An audit of treatment of proximal humerus fractures type 3 and 4 of Neer classification in a resource-poor setting in Sub-Saharan Africa

INTRODUCTION

Proximal humeral fractures (PHFs) account for 5.7–6% of all skeletal fractures, 45% of humeral fractures, and 10% of fractures in patients over 65.^[1-4] Neer’s classification precisely describes the different types of PHFs.^[5] Therapeutic indications remain open to debate, as surgical approaches vary and operative techniques are constantly evolving.^[6] Operative indications in the young subject include treatment by locked intramedullary nailing, locked plates, simple screw fixation, or pinning. In patients aged over 65, who are often subject to comorbidities, some surgeons resort to simple, stable elastic intramedullary pinning with satisfactory outcomes or shoulder arthroplasty.^[6,7]

Treating these fractures using an image intensifier is important to obtain excellent anatomical and functional outcomes.^[6] However, the image intensifier is part of the operating devices that many orthopedic surgery departments in French-speaking black Africa do not yet have. Surgery is still carried out blindly, and the outcomes can only be seen postoperatively on a follow-up radiograph.^[8]

The management of comminuted PHFs remains a real challenge for all practitioners.^[9] These are the lack or inadequacy of quality devices (surgical instruments, orthopedic implants, image intensifiers, etc.) and the persistence of traditional treatment practices. These are aspects whose effects indirectly can influence the clinical outcomes of surgical treatments in the concerned countries. The question then arises of to what extent these challenges influence the quality of clinical outcomes of PHF treatment in an environment with insufficient technical equipment. This study aimed to describe the various challenges associated with the management of PHFs and to examine their influence on the clinical outcome of PHF treatment in the lower economy countries of French-speaking black Africa.

MATERIALS AND METHODS

Surgical treatment

All fractures were treated surgically [Figure 1a-c]. No shoulder prosthesis was performed, although some cases met the indication criteria. At a minimum follow-up of 36 months, operated patients were assessed according to the Constant score.^[10] Shoulder joint amplitudes were also assessed at the follow-up clinical examination.

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Figures 1:

(a-c) Some control images of proximal humerus treated in a Sub-Saharan African country. An image intensifier was not used for these surgical interventions.

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RESULTS

After a minimum follow-up period of 36 months, treated patients were assessed clinically according to the Constant score. Follow-up radiographs were also taken.

DISCUSSION

As observed in our study, the predominance of male patients and traffic accidents was also found by several other authors in African series,^[11,12] in contrast to certain Western series where a predominance of the female sex was found.^[4,13,14] One point common to all series is the profile of the patient with PHF. The patient is usually young and has suffered a high-velocity trauma, or is elderly and has suffered a minor trauma to an osteoporotic bone. The minimum follow-up period of 36 months used in our study seems reasonable. Most authors used the same follow-up time.^[7,11,15,16]

The clinical examination carried out and measured the estimated values, in degrees, of the movements of the operated shoulder in each of our patients. Mean values were close to normal for all types of treatment (nail, plate, K-wire, or screw) [Table 4]. These outcomes were also close to those found by other authors who had used the same types of implants, although their procedures were different.^{[13,15,17,18]} Therefore, it was observed that a certain concordance with the outcomes of studies carried out by Western authors. Kouame et al. also achieved satisfactory outcomes, although they did not specifically report postoperative shoulder range-of-motion measurements.^[11]

The primary objective of surgical treatment of PHFs is to restore anatomy to obtain maximum mobility. Repairing the rotator cuff has always represented a major difficulty, constituting a well-known challenge for surgeons.^[6] The effectiveness of achieving this objective is judged by post-operative functional assessment of the shoulder. This assessment is often based on the Constant score^[10] a five-item score (Excellent, Very Good, Good, Average, and Poor). Each item is scored out of 100. The closer the value is to 100, the better the outcome.

Our evaluation outcomes according to the Constant score are shown in Figure 1. We found similar outcomes to those reported by other authors in similar circumstances.^[2,12,15]

In a study of 34 comminuted PHFs treated by Telegraph nails, Boughebri et al. found no immediate complications or delayed bone healing.^[19]

Elidrissi et al. found four cephalic necroses, three of which followed articular fractures and two cephalic necroses following locked plate treatment.^[20] Although cephalic necroses of the humerus are rare in the literature, we found 9 cases (8.3%) out of 108 PHFs treated in our study. However, some authors, such as Sahnoun et al. in Tunisia, have also reported similar proportions of cephalic necrosis, with 2 cases (8%) out of 25 PHFs operated on.^[21] Cephalic necrosis of the humerus is generally a complication resulting from the natural evolution of a four-part articular fracture.^[11,20-22]

Bhatia et al., reported five cases of shoulder stiffness at 8 months’ follow-up, but like Bonnevialle et al., they did not reveal any neurological complications.^[14,18]

Complications such as nonunion are rare in the literature. Brunner et al. found that only one case of pseudoarthrosis out of 58 (1.7%) patients operated.^[22] In our study, 11 (10.7%) operated that PHFs developed nonunion. These non-unions were essentially due to insufficient intraoperative reductions and patients’ failure to follow surgical instructions.

Infectious complications were common among the patients in our study [Table 2]. In all, 8 (7.8%) cases were due to plate and/or screw treatment, in contrast to other authors who found only small proportions of local infection.^[1,22] Bonnevialle et al. did not observe any infectious complications in their study.^[14]

Our study identified the main challenges: The lack of access to better-quality instruments and orthopedic implants. Difficulties related to the lack of state-of-the-art technical facilities and orthopedic implants and surgical instruments are the real cause of poor outcomes of surgical treatments in French-speaking Sub-Saharan Africa. For example, not all treating theaters are equipped with image intensifiers. What’s more, the latest-generation implants, such as the Bilboquet, which gives very good anatomical and functional outcomes in France, are not available in French-speaking Sub-Saharan Africa.^[6] Finally, we also find that shoulder arthroplasties are not yet commonly performed in our regions, although surgeons have the capacity to do so. In our context, the health-care system requires patients to pay for their own care. Our patients are generally people with low or average incomes. Thus, the lack of financial means or the low purchasing power of our patients, who come from lower-economy countries, means that most patients cannot buy the indicated and/or good-quality implants, forcing the surgeon to use a second or even third-line therapeutic choice. The consequence of this is the poor outcomes we have seen in our study.

CONCLUSION

The treatment of comminuted fractures of the proximal humerus is not only a challenge for the surgeon but also complicated in developing countries due to the lack of modern operating room equipment and implants. The high rates of poor outcomes and complications found in this study reflect the real difficulties of managing comminuted PHFs in developing countries. Recurrent post-operative complications are mainly due to the management difficulties described in this study.