Intramedullary nailing of displaced four-part fractures of the proximal humerus

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications

BACKGROUND

The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality.

METHODS

Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed.

RESULTS

48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction.

CONCLUSIONS

Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities

Background

Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures.

Methods

A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant.

Results

The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures.

Conclusion

Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review

Background

Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.

Methods

A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.

Results

Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.

Conclusion

Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures?

INTRODUCTION

After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate.

MATERIALS AND METHODS

All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B.

RESULTS

The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis.

CONCLUSION

Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant.

EVIDENCE LEVEL

IV, retrospective study.

The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not

PURPOSE OF REVIEW

The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing.

RECENT FINDINGS

According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement. Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.

Comparison of surgical efficacy of locking plates and interlocking intramedullary nails in the treatment of proximal humerus fractures

Background

The objective of this study was to evaluate the efficacy of locking plates versus interlocking intramedullary nails in the treatment of proximal humerus fractures to provide clinical data support and theoretical guidance.

Methods

Patients with proximal humerus fracture from the Third hospital of Shijiazhuang city and Third hospital of Hebei medical university and from January 2017 to June 2019 were selected, included and divided into the locking plate group and the interlocking intramedullary nail group according to the intervention received. Information pertaining to the perioperative period (operation time, hospital stay, blood loss, etc.) of patients in both groups was collected. VAS pain scores, shoulder activity Constant-Murley scores and postoperative complications were documented. The perioperative data of the two groups were compared, and P < 0.05 was considered statistically significant.

Results

A total of 64 patients were enrolled, including 36 patients in the locking plate group, with a mean age of 61.3 ± 13.9 years, while the mean age of the interlocking intramedullary nail group was 65.6 ± 11.2 years. There was no statistical difference in gender, affected side, injury mechanism and Neer classification between the two groups (P > 0.05). However, the average operation time of the locking plate group was shorter than that of the interlocking nail group (84.9 ± 11.7 vs. 102.6 ± 22.1 min, P = 0.00), and the intraoperative blood loss of the locking plate group (137.4 ± 16.8 ml) was higher than that of the interlocking nail group (72.5 ± 10.5 ml, P = 0.00). There was no significant difference in the VAS score and Constant-Murley score between these two groups at the final follow-up.

Conclusion

Interlocking intramedullary nails are more minimally invasive than locking plates, but fracture reduction and fixation take longer. There was no significant difference in pain and shoulder function scores between the two internal fixation strategies for the treatment of proximal humerus fracture.

Investigation of the Clinical Effect of New Shoulder Joint Abduction Frame in Humeral Fracture Patients after Arthroscopic Shoulder Surgery

Objective

This work is organized to analyze the clinical effects of new shoulder joint abduction frame on the bone metabolic markers, shoulder joint function, and visual analogue scale (VAS) of humeral fracture patients undergoing arthroscopic surgery.

Methods

118 patients with humeral fracture who planned to undergo shoulder surgery in our hospital from November 2018 to June 2021 were selected as the study objects and were divided into two groups according to the random number method, with 59 patients in each group. The patients in the two groups were subjected to arthroscopic shoulder surgery. New shoulder joint abduction frame was used for shoulder joint fixation in the abduction frame group, and sling was used for shoulder joint fixation in the sling group after surgery. The duration of fixation was 4-6 weeks. Finally, the prognostic indicators, complications, and serum bone metabolism levels in 4 and 6 weeks after surgery, shoulder joint function (Neer score), VAS score before surgery and after 3 and 6 months of surgery, and excellent or good rate of shoulder joint activity after 6 months of surgery were compared between the two groups.

Results

The postoperative fracture healing time and start time of shoulder joint training were shorter, and the humeral varus angle and femur height loss were smaller in the abduction frame group than in the sling group (P < 0.05). There was no significant difference in the total incidence of complications between the two groups (3.39% and 13.56%, respectively) (P > 0.05). After 4 or 6 weeks of surgery, the levels of serum osteoprotegerin (OPG) and carboxyterminal propeptide of type I procollagen (PICP) were increased but the levels of tartrate-resistant acid phosphatase-5B (TRAP-5B) were decreased in the two groups with more significant differences in the abduction frame group (P < 0.05). After 6 months of follow-up, 2 cases were lost to follow-up in the abduction frame group and 3 cases in the sling group. Neer scores were increased, while VAS scores were decreased in the two groups in the third or sixth months after surgery with significant differences in the abduction frame group (P < 0.05). The excellent or good rate of shoulder joint activity was 94.74% (54/57) in the abduction frame group, significantly higher than that in the sling group (80.36%; 45/56) (P < 0.05).

Conclusion

The fixation effect of new shoulder joint abduction frame is significant after arthroscopic surgery, and patients can carry out functional training as early as possible, which is helpful to promote fracture healing, relieve pain, and restore shoulder joint function with high safety.

Specific Radiologic Risk Factors for Implant Failure and Osteonecrosis of the Humeral Head after Interlocking Nailing with the Targon PH+ of Proximal Humeral Fractures in a Middle to Old Population

Background: Operative management of proximal humeral fractures is still challenging. While antegrade nailing has become a valid option in fracture fixation, risk factors for adverse events, and failure have not been sufficiently clarified. Methods: All patients of a single trauma center undergoing surgery for proximal humeral fractures with the Targon PH+ nail between 2014 and 2021 were evaluated retrospectively. This included complications, revisions, and failures. Pre- and postoperative radiographic imaging were assessed regarding fracture’s complexity, anatomic reduction, reconstruction of the medial hinge, metaphyseal head extension, and fixation of the implant in the calcar region. Follow-up was at a minimum of 12 months. Results: A total number of 130 patients with a mean age of 74.5 years (range 63−94, SD ± 8.2) are included in this study. Two- and three-part fractures were found in 58 patients, while 14 patients showed four-part fractures. Overall, a complication rate of 34.2% and an implant failure rate of 15.4% was found. Four-part fractures showed a significantly higher complication rate than two- and three-part fractures. Four-part fractures also showed significantly higher revisions (p = 0.005) and implant failures (p = 0.008). The nonsufficient anatomical reduction was found to be a risk factor for complications (p < 0.0001), implant failures (p < 0.0001), and later humeral head osteonecrosis (p < 0.0001). Insufficiently reconstructed medial hinges (p = 0.002) and a metaphyseal head extension of under 8 mm (p = 0.005) were also demonstrated as risk factors for osteonecrosis of the humeral head. Conclusions: Four-part fractures in an elderly population show high complication, revision, and implant-failure rates. Therefore, demonstrated radiologic risk factors should be evaluated for improvements. Anatomical reduction and fixation near the calcar proved to be vital for successful antegrade nailing of complex fractures. To prevent osteonecrosis of the humeral head, reconstruction of the medial hinge and metaphyseal head extension should be evaluated.

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications

INTRODUCTION

Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients.

METHODS

A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS.

RESULTS

Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively.

CONCLUSION

Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant-Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term

Purpose

Although proximal and diaphyseal humerus fractures are frequent, the optimal management remains controversial. Antegrade nailing prevents further damage to the soft tissues and to the vascularization, but it has been associated with postoperative shoulder pain and dysfunction. During the latest years a straight nail design was developed to minimize these problems.

Methods

A total of 243 patients who had undergone surgery for antegrade intramedullary humeral nailing between January 2013 and July 2018 in A. Gemelli Trauma Center were divided into two groups according to the nail design used: straight nail group (S-group) and curvilinear nail group (C-group). Clinical data were collected using assessment forms (SF12-v2, Quick-DASH, ASES and Constant-Murley). Radiographic bone healing was assessed with RUST score at 30, 90 and 180 days after surgery.

Results

The S-group was made up of 128 patients with a mean age of 59 ± 19 (range 18–97) and a mean follow-up of 46 ± 9 months. The C-group was made up of 115 patients with a mean age of 53 ± 16 (range 18–88) and a mean follow-up of 51 ± 8 months. The S-group had a mental component summary (MCS) score of 54.3 ± 7.7 and a physical component summary (PCS) score of 46 ± 10.2, the C-group had a MCS score of 50.9 ± 8.4 and a PCS score of 44.1 ± 7.4. Quick-DASH and ASES were respectively 18.8 ± 4.3 and 78.6 ± 8.2 in the S-group, 28.3 ± 11.6 and 72.1 ± 13.5 in the C-group with statistical significance. Constant-Murley score was 73.9 ± 9.1 in the S-group (76% of the contralateral healthy side) and 69.4 ± 10.4 in the C-group (73% of the contralateral healthy side). The radiographic union score in the S-group was 4.1 ± 0.3 at 30 days after surgery, 7 ± 0.8 at 90 days and 10 ± 1.2 at 180 days, while in the C-group it was 4.2 ± 0.4 at 30 days, 6.4 ± 0.7 at 90 days and 9 ± 0.9 at 180 days.

Conclusion

Newer generation straight nails allow a faster bone healing and better functional outcome at mid-term follow up.

Level of evidence III.

Nail Versus Plate: A Biomechanical Comparison of a Locking Plate Versus an Intramedullary Nail With an Angular Stable Locking System in a Shoulder Simulator With Active Muscle Forces Using a Two-Part Fracture Model

OBJECTIVES

To compare a locking compression plate versus an intramedullary nail with an angular stable locking system (ASLS) using a 2-part fracture model in a shoulder test bench.

METHODS

Twelve fresh frozen humeri were used for biomechanical testing in a shoulder simulator. A 2-part fracture model, with and without medial cortical support, was used to compare the locking plate and a nail with an ASLS. The varus impaction, varus per cycle motion, tilt, and tilt per cycle were analyzed.

RESULTS

No significant differences for the resulting forces in the glenoid fossa were evaluated. The stable fracture model showed no significant differences for the 2 groups. The median varus impaction was -0.96 degrees (range -0.55 to -4.26 degrees) in the plate group and 0.5 degrees (range -3.06 to 0.98 degrees) in the nail group, after 500 cycles of cyclic loading in the unstable fracture model. The plate group showed a significantly higher median varus impaction per cycle motion and median varus impaction at the 200th, 300th, and 400th cycle of physiological loading.

CONCLUSIONS

The intramedullary nail with the ASLS could be an alternative for patients suffering from osteoporosis and comorbidities.

Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

BACKGROUND

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries.

METHODS

Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed.

RESULTS

Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates.

CONCLUSION

Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Comparison of locking plates and intramedullary nails in treatment of three-part or four-part proximal humeral neck fractures in elderly population: A randomized trial protocol

BACKGROUND

Locking plate and intramedullary nail are two commonly applied methods to fix proximal humeral fractures. There are limited randomized studies that specifically evaluate the results of proximal humeral neck fractures with three-part or four-part treated by locking plates or intramedullary nails. Our goal was to compare functional outcomes, complications, and imaging features between the two groups.

METHODS

This single-center, prospective, randomized controlled test will be conducted in Tengzhou Central People's Hospital. Patients with these conditions will be included: age between 55 and 80 years; are able to communicate normally and agree to participate in our study; with the radiological evidence of proximal humeral fractures with three-part or four-part; surgical treatment was performed within twenty-one days after the acute fracture. Consecutive patients with proximal humeral fractures will be stochastic to be dealt with a locking plate or a bone nail. The informed consent will be acquired in each patients. Two groups will use the same postoperative rehabilitation protocol. Clinical outcomes include Intraoperative blood loss, operation time, Constant-Murley score, Disability, Arm, Shoulder and Hand score, shoulder range of motion (such as external rotation), and postoperative complications. The significance level was defaulted as P < .05.

RESULTS

This study will provide a solid theoretical basis for exploring which technique is better in treatment of 3-part or 4-part proximal humeral neck fractures in elderly population.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (number: researchregistry6047).