Proximal humerus fracture treatment remains controversial. If the conservative treatment is widely accepted for Neer I and Neer II fractures, the attitude is not very clear concerning Neer III and Neer IV fractures.

Several methods are proposed in the literature varying from suturing, pinning or plating the proximal humerus. Hemiarthroplasty are even considered.

In our study we present our results of an internal fixation procedure for 3 part or 4 part fractures of the upper part of the humerus.

Material and Methods: Antegrade nailing with self stabilizing screws, by T2 nail, is used in 13 patients treated between January 2004 and December 2005. Average age is 81 years old. The medial insertion technique is used because of the greater tuberosity fracture. Clinical and radiological data were available for the 13 patients with a mean follow up of 19 months. Functional outcome is assessed using the Visual Analog Scale (VAS) and the Constant Score.

Results: At last follow up, most of the patients are satisfied with their operation with a mean VAS of 2.46 and a mean Constant Score of 64.7. Mean antepulsion was 148° while mean abduction was 136°. No infection was reported. There are 4 cases of greater tuberosity necrosis without influence on the rotator cuff muscles. One case of head necrosis is signaled.

Discussion: Complex fractures of the proximal humerus remain a challenge for the orthopedic surgeons. To date, there is non agreement on the most appropriate osteosynthesis method and the results of shoulder arthroplasty or proximal plating remain controversial. The T2 nail appears to be a simple and reproducible method of achieving reduction, stability and early mobilization. It is an attractive alternative to shoulder prosthesis or proximal plating in trauma victims with complex displaced fractures.

Introduction: The treatment of the recently ruptured Achilles tendon is still controversial. Surgical procedures are commonly considered to restore excellent functional capacity and suffer low re-rupture rates, but are potentially associated with significant complications like wound infection and paraesthesia. Recent studies report very good results with a conservative treatment in rigid casts. Our aim was to evaluate a new method of functional and conservative treatment using immobilisation in an articulated cast.

Patients and Methods: Between March 1998 and August 2005, 12 women and 45 men with an average age of 45 (24–73), underwent a functional and conservative treatment for a recently ruptured Achilles tendon. After an immobilisation with a cast in equinus for 10 days, the patients were authorised to walk with full weight-bearing, protected by a commercial orthosis (VACO®ped, OPED). The equinus angle was set at 30° plantar flexion until the end of week 3, and at 15° until the end of week 4. At the 5th week the system was unlocked to allow ankle mobilisation of 30-15-0°, and at 30-0-0° at the seventh week. The orthosis was removed after 8 weeks. All patients had follow-up examinations up to 12 months after the trauma. The first 30 patients underwent a clinical examination and muscular testing with a Cybex isokinetic dynamometer at 6 and 12 months. In June 2006 all 57 patients were contacted and received a questionnaire. Their subjective opinions of the outcome, any change in their sport activities and eventual late complications were investigated. We evaluated the questionnaire and medical records using a scoring system based on the Leppilahti Ankle Score.

Results: After one year there was not any difference in the motion of the ankle in comparison with the healthy side. There was no substantial calf amyotrophy and we found very little difference in muscular capacity. The average overall satisfaction with the outcome was 8.1 out of 10. We observed 5 complete re-ruptures (9%), 2 partial re-ruptures and 1 deep venous thrombosis complicated by pulmonary embolism. We observed few minor skin complications.

Conclusions: The present treatment resulted in good to excellent functional results in most of the cases. It requires an active participation of the patient and a systematic medical follow-up during the first 6 months. The complication rate is acceptable. We think that early ankle mobilisation in the dynamic cast promotes better functional results than a rigid immobilisation technique.

There is a place for conservative functional treatment in the acute rupture of the Achilles tendon. But prospective comparison with modern surgical techniques, like minimal invasive suture, is still required, especially in patients with high functional demand.