Surgical Treatment With an Angular Stable Plate for Complex Displaced Proximal Humeral Fractures in Elderly Patients: A Randomized Controlled Trial

Objective: The objective of the study was to evaluate functional outcome, patient self-assessment, and radiographic outcome at 1 year in displaced three- and four-part proximal humeral fractures (OTA group 11-B2 and 11-C2). Design: Randomized controlled trial. Setting: Academic medical center. Patients/Participants: Fifty patients aged 60 years or older with displaced three- or four-part proximal humeral fractures and no previous shoulder injuries were randomized either to surgical treatment or to conservative closed treatment. Twenty-five patients were included in each group. Forty-eight patients completed 12-month follow-up. Two surgical patients died within 3 months. Intervention: The surgically treated group had a standardized surgical treatment with open reduction and internal fixation using an angular stable plate and cerclages. Instructed physical therapy started the third postoperative day. The conservative treatment group had a standardized nonoperative treatment that included closed reduction if displacement between the head and metaphyseal shaft fragment exceeded 50% of the diaphyseal diameter. Physical therapy started on the fifteenth postoperative day. Main Outcome Measurements: The main outcome was the mean difference in Constant score between the injured and noninjured shoulder at 12 months. The secondary outcomes were patient self-assessment (American Shoulder and Elbow Surgeons score) and radiographic ratings at 12 months. Results: At 12 months, mean Constant scores favored conservative treatment by 2.4 points (nonsignificant; P = 0.62). There was no significant difference in mean patient self-assessment. However, radiographic outcomes were significantly better for surgically treated patients. Conclusion: There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients.

[1]  C. Court-Brown,et al.  Minimally displaced proximal humeral fracturesEpidemiology and outcome in 507 cases , 2003, Acta orthopaedica Scandinavica.

[2]  Guillaume D. Dumont,et al.  Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures , 2014, JBJS reviews.

[3]  J. Macdermid,et al.  Proximal humeral fractures: a systematic review of treatment modalities. , 2008, Journal of shoulder and elbow surgery.

[4]  R. Hertel.  Fractures of the proximal humerus in osteoporotic bone , 2005, Osteoporosis International.

[5]  J. Gibson,et al.  Interventions for treating proximal humeral fractures in adults. , 2001, The Cochrane database of systematic reviews.

[6]  David L Helfet,et al.  First clinical results of the Locking Compression Plate (LCP). , 2003, Injury.

[7]  T. Gregory,et al.  Surgical treatment of three and four-part proximal humeral fractures. , 2013, Orthopaedics & traumatology, surgery & research : OTSR.

[8]  M. Leunig,et al.  Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. , 2004, Journal of shoulder and elbow surgery.

[9]  A. Carr,et al.  An evaluation of the Constant-Murley shoulder assessment. , 1996, The Journal of bone and joint surgery. British volume.

[10]  E. Schneider,et al.  Aspects of internal fixation of fractures in porotic bone. Principles, technologies and procedures using locked plate screws. , 2005, Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca.

[11]  K. Zyto.  Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. , 1998, Injury.

[12]  Christian Gerber,et al.  A review of the Constant score: modifications and guidelines for its use. , 2008, Journal of shoulder and elbow surgery.

[13]  D. Ring.  Current concepts in plate and screw fixation of osteoporotic proximal humerus fractures. , 2007, Injury.

[14]  Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures , 2008 .

[15]  J. Pajarinen,et al.  Internal fixation of proximal humeral fractures with a locking compression plateA retrospective evaluation of 72 patients followed for a minimum of 1 year , 2004, Acta orthopaedica Scandinavica.

[16]  R. Brand,et al.  Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: comparison with clinical neurological examination , 1999, Clinical Neurology and Neurosurgery.

[17]  T. Treumann,et al.  The impact of stereo-visualisation of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and Neer classifications in the assessment of fractures of the proximal humerus. , 2009, The Journal of bone and joint surgery. British volume.

[18]  Proximal humeral fractures and relation to osteoporosis: a cohort study of 49 hospitalized patients with 50 fractures , 2009, European Journal of Orthopaedic Surgery & Traumatology.

[19]  L. Bigliani,et al.  Complications of Proximal Humerus Fractures , 1997 .

[20]  P. Moonot,et al.  Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system. , 2007, The Journal of bone and joint surgery. British volume.

[21]  Laurent Audigé,et al.  How reliable are reliability studies of fracture classifications?A systematic review of their methodologies , 2004, Acta orthopaedica Scandinavica.

[22]  W. Menth-Chiari,et al.  Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. , 2004, The Journal of bone and joint surgery. British volume.

[23]  H. Resch,et al.  Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients. , 2008, The Journal of bone and joint surgery. British volume.

[24]  M. A. Miranda,et al.  Locking plate technology and its role in osteoporotic fractures. , 2007, Injury.

[25]  T. Frangen,et al.  Proximal humeral fractures in geriatric patients. Is the angle-stable plate osteosynthesis really a breakthrough? , 2007, Acta orthopaedica Belgica.

[26]  H. Resch,et al.  Percutaneous fixation of three- and four-part fractures of the proximal humerus. , 1997, The Journal of bone and joint surgery. British volume.

[27]  V C Mow,et al.  A standardized method for the assessment of shoulder function. , 1994, Journal of shoulder and elbow surgery.

[28]  C. Constant,et al.  A clinical method of functional assessment of the shoulder. , 1987, Clinical orthopaedics and related research.

[29]  S. Mawson,et al.  Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up). , 2007, Journal of shoulder and elbow surgery.

[30]  A. J. Wijgman,et al.  Open Reduction and Internal Fixation of Three and Four-Part Fractures of the Proximal Part of the Humerus , 2002, The Journal of bone and joint surgery. American volume.

[31]  L. Audigé,et al.  Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. , 2007, Journal of orthopaedic trauma.

[32]  C. Olsson,et al.  Long-term outcome of a proximal humerus fracture predicted after 1 year , 2005, Acta orthopaedica.

[33]  Shane J Nho,et al.  Management of proximal humeral fractures based on current literature. , 2007, The Journal of bone and joint surgery. American volume.