Injury, Int. J.

Care Injured 45 (2014) 444447

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Multifocal humeral fractures

A. Maresca a, R. Pascarella a,*, C. Bettuzzi b, L. Amendola b, R. Politano a, R. Fantasia a,
M. Del Torto a
a
Unita di Ortopedia e Traumatologia Ospedali Riuniti di Ancona, Italy
b
Unita di Ortopedia e Traumatologia Ospedale Maggiore Bologna, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Multifocal humeral fractures are extremely rare. These may affect the neck and the shaft,
Humeral fractures the shaft alone, or the diaphysis and the distal humerus. There is no classication of these fractures in the
Bifocal literature.
Classication Materials and methods: From 2004 to 2010, 717 patients with humeral fracture were treated surgically at
Multifocal
our department. Thirty-ve patients presented with an associated fracture of the proximal and
diaphyseal humerus: synthesis was performed with plate and screws in 34 patients, and the remaining
patient had an open fracture that was treated with an external xator.
Results: Mean follow-up was 3 years and 3 months. A classication is proposed in which type A fractures
are those affecting the proximal and the humeral shaft, type B the diaphysis alone, and type C the
diaphysis in association with the distal humerus. Type A fractures are then divided into three subgroups:
A-I, undisplaced fracture of the proximal humerus and displaced shaft fracture; A-II: displaced fracture
of the proximal and humeral shaft; and A-III: multifragmentary fracture affecting the proximal humerus
and extending to the diaphysis.
Discussion: Multifocal humeral fractures are very rare and little described in the literature, both for
classication and treatment. The AO classication describes bifocal fracture of the humeral diaphysis,
type B and C. The classication suggested in this article mainly concerns fractures involving the proximal
and humeral shaft.
Conclusions: A simple classication of multifocal fractures is suggested to help the surgeon choose the
most suitable type of synthesis for surgical treatment.
2013 Elsevier Ltd. All rights reserved.

Introduction typically occur in young patients with high-energy trauma [1,6,9].

There are numerous articles in the literature that describe the
classication and treatment of humeral fractures, when these are
divided into proximal, diaphyseal and distal segment
[2,4,5,7,8,10,1215,17]. However, bifocal or combined humeral
fractures are very rare and little described [3,11,16]. There are no
clear indications in the literature about which surgical treatment
should be performed in patients with multifocal fractures and
there are no data from clinical trials or randomised controlled
multicentre studies.
There are many aspects to be considered in this kind of injury,
including the mechanism of trauma and the type of treatment.
Fractures of the proximal humerus typically occur in elderly
patients with low-energy trauma, whereas diaphyseal fractures
* Corresponding author. Tel.: +39 0715964489/3358119947;
fax: +39 0715964480.
E-mail address: raffaele.pascarella@libero.it (R. Pascarella).
Fractures of the distal humerus occur in both the elderly and the
young. Fractures of the proximal humerus are often treated
conservatively, while those involving the diaphysis or the distal
humerus usually require surgical treatment. In addition, there are
plates available for the proximal humerus and plates for the
diaphysis, but in the case of associated fractures, hardware is
required to stabilise both humeral segments.
A classication is therefore proposed for multifocal humeral
fractures, particularly those involving the proximal portion and the
shaft, which can help the surgeon choose the most suitable type of
synthesis for surgery. The multifocal fractures of the humerus are
divided as follows: type A is fractures that affect the proximal and
the humeral shaft, type B the diaphysis alone, and type C the
diaphysis in association with the distal humerus. Type A fractures
are then divided into three subgroups: A-I, undisplaced fracture of
the proximal humerus and displaced shaft fracture; A-II: displaced
fracture of the proximal and humeral shaft; and A-III: multi-
fragmentary fracture affecting the proximal humerus and extend-
ing to the diaphysis (Fig. 1).

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http://dx.doi.org/10.1016/j.injury.2013.10.010
 A. Maresca et al. / Injury, Int. J. Care Injured 45 (2014) 444447
Fig. 1. Purpose of classication previously described.
Three surgical options are available: external xation, intra-
medullary nail and plate. External xation is difcult to perform as
the grip on the proximal portion can be problematic or impossible,
particularly in elderly patients. This method is indicated only for
patients who have severely exposed fractures. Intramedullary nail
and plates are more useful options (Fig. 2).
The aim of this study is to propose a new classication for
multifocal humeral fractures to give an indication for their
treatment. Treatment of multifocal fractures involving the
diaphysis alone or the diaphysis and distal humerus are already
standardised and are not discussed in this paper.
Materials and methods
From 2004 to 2010, 717 patients with humeral fracture were
treated surgically at our department. Thirty-ve of these patients
(4.8%) presented with an associated fracture of the proximal and
diaphyseal humerus. There were 18 male and 17 female patients
with a mean age of 64 years (range 3393 years). According to the
classication we propose, fractures were divided into: Type A-I 20
cases (57.1%), Type A-II 3 cases (8.5%), and Type A-III 12 cases
(34.2%).
One patient presented with a post-traumatic paralysis of the
radial nerve. One patient with a third degree open fracture
underwent reduction with external xator. Open reduction and
stabilisation was performed using Philos1 plates with angular
stability in 19 cases and straight plates in the remaining 16 cases.
Intramedullary nails were not used.
Results
All 35 patients were reviewed with a mean follow-up of 3 years
and 3 months (range 2 years 3 months to 6 years 6 months).
Fig. 2. A3 fracture treated with plating (Philos1).
445
The mean time of consolidation was 5 months. Major complica-
tions were one case of loosening of the xation 30 days after
surgery, one case of pseudarthrosis and one case of radial nerve
palsy.
The patient with loosening of the plate underwent removal of
the hardware, new reduction and xation with plate and medial
cortical homeoplastic bone graft. The patient with pseudarthrosis
underwent removal of the hardware, excision of the pseudar-
throsis tissue, reduction and internal xation with plate and
medial cortical homeoplastic bone graft. The radial nerve palsy
recovered spontaneously within 6 months.
The range of motion was evaluated using the University of
California, Los Angeles (UCLA) shoulder rating score and the Mayo
Elbow Performance Score (MEPS). Results were respectively: good/
excellent in 31 and 30 patients, and fair/poor in 4 and 5 patients
(Fig. 3). A total of 94.7% of patients were satised with the
outcome.
Discussion
Bifocal and multifocal humeral fractures are very rare and little
described in the literature, both for classication and treatment.
The AO classication describes bifocal fracture of the humeral
diaphysis, type B and C [17]. The classication suggested in this
article mainly concerns fractures involving the proximal and
humeral shaft. Treatment of multifocal fractures involving the
diaphysis alone or the diaphysis and distal humerus are already
standardised and are not discussed in this paper.
Bifocal diaphyseal fractures can be treated with plate and
screws or intramedullary nailing. In fractures involving both the
shaft and distal humerus, the fractures are usually treated
separately, using two different approaches.
Fig. 3. UCLA and MEPS evaluation of Range of Motion of the shoulder.
446 A. Maresca et al. / Injury, Int. J. Care Injured 45 (2014) 444447
Fractures of the proximal epiphysis and diaphysis have been
divided into three subgroups. Type I includes undisplaced fractures
of the head or neck, and displaced fractures of the shaft. This is the
largest group in our series. The injury is generally directed to the
shaft, where the muscle forces displace the fracture. During a fall
the fracture extends proximally to the neck. Type II includes
displaced fracture of the proximal and diaphyseal humerus. This
association is less common in our series, probably because
the injury should act simultaneously on the head and shaft.
The fracture probably initiates at the proximal humerus, with the
diaphyseal fracture a consequence of torsional forces that are
generated while the patient is falling. Type III is a multi-
fragmentary fracture of the proximal humerus involving the
diaphysis. This type of fracture can be compared with C1 of the AO
classication, but the extension on the shaft indicates a different
surgical treatment. Type III fractures are uncommon and are
usually a consequence of a high-energy trauma involving the
proximal meta-diaphyseal humerus.
When the fracture involves the neck or humeral head, a CT-scan
is recommended to enable the surgeon to study the injury features,
and to evaluate a possible associated dislocation or incarceration of
the humeral head into the glenoid. It is also recommended to
carefully consider the possibility of a radial nerve decit, which is
present in 1.818% of diaphyseal fractures [18] and represents the
most common peripheral nerve associated injury of long bone
fractures [19].
Intramedullary nailing was not used in our treatment protocol,
but still represents a good option for these lesions [20].
Intramedullary nailing must be performed without opening the
fracture site to avoid damage to the endosteal and periosteal
circulation. Absolute contraindications to intramedullary nailing
are fractures with double displacement, because the simultaneous
reduction of both fracture sites is difcult, and comminuted
fractures, because of risk of malreduction and inadequate stability
[21]. Moreover, in the presence of radial nerve palsy it is
mandatory to perform surgical exploration and xation of the
fracture with plate and screws. In most cases, the nerve presents a
neurapraxia that spontaneously resolves within several months.
However, rarely, the nerve may be entrapped in the fracture site or
be sectioned by a bone fragment, so exploring it releases the nerve
or enables the surgeon to perform a neurorrhaphy.
A relative contraindication to nailing is surgical access, which
may result in a lesion of the rotator cuff. Also it requires image
intensication during the whole procedure.
In the current study, external xation was used in only one case
of open fracture of degree 3A, according to the Gustilo classication
[22]. The remaining cases underwent reduction and xation with
plate and screws: angular stability plates (Philos1) were used in 19
cases and straight plates were used in 16 cases, because there were
no angular stability plates available at the time of surgery. Straight
plates can be used successfully in only type I fractures, but there is
risk of early mobilisation of the hardware, particularly in
osteoporotic patients, because only a few screws can be inserted
in the humeral head.
In our opinion, the Philos1 plate has all the characteristics
required for the treatment of multifocal fractures. The length
ranges from 90 to 114 mm in the standard plate and from 140 to
270 mm in the long plate. The low prole design is minimally
invasive and enables nine screws to be inserted into the proximal
humerus. Moreover, this plate enables fractures involving the
distal third of the diaphysis to be xed.
Plating enables anatomical reduction and the use of cortico-
cancellous bone grafts in cases of bone loss, or cortical homoplastic
grafts in cases of fragmentation of the medial cortex. The same
surgical approach may also be possible for exploration in cases of
radial nerve palsy [23].
Complications associated with plates are non-union (2.812%)
[24], infection (1.520%) and iatrogenic radial nerve palsy (4.1
31.3%).
Subacromial impingement occurs when the plate is not
correctly positioned proximally [25].
In our series we observed one case of early mobilisation (2.8%),
one case of non-union (2.8%) and one case of iatrogenic radial nerve
palsy (2.8%). There were no cases of infection or subacromial
impingement. Occasional shoulder pain was observed in three
patients (8.5%), nine patients referred to pain during heavy
activities (25.7%) and one patient complained of severe pain (2.8%).
A total of 94.7% were satised and had a good functional
recovery, with restoration of good or full range of movement of the
shoulder.
Conclusions
Multifocal fractures of the proximal and diaphyseal humerus
are rare, and the treatment is related to the displacement. Ideally, a
fracture classication system should act as a guide to treatment,
like the Neer classication or the AO system for proximal or
diaphyseal humeral fractures. However, other factors, such as
osteoporotic bone, associated soft tissue injury and the patients
overall health and motivation, will also inuence treatment
choices and outcome. The classication proposed in this paper
simplies these lesions and indicates an effective surgical
approach. In our experience, when the classication is properly
performed, there is complete restoration of functionality with a
low level of complications.
Conict of interest statement
The Authors declare that they have no conict of interest.
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