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Surgical Treatment of Three and Four-Part Proximal Humeral Fractures

¹ 1414 South Grand Avenue, Suite 123, Los Angeles, CA 90015. E-mail address: brian{at}briansolbergmd.com
² Cedars Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA 90048. E-mail address for C.N. Moon: charles.moon{at}cshs.org. E-mail address for D.P. Franco: dennis.franco{at}cshs.org. E-mail address for G.D. Paiement: guy.paiement{at}cshs.org

Investigation performed at Cedars Sinai Medical Center, Los Angeles, California

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Methods: The records of 122 consecutive patients who were fifty-five years of age or older and in whom a Neer three or four-part proximal humeral fracture had been treated surgically between January 2002 and November 2005 were studied retrospectively. After exclusions, thirty-eight patients treated with a locked-plate construct were compared with forty-eight patients who had undergone hemiarthroplasty. All patients had radiographic and clinical follow-up at a minimum of twenty-four months and an average of thirty-six months. Reduction and implant placement were evaluated radiographically. Clinical outcomes were measured with use of the Constant-Murley system.

Results: The mean Constant score (and standard deviation) at the time of final follow-up was significantly better in the locked-plate group (68.6 ± 9.5 points) than in the hemiarthroplasty group (60.6 ± 5.9 points) (p < 0.001). The Constant scores for the three-part fractures in the locked-plate and hemiarthroplasty groups were 71.6 and 60.4 points (p < 0.001), respectively, and the scores for the four-part fractures in those groups were 64.7 and 60.1 points (p = 0.19), respectively. Patients with an initial varus extension deformity in the locked-plate group had significantly worse outcomes than those with a valgus impacted pattern (Constant score, 63.8 compared with 74.6 points, respectively; p < 0.001). Complications in the group treated with locked-plate fixation included osteonecrosis in six patients, screw perforation of the humeral head in six patients, loss of fixation in four patients, and wound infection in three patients. Loss of fixation was seen only in patients with >20° of initial varus angulation of the humeral head. Complications in the hemiarthroplasty group included nonunion of the tuberosity in seven patients and wound infection in three patients.

Conclusions: In this series, open repair with use of a locked plate resulted in better outcome scores than did hemiarthroplasty in similar patients, especially in those with a three-part fracture, despite a higher overall complication rate. Open reduction and internal fixation of fractures with an initial varus extension pattern should be approached with caution.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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