Three- and four-part proximal humerus fractures: open reduction and internal fixation versus arthroplasty

Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate

OBJECTIVE

To present the experience in a single institution of the management of 82 consecutive fractures and fracture-dislocations of the proximal humerus treated with the Proximal Humeral Internal Locking System (Philos(®)) plate.

MATERIALS AND METHODS

A total of 81 patients with 82 proximal humerus fractures (one patient had bilateral fracture) were treated at our institution with open reduction and internal fixation with Philos(®) plate from January 2008 to December 2012 and the clinico-radiological outcome was analysed. Twelve of these patients also had a dislocation of the proximal humerus. According to the Neer classification, there were seven two-part fractures, 40 three-part fractures and 35 four-part fractures. All patients received a similar physical therapy programme following internal fixation. Mean final follow-up was 32 months. Functional outcome was evaluated for each patient using the Constant-Murley score; radiographic evaluation was also conducted and complications were recorded.

RESULTS

At the end of the follow-up period, the mean Constant-Murley score for the injured side was 75 points (range 42-92); results were graded as excellent for eight patients, good for 52, moderate for 17 and poor for five. Twenty-three patients (28%) had complications during the follow-up period. Reoperation was required in 12 patients. Complications included avascular necrosis of the humeral head in 10 patients (12%), varus positioning of the head in four patients (4.8%), impingement syndrome in three patients (3.6%), secondary screw perforation in three patients (3.6%), non-union of the fracture in two patients (2.4%) and infection in one patient (1.2%).

CONCLUSIONS

Open reduction and internal fixation of proximal humeral fractures with the Philos(®) plate was associated with good clinical outcomes provided the correct surgical technique was used. To better evaluate the real incidence of complications, it is important to follow patients for more than one year after surgery as some complications may arise after this time.

Functional outcomes following locking plate fixation of complex proximal humeral fractures

The purpose of this study was to evaluate the functional outcome of patients with complex proximal humeral fractures fixated by locking plate technology. Eighty-nine patients (27 men, 62 women) older than 50 years with 3- and 4-part proximal humeral fractures were treated using locking plate fixation and followed up for more than 1 year. Functional outcomes were assessed by using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Constant scores, and the complications were evaluated through physical and radiographic examinations. Mean DASH and Constant scores for all 89 patients were 19.6 and 66.6 points, respectively. No significant differences existed in the 2 scores between patients with 3- and 4-part fractures. Of the 71 patients without complications, 68 had an excellent functional outcome according to the DASH score, whereas 2 patients had an excellent outcome on the Constant score. For the 18 patients with complications, the functional outcomes were significantly poorer compared with patients without complications. According to the Constant score, all patients with complications were classified into a moderate or poor functional outcome, but the rate was 12% with the DASH score. In patients with 3- and 4-part proximal humeral fractures fixed with locking plate fixation, complications were the major cause of compromised functional outcomes. Based on these results, different conclusions would be reached when the functional outcome was assessed by using the DASH and Constant scores separately. Because the clinician-based Constant score may bias the results, patient-based assessments, such as the DASH score, are required for the evaluation of functional outcome after shoulder surgery.

Open Reduction and Internal Fixation (ORIF) of Complex 3- and 4-Part Fractures of the Proximal Humerus: Does Age Really Matter?

INTRODUCTION

Treatment of complex fracture patterns of the proximal humerus continues to be a challenging and controversial clinical scenario. The aim of this study was to report on the outcomes of complex displaced 3- and 4-part fractures of the proximal humerus treated with locked plating and compare the functional results of patients on the basis of age at time of injury.

METHODS

A retrospective review was completed to identify patients whom had sustained a 3- or 4-part fracture of the proximal humerus (Neer classification), treated surgically with locked compression plating. Patients were recruited for a final follow-up, with clinical (Constant and Disabilities of the Arm, Shoulder, Hand [DASH] scores) and radiographic outcome analysis. Results were compared (t test and Wilcoxon test) with fracture type (3- vs 4-part) and patient age at time of fracture (<65 years vs >65years) as the primary outcome measure. The presence or absence of a complication and presence or absence of a concomitant osseous injury at the time of presentation were evaluated as secondary outcome measures, in regard to overall functional results of the treatment in question. Complications were defined as posttraumatic osteoarthritis, avascular necrosis of the humeral head, and screw cutout with chondrolysis. The null hypothesis being that age of the patient at the time of injury would not greatly affect functional outcome measurements.

RESULTS

Forty-five fractures were identified in 45 patients, with 31 three-part fractures and 14 four-part fractures, and 17 patients were available for final follow-up (9 three-part and 8 four-part). Twelve patients were identified as under the age of 65 years and were compared with 5 patients who were identified as older than 65 years of age. The relative Constant score, at final follow-up, for those under the age of 65 was 88.58, while the score for those above the age of 65 was 82.5. In a similar fashion, the DASH score for those younger than 65 was 11.67, while the score for those older than 65 was 12.5. Neither the Constant score nor the DASH score differed in a statistically significant manner, when comparing patients who were younger than 65 to those older than 65 years of age.

CONCLUSION

The current series of fractures was able to demonstrate similar and satisfactory outcomes following locked plating treatment of complex 3- and 4-part proximal humerus fractures in younger patients and patients older than the age of 65, while still accepting the null hypothesis.

Four-part fracture dislocations of the proximal humerus in young adults: results of fixation

INTRODUCTION

Four-part fracture dislocations of the proximal humerus occurring in young age are extremely difficult fractures with a high incidence of complications. The risk of avascular necrosis is high; hence, prosthetic replacement is the treatment of choice in older patients with these complex fractures; on the other hand, the longevity of the prosthesis is the main concern in young age. Thus, every effort should be made to fix these fractures in the young. The purpose of this study is to evaluate the results of fixation in a series of young patients with four-part fracture dislocations; to support the trend to fix these fractures; and reserve prosthetic replacement to older patients.

METHODS

In a prospective study, 39 patients younger than 40 years of age with four-part fracture dislocations were treated with open reduction and fixation either with K-wires or with a proximal humerus plate. Ethibond sutures were used in all patients to supplement fixation of tuberosities. In 18 patients, the dislocation was anterior and in 21 patients it was posterior. Twelve patients had an anatomic neck fracture and 27 had a surgical neck fracture. Surgery was performed within 1 week after the injury. Physiotherapy was initiated according to the general condition of the patient and the stability of fixation; the average time was 5 days after surgery.

RESULTS

Patients were followed up for an average of 26 months. Union was achieved in 36 patients and three patients had nonunion, all in anatomic neck fractures. Avascular necrosis developed in eight patients, seven of which were fractures of the anatomic neck and one was in the surgical neck. The average Constant score was 77; 26 patients were pain free, nine had mild pain and four had moderate pain. The mean active anterior elevation was 145°. Patients were divided into two groups based on the anatomic configuration of the fracture; in 12 patients (group 1), the head was fractured at the anatomical neck and in 27 patients (group 2), the head was fractured at the surgical neck. In group 2, the active anterior elevation was significantly better and the Constant score was higher.

CONCLUSIONS

Anatomical reduction and rigid fixation with meticulous surgical technique can lead to satisfactory results. The results in surgical neck fractures are superior to anatomic neck fractures with significantly less complications.