide
knowledge about the anatomy and the shoulder bio-mechanics plays
significant role in the outcome of these fractures.
Most of the undisplaced proximal humerus fractures can be treated
conservatively, but the treatment of displaced fractures remains
controversial.3It is of utmost importance to select the appropriate implant and
2
The wide availability of operative techniques evolved in managing
proximal humerus fractures includes external fixator, pin osteosynthesis, nail
osteosynthesis, conventional plate osteosynthesis, locking plate osteosynthesis
and hemiarthroplasty.
The new locking plate technology has overcome the complications and
failures associated with that of older fixation methods. The combination of
anatomical pre-contoured plate with the newly designed locking screw forms
the basis of new locking plate osteosynthesis. The principle is based on the
fixed angle relationship between the screws and the plate, that provides angular
and axial stability with adequate buttressing and load bearing support which
together prevents loss of reduction and collapse of the fracture fragments.
Many clinical studies indicate proximal humerus fractures managed with
proximal humerus locking plate construct that has got improved biomechanical
stability and offers many potential benefits compared to other operative
techniques.4 But various complications like screw cut out, screw penetration,
varus collapse are still documented.5 These complications are attributed to
increased stiffness and rigidity of the construct with pre-existing osteoporosis.
Eventhough locking plates were recommended in the fixation of proximal
humerus fractures, there are varying observations among different studies
regarding the complications and functional outcomes. Hence the present study
is conducted to evaluate the functional and radiological outcome in displaced
3
AIMS AND OBJECTIVES
To assess the functional and radiological outcome of unstable two-part,
three- part and four- part proximal humerus fractures fixed by proximal
ANATOMY
AND
4
ANATOMY OF THE SHOUDER JOINT
DEVELOPMENTAL ANATOMY
The humerus ossifies from one primary centre and seven secondary
centres. During the 8th week of development the primary centre first appears in
the middle of the diaphysis. In infants the epiphysis of proximal humerus is
spherical in shape.
The upper part of humerus ossifies from three secondary centres. One
centre for the humerus head appears during the first year, one for the Greater
tuberosity develops in the second year and the last one for the lesser tuberosity
appears during the fifth year of life. These three will fuse and form the
epiphysis by six years which in turn fuses with the diaphysis by twenty years of
age.
The epiphysial line is seen to encircle the head at its lowest margin and
this forms the growing end of the bone
RELEVANT ANATOMY
Understanding the shoulder anatomy is very essential because the
functional outcome depends on the correct alignment and proper interaction of
its anatomical structure.
The humerus is the longest and largest bone in the upper limb with
expanded proximal end called as the “ PROXIMAL HUMERUS “ , a shaft and
5 The proximal humerus consists of:
1 .Humerus head
2.Greater tuberosity
3.Lesser tuberosity
4.Bicipital groove
5.The shaft of proximal humerus
HEAD
It is larger than the glenoid cavity and forms 1/3rd of the sphere. The
head is directed medially, upwards and backwards . It articulates with the
glenoid cavity of the scapula .The articular surface is covered by hyaline
6
GREATER TUBEROSITY
It is the most lateral projection in the proximal humerus. It has three
impressions in the posterior aspect divided into upper, middle and lower in to
which the supra spinatus, infra spinatus and teres minor muscles are inserted
respectively. It is covered by the deltoid that gives rounded contour for the
shoulder.
LESSER TUBEROSITY
It is a projection on the anterior aspect of the proximal humerus .It is
directed forwards and medially and the subscapularis gets inserted
into it.
INTERTUBERCULAR SULCUS
It is also called as bicipital groove. It separates the lesser tuberosity
present on the medial side from the anterior aspect of greater tuberosity .The
medial and lateral lips of the sulcus corresponds to the downward projection of
lesser and greater tuberosities. The pectoralis major muscle gets inserted into
the lateral lip of the sulcus , the latissimus is inserted into the floor and the
teres major is inserted into the medial lip of the sulcus.
The contents of the bicipital groove are:
1) tendon of the long head of biceps along with synovial sheath
7
The tendon of long head of biceps is enclosed by transverse humeral
ligament.
ANATOMICAL NECK
The line demarcating the head, from rest of upper end of proximal
humerus neck, is called as the anatomical neck. It is seen as a slight
constriction adjacent to the articular surface, at the junction of head and
tuberosities.
SURGICAL NECK
The narrow line that separates the upper end of proximal humerus from
the shaft is called as the surgical neck. It is seen just below the greater and
lesser tuberosities
ANATOMY OF THE ANTERIOR PART OF THE SHOULDER JOINT
GLENOID
It is a shallow convex and inverted “comma” like structure, involving
approximately 1/3rd of the surface area of the humeral head, during articulation
which also gives attachment for the capsule and the glenoid labrum.
GLENO HUMERAL JOINT
The shoulder joint is a ball and socket type of synovial joint. The joint is
8
has got the highest range of motion, than any other joints in the body. It is a
structurally weak and unstable joint because of the shallow and small sized
glenoid cavity which holds the head of the humerus. The humeral head is
approximately three to four times larger than the glenoid cavity. This
orientation allows greater range of motion in the shoulder joint .
The factors maintaining the stability of the shoulder joint are:
1) The rotator cuff forming the musculo- tendinous envelop for the
shoulder joint.
2) The coraco- acromian arch
3) The glenoid labrum which helps to deepen the glenoid fossa
Extra stability is provided by the long head of biceps, triceps and the
pectoral gridle muscles. The static stabilizers of the shoulder joints are: the
fibrous capsule, gleno- humeral ligament,coraco -humeral ligament, transverse-
9
The dynamic stabilizers of the shoulder joint are : the rotator cuff
muscles, deltoid, trapezius, serratus anterior, latissimus dorsi, levator scapulae
and rhomboideus.
The two main factors maintaining the stability are: the normal retro tilt
of the glenoid articular surface in relation to the axis of the scapula and the
retro torsion of the humeral head in relation to the shaft.
10
The muscles surrounding the shoulder joint are divided into intrinsic and
extrinsic groups. The extrinsic group of muscles aids in scapular movements.
The intrinsic group of muscles are the deltoid, teres major, latissimusdorsi,
pectoralis major and the rotator cuff muscles. They help in the movement of
proximal humerus and act as deforming forces following fracture of the
proximal humerus. The rotator cuff muscles forms a fibrous sheath of four
flattened tendons, which blends with the shoulder joint capsule and strengthens
it. The muscles of the rotator cuff are : infraspinatus, supraspinatus, teres minor
and subscapularis. They arise from the scapula and gets inserted into greater
tuberosity, expect the subscapularis which gets inserted into lesser tuberosity of
the proximal humerus. The rotator cuff muscles acts as a fulcrum for shoulder
joint during abduction.
During closed reduction, the long head of biceps gets tethered and
blocks the reduction manoeuvres. During open reduction the long head of
biceps acts as a crucial land mark for identifying the rotator interval so that the
muscles of the rotator cuff are preserved and fracture fragments are properly
identified and reduced.
VASCULAR ANATOMY
The major blood supply to the head of the proximal humerus is from the
anterior circumflex humeral artery which is a branch from the third division of
the axillary artery. The arcuate artery is a continuation of the ascending branch
11
is called as “Arcuate artery of Laing”. It enters the bone through the bicipital
groove hence, AVN of the humeral head occurs if the fracture line displaces the
anatomical neck of the proximal humerus. Minor contributions also arise from
the branches of the posterior circumflex humeral artery through the
metaphyseal vessels that supplies the posterior part of the proximal humerus.
NERVE SUPPLY
The shoulder joint is supplied by the axillary, musculocutaneous, and
suprascapular nerves through its intra articular branches. The axillary nerve lies
very close to the surgical neck of proximal humerus along with posterior
circumflex humeral artery. Approximately 5% of the proximal humerus
12
BIOMECHANICS
The shoulder joint is formed by three bones namely the scapula, clavicle
and the humerus. The ball and socket variety of the shoulder joint has got
significant forces acting across the gleno- humeral articulation.
There are three joints in the shoulder complex namely the glenohumeral
joint, the sternoclavicular and the acromioclavicular joint. The movements
possible at the glenohumeral joint are flexion, extension, internal rotation,
external rotation, adduction and abduction. The Glenohumeral joint moves
along with other joints of the shoulder complex. This co-ordinated movement is
referred as the scapulo-humeral rhythm. For every 15 degrees of shoulder
abduction, 10 degrees occurs at the glenohumeral joint and 5 degrees at scapulo
thoracic joint. The shoulder joint is not exactly oriented in the sagittal or
coronal plane of the body, but it is 35 to 45 degrees away from the sagittal
plane of the body.
The humerus head is retroverted 30 to 40 degrees with an average radius
of curvature of 25mm.62 Only 25%-35% of the head articulates with the glenoid
13
The avulsion of the greater tuberosity is pathognomonic of associated
rotator cuff injury and will destabilise the shoulder joint during elevation by
causing superior subluxation. This will also lead on to sub –acromial
impingement and loss of normal gliding motion of the shoulder joint.
Hence poor range of motion, pain & loss of strength can occur if the
anatomy is not properly restored.
The various fracture patterns and the displacements types are 76 :
1) greater tuberosity fragment gets displaced postero-superiorly by
supraspinatus and infraspinatus pull.
2) lesser tuberosity fragment gets displaced medially by subscapularis
pull.
3) shaft gets displaced medially and anteriorly by pectoralis major pull.
In general, based upon the bone quality two groups of patients can be
14
to advanced age and diminished bone mineral density. They most often present
with impacted fractures and because of which reduction and stable fixation will
be a challenge. The group II will include younger individuals with either
minimally displaced or more comminuted fracture fragments and they will be
15
CLASSIFICATION
Various systems of classification has evolved to understand and to aid in
the fixation of these fractures.
Kocher’s Classification
It is based on different anatomical levels of fracture involvement namely
1. Anatomical neck
2. Surgical neck
3. Epiphyseal region
Limitation of this classification is that, it failed to differentiate between
displaced and undisplaced fractures.
Watson-Jones Classification
It is based on mechanism of injury and is classified into –
1. Abduction type
2. Adduction type
3. Contusion crack fractures
Limitation of this classification is that, depending on x-ray taken in
internal rotation or external rotation, the fracture is visualised as adducted or
16
Codman Classification
In 1934, he proposed this classification by understanding that the
proximal humerus can be separated into four distinct fragments along the
anatomical lines of epiphyseal union. This formed the basis for the future
Neer’s classification.
Limitation of this classification is that it does not talk about the
biomechanical forces causing displacement and the treatment plan.
Neer’s four part Classification
In 1970, Charles Neer from New York proposed the comprehensive
system of classification based on anatomy, biomechanical forces and related it
to the diagnosis and treatment. The number and displacement of the four
anatomical segments namely - humeral head, greater tuberosity, lesser
tuberosity and the shaft of humerus forms the basis for this classification.
A segment or a part is defined as displaced if it exceeds 1cm of
separation or 45-degrees of angulation.
Till date the Neer’s proximal humerus fracture classification system
remains the most commonly followed classification system.
Few drawbacks noted with this system are poor inter-observer and
intra-observer reliability, lower prediction regarding the risk of AVN of humeral
17
Neer’s fracture dislocation Classification
When the head is dislocated outside the shoulder joint in addition to a
fracture, it is termed fracture dislocation .It is classified according to the
direction of dislocation into :
1. Anterior dislocation
2. Posterior dislocation
Based on the number of fracture fragments, it is further classified into –
1. Two part fracture dislocation
2. Three part fracture dislocation
Or as special variants like
1. Head splitting fractures
2. Impression fractures
3. Valgus impacted fractures.
Since the Neer’s classificat
the humeral head, Hertel
regarding the risk factors of AVN. It mainly depends on the number of fracture
planes rather than the fracture segments.
18 Or as special variants like
Head splitting fractures
Impression fractures
Valgus impacted fractures.
Since the Neer’s classification system failed to predict the AVN risk of
the humeral head, Hertel9 proposed another classification system with emphasis
regarding the risk factors of AVN. It mainly depends on the number of fracture
planes rather than the fracture segments.
ion system failed to predict the AVN risk of
proposed another classification system with emphasis
19
Hertel9 in his article reported that the length of the metaphyseal head
extension <8 mm, the integrity of the medial hinge and the fracture of
anatomical neck remains as good predictors for ischemia of the humeral head.
AO Classification
AO-ASIF group applied the AO system for classifying the proximal
humerus fractures into three types based on increasing severity of injury.
Type A
• Extraarticular
• Involves two of the four segments
• No vascular isolation of articular fragments
• No risk for AVN
• Least severe
Type B
• Partially intra articular
• Involves three out of four segments
• Least risk for AVN
• Partial vascular isolation of articular fragments.
20
Type C
• Intra articular
• Involves all the four segments
• Complete vascular isolation of articular fragments.
• Highest risk for AVN
• More severe
Each alphabetical injury type, is further subdivided into higher order
numbers indicating the increasing order of severity.
Among all the above classification, the Neer’s classification is still the
most commonly followed system worldwide due its implications in the
21
REVIEW OF LITERATURE
EPIDEMIOLOGY
Osteoporotic fractures have become a major health problem in the recent
years with proximal humerus fractures being the third most common fracture
among the elderly population. The incidence ranges from 57.4 to 136.8 per one
lakh person years with more predilection among women.6
MANAGEMENT
As there is no unique algorithm for treating proximal humerus fractures
the management has been controversial over the years. The treatment options
for these fractures are broadly classified into conservative or surgical. Again,
the surgical management can further be subdivided into reconstructive or
replacement techniques.
CONSERVATIVE MANAGEMENT
Most of the proximal humerus fractures are undisplaced or minimally
displaced and yields good functional results after conservative management by
immobilising the arm and instituting early mobilisation when pain
subsides.13Irrespective of the management techniques, early mobilisation plays
a key factor for faster functional recovery and achieving good pain relief.14
Hanson et al.15 reviewed 160 proximal humerus fractures treated
conservatively. The study included 75 cases with one-part, 60 two-part, 23
22
follow up period of one year. Patients were immobilised using cuff and collar,
arm slings and braces. Average duration of immobilisation was 24 days. The
Constant-Murley score was 74.3 after one year. At the end of one year follow
up, 93% of patients achieved union with an average time of 14 weeks. The
complications encountered were shoulder impingement, stiffness among 11
cases and fracture displacement among 17 cases.
Zyto et al.16 studied 40 patients with three and four-part proximal
humerus fractures. The average age was 74 years. The patients were treated
both conservatively and surgically with 20 patients in each group. Among
conservative group, the arm was immobilised using arm sling for 7 to 10 days
followed by rehabilitation. At the end of 60 months, the observed
Constant-Murley score was 60 among the surgical group and 65 among the conservative
group with no statistical difference among the two groups. The study concluded
that, at one year follow-up optimal shoulder function was achieved among both
the groups regardless of the type of treatment. Since more complications were
found among the surgically managed group, conservative management should
be considered in older individuals with three- part proximal humerus fractures.
SURGICAL MANAGEMENT
Improved surgical modalities and newer implants have shifted the
balance more towards surgical fixation especially among displaced fracture
patterns of proximal humerus fractures. The main goal in fixation is
23
the anatomy, with minimal soft tissue damage and preserving the vascular
supply. Various surgical modalities have been followed for the management of
these fractures like external fixation osteosynthesis, pin osteosynthesis, nail
osteosynthesis, plate osteosynthesis and endoprosthesis replacement with each
having their own advantages and drawbacks.
EXTERNAL FIXATION
External fixation was preferred among patients of proximal humerus
fractures with poor general condition, multiple injuries, with weak bone and
poor soft tissue conditions and also in open fractures as a minimal invasive
procedure.
Meselhy and Singer17 reviewed 14 patients having two-part and
three-part proximal humerus fractures. The reported mean age among the three-participants
was 43 years. Illizarov external fixation was used in the management of all
these fractures. In this study the average time for the union was 10 weeks. Two
weeks following the union the fixator was removed. The mean
Constant-Murley score observed was 73, after 18 months of follow up. In this study the
complications observed was superficial pin tract infection among 10 patients
and 1 case of AVN of the humerus head. The author concluded that Illizarov
external fixator was useful in the management of proximal humerus fractures,
by allowing indirect reduction without compromising the blood supply to
24
The advantages of external fixation in the management of proximal
humerus fractures are minimal soft tissue stripping and hence it is associated
with higher union rates with lower incidence of AVN of the humerus head. The
main complication associated with this technique is pin tract infections.18
PIN OSTEOSYNTHESIS
Closed reduction and percutaneous pinning for proximal humerus
fractures are less invasive and this technique requires good bone quality,
minimum fracture communication and good surgical skills. 19
Kocialkowski and Wallace20 studied 22 displaced two-part, three-part,
and four-part displaced proximal humerus fractures managed by closed
reduction and percutaneous fixation with Kirschner-wires(K- wire). Only 45%
of the cases obtained good reduction and only 7 out of 22 patients showed
excellent functional results. Complications observed were pin migration
followed by pin tract infection and radial nerve palsy. This study concluded
25
hence open reduction is recommended since functional outcome and the union
rates were directly related to the reduction achieved.
Muncibi et al.21 studied 35 cases of two-part, three-part and four-part
proximal humerus fractures managed by closed reduction and percutaneous
K-wire fixation. The mean age group in this study was 66 years and the mean
follow up was 24 months. All the fractures healed by 8 weeks duration.
K-wires were removed on an average of 29th post operative day. The score
achieved at the end of the study was 87.6 with no complications reported.
Bonnevialle et al.22 retrospectively studied 32 patients with three-part
and four-part displaced proximal humerus fractures. The mean age of the study
group was 63 years and the mean follow up was 25 months. All the cases were
treated by 2mm K- wire fixation. The mean Constant-Murley score achieved
was 68. In this study the complications observed were K-wire migration among
8 cases which has resulted in early removal, two cases of greater tuberosity
osteolysis, two cases of humeral head AVN and three cases of adhesive
capsulitis. The author does not recommend this method for fixing proximal
humerus fractures among older individuals >70 years due to complications in
osteoporotic bone like K-wire migration and varus collapse.
Potential advantages of this technique are less soft tissue stripping and
decreased risk of AVN of humerus head23.However the main drawbacks of pin
osteosynthesis are poor biomechanical stability than nail and plate
26
infection, pin migration and malunion, therefore cannot be employed in
fixation of osteoporotic bones among older individuals which constitutes
majority of fracture population.
Nail osteosynthesis
Intramedullary nailing is useful in fixation of proximal humerus
fractures with segmental, pathological25 and metaphyseal extension26. It
reduces the fracture fragments indirectly and preserves the blood supply to the
injured bone. It is found to have comparatively lower rates of AVN risk to the
humerus head and higher union rates. For intramedullary nail osteosynthesis
technology, the bone quality, the age of the patient, activity level, compliance
with the post operative rehabilitation must be taken into consideration, in
addition to any medical co morbidities that may preclude the surgical
intervention.
Young et al.25 has assessed three specific aspects like the pattern of
injury, head vascularity, tuberosity orientation to the head and stability of the
head complex, in relation to the shaft using locked intramedullary nailing for
displaced proximal humerus fractures and concluded that it is a technically
demanding procedure with higher complication rates.
Hao and haut27, in his prospective study reviewed 22 patients of
proximal humerus fractures with mean age of 56 years. The study included 11
two-part, 9 three-part and 2 four-part fractures. All the fractures were managed
27
score reported was 75.5. The average union time for the fracture was three
months. Only one patient had complication because of proximal screw backout
and second surgery for screw removal was done. The author has concluded that
good functional outcome was observed in two-part and three-part proximal
humerus fractures with low complication rates and suggested larger studies are
needed to find out the usefulness of this technology in fixing four-part proximal
humerus fractures.
Wong et al.28 reported meta-analysis of 14 studies with two-part,
three-part, four-part proximal humerus fractures treated using intramedullary nailing.
487 patients were included in the study with mean age group of 64 years and
mean follow up period was 23 months. The Constant-Murley score observed
was 72.8. In this study the Constant- Murley score was higher among two-part
and three-part fracture groups compared to four-part fractures of proximal
humerus. The author has concluded that intramedullary nailing technology
gives satisfactory results among two-part and three-part fractures of proximal
humerus but redo surgery and complications following this technology remain
higher.
The main drawbacks of this technique are potential damage to the
rotator cuff muscles and inadequate fixation of the humerus head. 29
Endoprosthesis
In complex proximal humerus fractures that are not feasible for
28
endoprosthesis is performed. Shoulder hemiarthroplasty is preferred in
comminuted proximal humerus fractures among the elderly patients with poor
bone stock. It has achieved good pain relief but reported unsatisfactory with
regard to shoulder function. 30,31
Valenti et al.32 in his retrospective study analysed 51 patients with
displaced three-part and four-part proximal humerus fractures treated using
shoulder hemiarthroplasty. The mean age group was 71 years and the mean
follow up period was 18 months. The mean Constant-Murley score observed
was 50. In this study he has observed 4 cases of implant revision, 1 case of
peri-prosthetic fracture, 2 cases of rotator cuff tear that required reverse total
arthroplasty . The author concluded that patient satisfaction depends on pain
relief rather than functional outcome.
Agarwal et al.33 in his study reviewed 29 patients having three-part and
four-part displaced proximal humerus fractures. The mean follow up duration
was 18 months. The cemented hemiarthroplasty endoprosthesis was used for all
the cases. The Constant-Murley score achieved was 56.6. Complications of his
study were proximal migration of tuberosity among 4 patients, higher
placement of prosthesis in 1 patient and radiolucency at the bone cement
interface in 1 patient. This study has concluded that tuberosity healing plays a
significant role in the functional outcome of these fractures.
Reverse shoulder arthroplasty76 gave good results when performed as a
29
procedures. It is indicated in proximal humerus fractures that are associated
with rotator cuff insufficiency, failed hemiarthroplasty and complex proximal
humerus fractures. Postoperative scapular notching and implant loosening are
the main complications obsereved.
Longo et al.35 reported a systemic review of 10 studies that used reverse
total shoulder arthroplasty for managing proximal humerus fractures. This
study included 256 patients with mean age group of 75.5 years and the mean
follow up period was 28 months. The Constant-Murley score achieved was 57.
The most common complication observed was scapular notching in 82 cases
followed by infection among 7 cases, complex regional pain syndrome in 3,
deep vein thrombosis in 1, lymphedema in 1, brachial-plexopathy in 1, radial
nerve injury, dislocation in 4 and humerus stem loosening in 1 patient.
Boileau et al.36 has reported that reverse shoulder total arthroplasty has
higher complication rates following failed hemiarthroplasty than those operated
with primary rotator cuff insufficiency.
The author has concluded that reverse total shoulder arthroplasty can be
preferred in patients of proximal humeral fractures having rotator cuff
dysfunction without any nerve injuries.
Plate osteosynthesis
The conventional non-locking plate osteosynthesis is associated with
higher failure rates like implant failure, because of poor purchase of screws in
30
stripping thereby compromising vascularity to the humerus head and hence
increasing the risk of AVN.37
Higher rates of complications observed in fixing proximal humerus
fractures with previous technologies ( Pin osteosynthesis, Nail osteosynthesis,
Non-locking plate osteosynthesis) which includes screw cut-out or back-out,
loss of fixation, loosening of non-locking conventional plate, non-union,
malunion, rotator cuff impingement and migration of nail and pins23,24,29, has
made the invent of new locking plate technology that can address most of the
above mentioned complications and aids in better fixation of these fractures.
Most of the proximal humerus fractures seen among older individuals
have osteoporotic bones, who lack adequate purchase due to poor bone quality
and will lead on to implant failure. The new locking plate technology addresses
this drawback with new innovative design, in which several fixed angle locking
screws are used to fix the humerus head thereby optimising the screw purchase
and stabilising the tuberosity by using screws that are nearly perpendicular the
to the humerus head. By providing angular and axial stability the locking
screws helps to reduce the risk of collapse of the fragments following
reduction. The locked interface helps to provide stability , and adequate
buttressing support which altogether contributes in preventing the collapse of
the fragments. Hence it is a more stable construct than pin, nail or conventional
31
The fixation of proximal humerus fractures using conventional
non-locking plate osteosynthesis requires more of soft tissue stripping to fix the
plate with the bone for achieving compression effect. This leads to avascular
necrosis of the humerus head because of vascular disruption.37 The new locking
plate design addresses this issue by combining the principles of locking screws
with those of conventional plate fixation. Inside the body the locking plate acts
like an external fixator. By using this technology, it is unnecessary to strip off
the periosteum for fixing the plate to the bone. These plates are anatomical and
contoured to match the proximal humerus. Hence application of these plates
will not require much of soft tissue stripping and thus preserves the biological
integrity of the humeral head. In addition, compression of the plate to the bone
surface is not required which is believed to further compromise the periosteal
blood supply to the injured bone. 39,40
Even though literature provides sufficient references that favour the use
of locking plates in displaced two-part and three- part proximal humerus
fractures, the ideal method for the management of four-part proximal humerus
fracture is still unclear. 41,42,43
Locking Compression Plate Design
The Proximal Humerus LCP is a 3.5 System construct which has the
following features:
• Anatomically contoured
32
• The locking holes in the proximal part accepts 4mm locking screws to
provide a stable locked construct in the humeral head.
• The distal part contains 3-6 locking holes for the shaft fragment,
including 1 elongated hole to aid in plate positioning.
• The plate may have a diverging or converging screw pattern for the head
segment with studies supporting better stability with the divergent
33
FINAL CONSTRUCT
Vijayvargia et al.44 reviewed two-part, three-part and four-part proximal
humerus fractures among 26 patients with an average age group of 46 years.
The follow up period was 6 months and the Constant-Murley score achieved
was 72.5. The complication rate observed in this study was 15.4% with 2 cases
of varus malunion, with 1 case of wound infection and 1 case of screw cutout
into the joint. The author has concluded that only two out of 26 patients have
poor outcome and hence good functional outcomes can be provided using
locking plate fixation for these fractures.
Erasmo et al.45 in his retrospective study of 81 patients having proximal
humerus fractures with mean age group of 56 years and follow up period of 32
months. The Constant-Murley score observed was 73. This study included
two-part, three-part and four-part fractures. Only 5 out of 82 patients had poor
functional outcome. The 28% of their participants had complications which
34
screw penetration into the joint, 3 cases of subacromial impingement, 1 case of
surgical wound infection and 2 cases of non-union. The author has concluded
that majority of the patients (77 out of 82) had good functional outcome with
Constant-Murley score >55, hence using locking plate technology for fixation
is a better technique for managing proximal humerus fractures.
Kumar et al.46 reviewed 51 cases of two-part, three-part and four-part
proximal humerus fractures. The mean age of the study patients was 38 years
and the mean follow up period was 30 months. The Constant-Murley score
achieved was 79. The complications observed in 7 patients includes 4 cases of
varus malunion, 1 case of intra articular screw cutout, 1 case of subacromial
impingement and 1 case of surgical infection. Good functional outcome was
observed in majority of the study patients and the author concluded the locking
plate technology as the stable fixation method of fixing these fractures.
Hirschmann et al.47 in his study reported the longterm outcomes of
using locking plate technology for proximal humerus fractures among 57
patients with the mean age of the patients as 65 years and the mean duration of
the follow up as 4 years. The mean Constant-Murley score was 71 with 75% of
the patient achieved good to excellent shoulder function. The author concluded
that three-fourth of the patients had good to excellent functional outcome in the
long term follow up. Hence locking plate technology is preferred in fixation of
35
Thyagarajan et al.48 reviewed 30 patients with two-part, three-part and
four-part proximal humerus fractures. The mean age of the patients in the study
was 58 years and the follow up period was 9 months. The Constant-Murley
score observed was 58. Complications were seen in a total number of 3 cases,
with 2 cases of subacromial impingement and 1 case of implant infection that
required revision surgeries. The author concluded that the locking plate
technology provided excellent fracture stability and allows early rehabilitation,
hence recommended the use of locking plate fixation in the management of
proximal humerus fractures.
Geiger et al.49 reviewed 28 patients with two-part, three-part and
four-part proximal humerus fractures. The mean age of the patients in the study was
61 years and the follow up period was 25 months. The Constant-Murley score
observed was 58. The observed complication in this study was 6 cases of
subacromial impingement, 2 cases of AVN humeral head, 1 case of plate
breakage and 1 case of loosening of the locking head screw. The author
concluded that locking plate fixation has provided moderate to good results
among 61% of the patients.
Fazal et al.50 reviewed 27 patients with two-part, three-part and
four-part proximal humerus fractures. The mean age of the patients in the study was
56 years and the follow up period was 13 months. The Constant-Murley score
observed was 70. Only one patient reported screw penetration into the joint.
36
recommended the usage of locking plate fixation in the management of
proximal humerus fractures.
Complications like screw penetration, screw cut-out, varus collapse have
been attributed to increased rigidity and stiffness of the fixation in pre-existing
osteoporosis.51 It can be reduced by using standard cortical screws instead of
locking screws in the humerus shaft.41
Gardener et al.52 introduced the idea of inferomedial screw to prevent
varus collapse of the humerus head. It also provides medial buttress and hence
preventing screw cut-out.
In severe osteoporotic fractures, the failure rates are still high due to the
lack of purchase of the locking screws in the weaker bone. Screw augmentation
by using bone cement described by Roderer et al.53 is the best option available
in such patients.
Vascular compromise leading to AVN of the humerus head is one of the
major complications encountered in proximal humerus fractures. The incidence
is based on the fracture pattern with higher incidence among four-part than in
three-part proximal humerus fractures. Sturzenegger et al.54 described extensive
soft tissue stripping could be an independent risk factor for AVN of the
humeral head. Younger patients having complex proximal humerus fractures
with the risk of AVN as described by Hertel et al.8 is best treated using locking
37
revascularisation of initially ischemic humerus head , hence the study supports
that fixation should be attempted in younger individuals before replacement.
Even with the occurrence of AVN, if malunion is avoided the outcome
can be good as reported by Gerber et al.55 This signifies the importance of
adequate tuberosity reduction. If the reduction of the head fragments and the
tuberosities could not be achieved, it is recommended to convert the procedure
to primary hemiarthroplasty since the outcome will be better than the one
which is done post AVN of the humeral head.56
In the elderly patients with osteoporotic bone, head preserving surgeries
were not described in complex proximal humerus fractures due to high risk of
implant failures and AVN to the humerus head. But with invent of angle-stable
locking plate technology, there is increasing evidence of good functional
outcome even among elderly patients with osteoporotic fractures of the
proximal humerus. 8
Comparison of different modalities of treatment in the management of proximal humerus fractures
In the majorities of studies57,58,59 that were published comparing various
modalities of treatment in the management of proximal humerus fractures have
found no technique is superior of one over the other. The choice of treatment
chosen is based on multitude of factors like age, fracture pattern, co-morbidity,
38
Locking plate vs percutaneous K-wire osteosynthesis
Edelmann et al.60 compared K wire fixation and locking plate fixation
methods in treating three-part and four-part proximal humerus fractures. The
mean age of patients in the locking plate group was 62 years and 66 years in
the percutaneous K-wire fixation. The average follow up duration was 30
months. The K-wire fixation group has showed significantly worse functional
outcome when compared to locking plate fixation group. The author hence
recommended the use of locking plate fixation in the three-part and four-part
proximal humerus fractures and advices not to use K-wire fixation among these
fractures
Jaura et al.59 published long term follow up of locking plate and
percutaneous K-wire fixation in elderly patients having proximal humerus
fractures. In this study 60 patients were included with 30 patients under each
group. The mean Constant-Murley score achieved was 76.4 in the K-wire
fixation group and 84.6 among locking plate fixation group and showed no
statistical different between the groups. In multi fragmented osteoporotic
fractures the locking plate fixation for these fractures provided excellent stable
construct and has an advantage of absolute reduction and early mobilisation
39
Locking plate versus nail osteosynthesis
Lekicet al.61 in his study compared locking plate versus intramedullary
nailing for treatment of proximal humerus fractures. Both the study group had
12 patients each. The study found similar functional results among both the
groups but higher complications were reported in the intramedullary nail
osteosynthesis group when compared to locking plate osteosynthesis.
COMPLICATIONS
Venkat Kavuri et al.76 reviewed the complications associated with
locking plate for proximal humerus and observed 9.5% intra articular screw
penetration, 6.8% varus collapse, 4.6% avascular necrosis, and 5%
subacromial impingement.
Akshdeep et al.77 in his study of 53 cases of proximal humerus fractures
has observed AVN among 3 patients and concluded that risk of AVN is more
common among four part proximal humerus fractures . Two out of three cases
had poor functional outcome.
Visser et al.78 in his prospective study among 142 cases of proximal
humerus fractures has observed that axillary nerve followed by suprascapular
nerve were the most commonly injured nerves. It is found to be common
40
CLINICAL EVALUATION
Most fractures involving the proximal humerus are diagnosed based on
history and physical examination. Patients usually presents with complaints of
pain, swelling and inability to move the shoulder joint. It is important to
obtained detailed history regarding mechanism of injury, since severity of
trauma differs between younger and older individuals. Most fractures of the
proximal humerus occur in older people with osteoporotic bone as a
consequence of minor trauma, whereas most complex patterns are seen among
younger individuals due to high energy injury, which can injure the shoulder
joint function significantly.9
During physical examination, typical fracture signs like swelling,
crepitus, contusion, abnormal mobility and painful joint movements are seen. It
is very important to exclude neurovascular injuries, since the axillary nerve and
the brachial plexus are at great risk among proximal humerus fractures. The
cause of nerve injury may, a direct injury to the nerve or any traction
mechanisms applied during immobilisation. Most of the nerve injuries can be
managed conservatively except in younger individuals where early exploration
may be beneficial.
Vascular injuries, if present are usually associated with fracture
dislocations. They are treated by end-to-end anastomosis and grafting
41
Radiological evaluation forms the basis for most of the classification
systems used to assess the proximal humerus fracture types, and it also plays a
critical role choosing different treatment modalities.
The radiographic assessment included are a standard anteroposterior,
axillary and scapular Y view of the injured shoulder joint. Since it is very
difficult during the acute phase of injury to abduct the shoulder to 90 degrees
for obtaining an axillary view, Velpeau axillary view was suggested as an
alternate for this. CT scans aids to assess the complex fracture patterns when
the orientation of the fracture fragments is hard to make out in plain X rays.12It
also aids in planning reduction of the fracture fragments. In suspected vascular
42
MECHANISM OF INJURY
Most fractures of the proximal humerus are seen among older patients
with osteoporotic bones. The most common mechanism among these patients
will be a simple trivial fall with outstretched hand .In younger individuals the
fracture is usually seen following high velocity injuries like sports injuries,
road traffic accidents and fall from height. The greater tuberosity fractures are
usually seen following a strong muscular pull or contraction as seen in cases of
electrical shock or seizure disorder.
Fracture of the proximal humerus can also occur from a direct blow to
the side of the shoulder. Which is associated with higher chances of fracture
displacement.65 Bilateral fracture with dislocation is seen following convulsive
43
MATERIALS AND METHODS
This is a retrospective and prospective study to evaluate the functional
and radiological outcomes of proximal humerus fractures treated by proximal
humerus locking plate. The study period was from March 2017 to August 2018
at Institute of Orthopaedics and Traumatology, Madras Medical College, Rajiv
Gandhi Government General hospital, Chennai. The study was approved by the
department and institute’s ethical committee.
In this study, the patients were included as per the following criteria –
INCLUSION CRIETRIA
• Closed displaced two-part, three-part or four-part proximal humerus
fractures according to Neer’s classification.
• Age > 18 years (skeletally mature) and < 80 years.
• Proximal humerus fractures with associated dislocation and subluxation
of shoulder joint.
EXCLUSION CRITERIA
• Age < 18 years
• Compound fractures
• Pathological fractures (except osteoporotic)
• Undisplaced proximal humerus fractures
• Neglected proximal humerus fractures.
• Associated fractures present in the ipsilateral upper limb and
44
The patients with the above-mentioned criteria were excluded from the
study. Patients arriving to the trauma ward of this hospital were initially
managed by shoulder immobilisation either with an arm sling or U-slab.
These patients were further investigated with X-ray of the involved
shoulder joint. The standard antero-posterior view are taken.The AP- view of
the involved shoulder was taken in standing position with the arm in neutral
and the torso rotated 30-45 degrees towards the injured shoulder so that the
X-ray will fall perpendicular to the plane of scapula. The axillary view is taken in
supine position with the affected arm abducted as much as possible. X-rays are
projected beneath the axilla to the cassette which is placed over the shoulder
joint. The scapular Y-view was taken with the patient facing towards the
cassette in the standing position with the torso rotated to 60 degrees thereby
45
Computed tomography (CT) scan along with 3D reconstruction was
useful in selected cases where the fracture line cannot be made out clearly
using plain X-rays. It was also helpful to evaluate the fracture line extension
into the articular surface and to assess tuberosity displacement in comminuted
fractures.
After diagnosing the proximal humerus fracture, and if the patient falls
into the inclusion criteria, they were informed about the study and proceeded
with the surgery after getting written and informed consent.
The fractures were classified according to Neer’s system73 of proximal
humerus fracture classification by using radiological images. This classification
system is based on the number and displacement of the four anatomical
segments of the proximal humerus i.e. greater tuberosity, lesser tuberosity,
head of humerus and shaft of humerus.
A part or segment is defined as displaced if there is more than 1 cm of
separation or 45 degrees of angulation.
One-part fractures: A fracture with no segments found to be displaced
regardless of the number of fracture line or their location.
Two-part fractures: One segment is displaced, which may be either the
anatomical neck, the surgical neck, greater tuberosity or lesser tuberosity.
Three- part fractures: Three of the segments that are mentioned above
46
Four-part fractures: All four above mentioned segments are
considered to be displaced in relation to one another.
These fracture patterns can occur in combination with gleno-humeral
dislocation.
The surgeon makes the decision regarding management by open
reduction and internal fixation by using locking plate.
A total of 21 patients were followed during the study period of 18
months.The follow up period ranges from 3 months to 36 months This includes
13 male and 8 female patients with mean age of 46.6 years with displaced
two-part, three-part or four-part proximal humerus fractures . All the patients
have undergone open reduction and internal fixation with proximal humerus
locking plate.
All the patients were operated under general anaesthesia.
The surgical approach followed for all the cases was deltopectoral
47
APPROACH
Deltopectoral approach:
All 21 patients were fixed by using deltopectoral approach. The patients
were put on beach chair position under general anaesthesia. The skin incision
extends from just medial to the coracoid process down along the medial aspect
of arm to the deltoid insertion. The cephalic vein seen in the deltopectoral
groove guides in identifying the inter-nervous plane between the deltoid and
pectoralis major muscle. The cephalic vein can be either retracted either
medially or laterally. However, mobilising the cephalic vein medially allows
better exposure when lateral retraction of deltoid is required. Retract the
pectoralis major medially and deltoid laterally to expose the conjoined tendon
of short head of biceps and coracobrachialis. Incise the fascia over the lateral
aspect of the conjoined tendon. Note for the leash of vessels at inferior end of
subscapularis muscle. Retract the conjoined tendon medially to have better
exposure of the subscapularis tendon. By incising and retracting the
subscapularis muscle the proximal humerus fracture site is exposed and
reduced temporarily using K-wires or by ethibond sutures passed through the
osseo-tendinous junction of rotator cuff. The proximal humerus locking plate is
applied lateral to the bicipital groove and 5-8mm distal to the tip of greater
tuberosity. The placement is checked under image intensifier. After confirming
the satisfactory reduction the locking screws are applied to the humerus head.
48
humerus can be fixed either with locking or cortical screws. Finally the wound
is closed with suction drain and sterile dressing.
IMPLANTS & INSTRUMENTS REQUIRED
• Kirschner ‘K’ wire (1.5& 1.8 mm)
• Drill bit ( 2.5mm,2.8mm)
• Drill sleeve
• Screw driver (3.5 mm)
• Cancellous locking screw (4 mm)
• Cortical locking and non lockingscrews (3.5 mm)
49
SURGICAL TECHNIQUE
The ultimate goal is to achieve stability of the reduced fracture
fragments. This can be achieved by :
1. Medial pillar reconstruction
2.Rotator cuff reattachment
3.Adequate reduction of the tuberosities
MEDIAL PILLAR RECONSTRUCTION
In most cases, it can be achieved indirectly by using image intensifier
and manipulative techniques. If this fails, any of the following measures can be
taken because inadequate medial column reconstruction will lead to varus
collapse and varus malunion:
• By using a locking or a cortical screw (CALCAR SCREW)
which is directed from inferior aspect of lateral cortex of humeral
neck to the subchondral region.
• Placing fibular strut graft along the inferior aspect of humeral
neck.
• By causing primary valgus impaction.
APPROPRIATE PLATE SELECTION
The selected plate must allow at least three screws to be placed in the
50
head. It is ideally placed posterior to the biceps tendon and just below greater
tuberosity to prevent tendon impingement and subacromial impingement.
First two locking screws are inserted into the proximal segment through
the ellipsoidal hole followed by single screw in the shaft region.
Minimum of five to six screws should be inserted into the proximal
cortex by drilling the near cortex only without penetrating the subchondral
bone thereby reducing the chances of secondary screw penetration.
Non locking screws are used to pull the shaft segment onto the plate and
this helps in correcting residual malalignment and to achieve cortical plate
apposition.
Trans-tendinous sutures are tied onto the plate holes to provide
additional stability.
Finally the fracture is taken through the functional range of motion of
the shoulder joint to rule out impingement and to confirm stability.
Various potential complications are-
• Mal union
• Varus collapse
• Subacromial impingement
• Head screw penetration into the joint
51
POSTOPERATIVE PROTOCOL
We followed Jordan Young Institute79 post operative protocol.
Postoperatively immobilisation was done using arm sling.
PHASE 1- Early motion phase(0-5 weeks)
A. During the first week early passive range of movements are initiated.
B. During the second week pendulum exercises were initiated with active
assisted range of movements ,with flexion upto 140 deg.
C. During third to fourth week isometric exercises are started along with
active assisted range of movements.
PHASE 2- Active motion phase (4-12 weeks)
A. During 4-6 weeks active range of movements are initiated along with
full passive range of movements and isometric strengthening exercises.
B. During eighth week early resisted range of movements initiated along
with weight lifting if pain permits.
PHASE 3- Strengthening and Stretching phase(>12weeks)
52
THE CONSTANT-MURLEY SCORE
The shoulder functions were assessed using standard Constant-Murley
score proforma74 at six weeks, three months and six months.
The Constant -Murley score includes the following 4 major categories
for assessing shoulder functions both subjectively and objectively.
CATEGORIES SCORES
Pain 15
Activity of daily living 20
Range of movements 40
Strength 25
[image:64.595.100.531.243.447.2]Total 100
Table: shows four major categories of Constant-Murley score
Pain and activities of daily living are subjective measures whereas
strength and range of motion are objective measures.
Pain: The patient is asked to tick on 15 cm scale to assess the pain felt
during last 24 hours. Anchors towards left denote no pain with score of 15 and
towards right denotes intolerable pain with score of 0.
Activities of daily living: The subjective capability to perform all the
activities of daily living over the past 1 week is recorded. It has got 2
