Proximal and Distal Humerus Fractures in a Patient with Chronic Inflammatory Joint Disease Undergoing Biologic Therapy

1 Clinic of Orthopedics and Traumatology, „Carol Davila” University Central Military Emergency Hospital, Bucharest, Romania 2 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Corresponding author: Razvan Nicolae Turcu, Clinic of Orthopedics and Traumatology, „Carol Davila” University Central Military Emergency Hospital, Bucharest, Romania. E-mail: razvan_turcu@yahoo.com Abstract


INTRODUCTION
Rheumatoid arthritis aff ects women more frequently, aged 40 to 70, three times more frequently than men.Bone changes occurring in people with rheumatoid arthritis increase the incidence of fractures in these patients 1 .
In the complex fractures of the proximal 3 of the humerus, the treatment of choice is represented by open reduction and osteosynthesis.Th is method can also be applied minivasively, known as minimally invasive plate osteosynthesis (MIPO) 2,3 .
Stabilized anatomically and angulated locked plates allow the screws to be fi xed in various planes, varying up to 30 degrees, having the role of an internal fi xator.Th eir use reported results confi rmed by numerous studies, representing the treatment of complex fracture at diff erent levels: distal femoral fractures, tibial plateau, tibial pilon, distal radial epiphysis, proximal humerus, distal humerus, clavicle 4 .
In the treatment of proximal humerus fractures, the literature highlights the superiority of osteosynthesis through the mini-invasive approach (MIPO) versus the transdeltoid approach.Th e advantages of using MIPO are reduced soft tissue damage, reduced postoperative pain, reduced functional impairment, axillary nerve protection 2,5 .
In the complex fractures of the humerus, the distal treatment of the choice is represented by open reduction and osteosynthesis 6 .
Because of the important role of the distal portion of the humerus within the elbow joint, new fi xation techniques have been developed, such as stable locked pla-   Th e analysis of the three-dimensional reconstruction of computed tomography allowed the preoperative planning to be performed and the optimal therapeutic course to be established.

MATERIALS AND METHODS
Th e patient was positioned on a surgical table in a beach chair position for osteosynthesis by MIPO technique of the proximal humerus fracture, then in ventral decubitus for the posterior approach of the elbow, for the reduction and osteosynthesis of the distal humerus fracture.Surgery was performed under general te osteosynthesis 7 .anatomically precontoured locking plates off er a superior biomechanical and stability in the treatment of complex fractures even in the elderly with a diminished bone stock due to osteoporosis 8 .

CASE REPORT
A 60-year-old female patient, known for chronic hepatitis C virus with undetectable viremia, rheumatoid arthritis under biological therapy, ischemic cardiopathy, presented at the Emergency Room accusing pain and functional impotence of the right arm, after a fall injury from same level.Th e clinical examination revealed total functional impotence, arm and elbow, local shoulder and elbow deformity, abnormal mobility, massive  extensive dissection and retraction of the soft tissues of the two incisions, approximately 3 centimeters 10 .Fracture reduction was achieved by axial stretch of the humerus and indirect reduction by ligamentotaxis by manipulation of the rotator cuff .Osteosynthesis by locking plating of the proximal humerus involves fixation of the locking plate proximally, just below the anesthesia, a broad spectrum antibiotic for infection prophylaxis was administered 9 .Th e approach used for the MIPO technique involves a minimal transdeltoid approach, approximately 5 centimeters distal to the edge of the acromion, and a metaphysis approach to fi x the locking plate to the humeral diaphysis.Th e axillary nerve was protected by avoiding

DISCUSSIONS
Th e mechanism underlying bone damage is the local response to cytokines, hypervascularization, periarticular bone edema, bone catabolism imbalance, bone demineralization in relation to sedentarism and the eff ects of rheumatoid arthritis 1 .
Th e standard deltopectoral approach for proximal humerus fractures off ers limited access, so viewing the reduction of greater tuberosity can be diffi cult.Th e deltopectoral approach requires extensive soft tissue dissection and muscle retraction for adequate exposure to the lateral part of the humerus 14 .
Th is may have consequences on the fractured fracture vascularization during dissection, reduction and osteosynthesis, resulting in damage to the vascular support of the humeral head.Th e transdeltoid approach is an alternative that provides a view of the posterolateral portion of the shoulder, without extensive dissection and violent retraction of the soft parts.Th e inconvenience of applying this approach is the possibility of axillary nerve damage 2, 15 .
MIPO provides a good view of the posterolateral surface of the huneral head through a reduced incision, avoiding extensive dissection of the soft tissue.Reducing the fractured greater tuberosity will be performed at sight, thus shortening the operator time required to reposition the fragment 10 .

CONCLUSIONS
Th e advantages of MIPO are lower intraoperative time than the classic reduction and osteosynthesis procedure, a lower amount of blood loss, a shorter relative hospitalization duration, a better pain score, a cosmetic aspect of postoperative scarring 10 .
Th e success of the treatment of distal distal humeral fractures is dependent on correct fracture diagnosis, a correct reduction with a reconstruction of the joint surfaces, a stable fi xation of the fragments, and a functional recovery program with the fastest postoperative onset 4,16 .apex of greater tuberosity and non-resorbable suturing of the rotator cuff to the implant.Several stable angular screws are blocked at the humeral head 11 .Th e posterior approach to the elbow was practiced.Th e "V" osteotomy of the olecranon was practiced to retract brachial triceps and have a good articular and distal humerus exposure 12 .After fracture reduction and restoration of articular surfaces, osteosynthesis was performed with 2 fi xed angular locking plates respecting the 2 humeral columns, and the defect was fi lled with a bone substitute, artifi cial bone graft.After the visualization of the radiological control, the olecran reduction was performed and fi xed by tension band wiring 13 .Th e postoperative recovery program involves passive movements after surgery, an immobilization in orthesis for 2 weeks, and active movements within the range of pain tolerance 2 .

Figure 2 .
Figure 2. Radiography of right elbow joint profi le.

Figure 7 .
Figure 7. Intraoperative aspect -osteotomy of olecranon with retraction of insertion of brachial triceps, restoration of articular surface, distal humerus osteosynthesis with 2 locking plates, fi lling the bone defect with artifi cial bone graft.