Selective Glenohumeral external rotation deficit – sequelae of post-ORIF deltoid adhesions after treatment of the proximal humerus fracture

Abstract

Background The deltopectoral approach is commonly used for plate stabilization of proximal humerus fracture. Although adhesions between the deltoid, plate, and humerus are common sequelae of plate ORIF, little is known about their effect on the range of movement and a function of the shoulder. To confirm their impact, the preoperative and intraoperative evaluation of the range of motion (ROM) was measured during the sequential arthroscopic release of adhesions, with special regard to external rotation. Postoperative ROM and subjective shoulder function were also evaluated. Methods Eighteen patients treated with ORIF of the proximal humerus were scheduled to the unified arthroscopic procedures comprising sequential limited subacromial bursectomy, removal of the adhesions between the deltoid, plate, and humerus, as well as the plate removal. The ROM of the operated and opposite shoulders were assessed before surgery, intraoperatively and after a minimum two-year follow-up, with special regard to external rotation in adduction (AddER) and abduction (AbdER). Besides, the Constant-Murley score and Subjective Shoulder Value (SSV) were evaluated before a plate removal and after a minimum two-year follow-up after the surgery. Results Deltoid adhesion release correlated with considerable and statistically significant improvement of AddER (p < 0.0002) but not with the intraoperative range of AbdER. Significant improvement of AddER, but also of AbdER and other range of motion was noted at the follow-up. The improvement of the affected shoulder function following arthroscopic plate removal was considerable and statistically significant according to the modified Constant-Murley score (p < 0,01) and SSV (p < 0.0000) after a minimum of two-year follow-up. Conclusions Our findings are the first to highlight the influence of deltoid muscle, plate, and humerus adhesions on limiting external rotation in adduction after ORIF treatment of proximal humerus fractures. These observations allow the identification of a new shoulder evaluation symptom: Selective Glenohumeral External Rotation Deficit (SGERD) as well as functional deltohumeral space.

Functional outcomes before and after implant removal in patients with posttraumatic shoulder stiffness and healed proximal humerus fractures: does implant material (PEEK vs. titanium) have an impact? – a pilot study

“…These results confirm previous studies in which patients with reduced shoulder function after plate osteosynthesis of a proximal humerus fracture had a better functional outcome after implant removal [ 13 , 14 , 21 – 23 ]. Acklin et al showed that the Constant Score improved significantly from pre- to postoperative in 20 patients with persistent limited range of motion, after elective implant removal at the proximal humerus.…”

“…Waszczykowski et al highlighted in their publication that in addition to implant removal, excision of the soft tissue overlying the plates can also be attributed positive effects in postoperative improvement of range of motion. However, no statement is made about implant materials in this study either [ 23 ]. In this previous work, especially external rotation with the humerus at rest was improved by releasing the adhesions over the plate, [ 23 ] whereas the data presented in that manuscript also show an improvement in external rotation with the humerus abducted at 90° for PEEK plates.…”

“…However, no statement is made about implant materials in this study either [ 23 ]. In this previous work, especially external rotation with the humerus at rest was improved by releasing the adhesions over the plate, [ 23 ] whereas the data presented in that manuscript also show an improvement in external rotation with the humerus abducted at 90° for PEEK plates. Although only small patient cohorts were evaluated in all publications, it can be stated that in patients with persistent limited range of motion after plate osteosynthesis of a proximal humerus fracture, implant removal and extraarticular arthrolysis can improve the range of motion.…”

How to treat stiffness after proximal humeral fractures?

“…Generally, contracture of the rotator interval will limit external rotation in adduction; contracture of the antero-inferior capsule will limit external rotation in abduction; and contracture of the posterior capsule will limit internal rotation. Greater limitation of rotation in adduction compared to abduction may be due to extraarticular adhesion around the hardware ( 34 ).…”

“…Osteosynthesis implant removal can be done through an open approach, assisted by an arthroscope or completely arthroscopically. There are several articles demonstrating the feasibility of the removal of a proximal humeral plate arthroscopically ( 2 , 31 , 36 , 37 , 38 ), showing good results without increased complications ( 26 , 34 , 39 , 40 , 41 ). Removal of the plate or nail via an open surgical approach has also shown satisfactory results ( 12 , 28 , 30 ).…”