Early complications of operatively treated proximal humeral fractures

doi:10.1016/j.jse.2006.05.008

Journal of Shoulder and Elbow Surgery

Volume 16, Issue 1, January–February 2007, Pages 14-24

https://doi.org/10.1016/j.jse.2006.05.008 Get rights and content

Minimal information exists regarding early complications after operatively treated proximal humeral fractures. Of the 82 shoulders that had osteosynthesis, 42 had a (nonmedical) complication, with 21 requiring further surgery. Of 42 shoulders with complications, 12 were related to incomplete reduction, 16 had loss of anatomic fracture fixation, 9 had delayed healing, 3 had an infection, 1 had rotator cuff failure, and 1 had loose bodies. Fixed-angle plates had lower rates of initial malpositioning and resultant malunion. Of the 22 shoulders requiring hemiarthroplasty, 14 had an early complication. Of these, 7 had complications relating to implant insertion or tuberosity malreduction at the index operation and 7 had problems with tuberosity healing. The rate of complications after operative treatment of proximal humeral fractures is high. All efforts at fracture fragment fixation with osteosynthesis and hemiarthroplasty should be directed at obtaining anatomic fracture fixation that resists displacement.

Section snippets

Methods

A computer-assisted search of the surgical database at our institution was performed to identify patients who had operative fixation or arthroplasty for fracture of the proximal humerus from January 1995 to December 2002. Only skeletally mature patients from a 60-mile radius (regional service area) with acute fractures (<3 weeks from injury) were included in the study to eliminate selection problems from our institution’s referral pattern, which frequently deals with unusual or highly complex

Medical complications

Major medical complications occurred in 6 of 102 patients within 3 months of the injury. There were 4 patients who had a pulmonary embolus and 2 who had a myocardial infarction during the initial hospitalization and survived for fracture care follow-up. The median number of hospital days to discharge was 10 (range, 6-18 days).

Complications in osteosynthesis group

Of the 82 shoulders undergoing osteosynthesis of the proximal humerus, 42 (51%) had an early complication, with 21 shoulders (26%) undergoing reoperation. Of the 82

Discussion

Nonoperative treatment of proximal humeral fractures is generally recommended for nondisplaced or minimally displaced fractures of the proximal humerus, with satisfactory results being expected.²⁰ Operative intervention is usually recommended for the treatment of displaced fractures to prevent deformity and improve function,²⁷ but several authors have questioned whether operative intervention with any fracture type significantly improves functional outcomes (compared with nonoperative care) or

References (43)

S.A. Antuna et al.
Shoulder arthroplasty for proximal humeral malunions: long-term results
J Shoulder Elbow Surg
(2002)
S.A. Antuna et al.
Shoulder arthroplasty for proximal humeral nonunions
J Shoulder Elbow Surg
(2002)
P. Boileau et al.
Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus
J Shoulder Elbow Surg
(2001)
P. Boileau et al.
Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus
J Shoulder Elbow Surg
(2002)
F. Cuomo et al.
Open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus
J Shoulder Elbow Surg
(1992)
M.A. Frankle et al.
Stability of tuberosity reattachment in proximal humeral hemiarthroplasty
J Shoulder Elbow Surg
(2002)
P. Mansat et al.
Shoulder arthroplasty for late sequelae of proximal humeral fractures
J Shoulder Elbow Surg
(2004)
C.S. Neer
Four-segment classification of proximal humeral fractures: purpose and reliable use
J Shoulder Elbow Surg
(2002)
U. Prakash et al.
Hemiarthroplasty for severe fractures of the proximal humerus
J Shoulder Elbow Surg
(2002)
H. Resch et al.
Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head
Injury
(2001)

M.W. Shrader et al.

Understanding proximal humerus fractures: image analysis, classification, and treatment

J Shoulder Elbow Surg

(2005)

G.R. Williams et al.

Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning

Orthop Clin North Am

(2000)

U. Bengner et al.

Changes in the incidence of fracture of the upper end of the humerus during a 30-year periodA study of 2125 fractures

Clin Orthop Relat Res

(1988)

P.K. Beredjiklian et al.

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

J Bone Joint Surg Am

(1998)

J. Bernstein et al.

Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs

J Bone Joint Surg Am

(1996)

S. Blom et al.

Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerusA clinical and electromyographic study

Acta Chir Scand

(1970)

C.M. Bono et al.

Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder

J Bone Joint Surg Br

(2001)

S. Brorson et al.

Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists

Int Orthop

(2002)

R.H. Cofield

Comminuted fractures of the proximal humerus

Clin Orthop Relat Res

(1988)

C.M. Court-Brown et al.

The translated two-part fracture of the proximal humerusEpidemiology and outcome in the older patient

J Bone Joint Surg Br

(2001)

M. Demirhan et al.

Prognostic factors in prosthetic replacement for acute proximal humerus fractures

J Orthop Trauma

(2003)

Cited by (84)

Proximal humeral fracture locking plate fixation with anatomic reduction, and a short-and-cemented-screws configuration, dramatically reduces the implant related failure rate in elderly patients
2021, JSES International
Multiple studies have reported an unacceptable implant-related complication rate in proximal humeral fractures treated with locking plates, particularly in older patients. Our objective was to compare the fracture fixation failure rates in elderly patients, after a dedicated technique for locking plate fixation with cement augmentation or without it.
A total of 168 open reduction and internal fixation with locking plates were performed for complex proximal humerus fractures by a single surgeon in 136 women and 32 men older than 65 years of age (average 76 years). Treatment groups included group 1 with noncemented screws (n = 90) and group 2 with cemented screws (n = 78). As per Mayo-FJD Classification, there were 74 (44%) varus posteromedial impaction, 41 (24%) algus impaction, 46 (28%) surgical neck, and 7 (4%) head dislocation injuries. A retrospective radiographic and a clinical analysis was performed.
At a mean follow-up of 33 months, the implant failure rate was significantly lower in the cement augmentation group (1% vs. 8%, P = .03). The overall complication rate was 21% (25% group 1, 15% group 2; P = .1). Global avascular necrosis was associated with sustaining a valgus impacted fracture (P = .02 odds ratio 5.7), but not to augmentation. Partial avascular necrosis occurred only in patients treated with cemented screws (3.8%). The overall revision rate was 9% in both groups. Forward elevation was 126 ± 36 degrees and external rotation was 44 ± 19 degrees. The mean Constant score was 70 ± 15 in group 1 and 76 ± 15 in group 2 (P = .03).
Cement augmentation significantly decreased the rate of implant failure. Good results are expected for most patients treated with this technique.
Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial
2019, Journal of Shoulder and Elbow Surgery
Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3- or 4-part PHFs in elderly patients.
This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3- and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), EuroQol 5 Dimensions, and EQ-VAS scores.
We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes at 12 months' follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P = .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P = .075); the VAS scores were 1.6 and 0.9, respectively (P = .011); the physical SF-12 scores were 36 and 37, respectively (P = .709); the mental SF-12 scores were 43 and 42, respectively (P = .625); the EuroQol 5 Dimensions scores were 0.89 and 0.92, respectively (P = .319); and the EQ-VAS scores were 65 and 67, respectively (P = .604).
This study yields important evidence for the treatment of complex PHFs in elderly patients suggesting minimal benefits of RSA over nonoperative treatment for displaced 3- and 4-part PHFs. At short-term follow-up, the main advantage of RSA appeared to be less pain perception.
Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures
2018, Injury
This study evaluates the clinical outcomes in patients with proximal humerus fractures (PHF) treated with reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed fixation that have more than 5 years of follow-up.
This is a retrospective study of 270 RTSA. The inclusion criteria for this study consisted of patients initially treated with either open reduction and plate fixation (ORIF) or fixation using an intramedullary nail (IMN), who were managed with a single-stage revision to a RTSA, and had a minimum of 24 months clinical and radiological follow-up. Six patients with failed fixation of displaced PHF were revised with RTSA. One patient was excluded from the study because she died. Five shoulders were reviewed for the purpose of this study. The patients were evaluated using Constant score, relative Constant score and visual analogue scale for pain.
The mean follow-up was 89 months (65–108). The mean absolute Constant score improved from 31, 81 to 44, 2 and the relative Constant score improved from 31,81% to 67,2%. Mean VAS improved from 6, 8 to 2. One patient rated their outcome excellent, 1 good, 1 satisfied and 2 poor.
RTSA is an appropriate treatment as a revision surgery for failed fixation of PHF. Patients should be adequately warned that they will improve their function but may have complications following this salvage procedure.
Three- and four-part proximal humerus fractures in the elderly: Eminence versus evidence
2017, Seminars in Arthroplasty JSES
The majority of proximal humerus fractures are minimally displaced and good outcomes can be achieved with nonoperative treatment strategies. However, controversy exists regarding the best management of highly comminuted and displaced proximal humerus fractures that occur in elderly patients with poor bone quality. Although surgical options including open reduction and internal fixation or hemiarthroplasty can restore excellent function, the rate of catastrophic failure remains high measuring between 20% and 40%. Reverse total shoulder arthroplasty has recently been introduced as a means for treatment of these fractures with intermediate results demonstrating improved range of motion, functional outcomes, and lower rates of revision.
Radiographic and clinical results of tension suture fixation using two washers with PHILOS plate for proximal humeral fractures
2017, Injury
Citation Excerpt :
Because of its reported complications, several authors have emphasized the importance of maintaining soft tissues around the proximal humerus with respect to limiting displacement and maintaining stability [2,10–13]. To prevent these postoperative complications, several supplementary suture techniques using non-absorbable suture allowing for the incorporation of the rotator cuff as a fixation point have been described [2,11,12]. The purpose of this study was to evaluate the radiographic and clinical results of tension suture fixation using two washers with PHILOS plate (Synthes, West Chester, PA, USA) for proximal humeral fractures.
The purpose of this study was to evaluate the radiographic and clinical results of tension suture fixation using two washers with PHILOS plate (Synthes, West Chester, PA, USA) for proximal humeral fractures.
Consecutive 39 patients were included and divided into two groups of adequate and inadequate medial support (MS (+) group vs MS (−) group). The mean follow-up period was 45months (range: 26–69 months). The mean age at the time of surgery was 59 years (range: 17–86 years) and there were 12 men and 27 women. The clinical results were evaluated using the visual analogue scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV). The radiographic results were evaluated by serial radiographs and Paavolainen method, which measures the neck-shaft angle (NSA). We used the Paired T and Kruskal-Wallis test to compare radiographic and clinical results between the two groups.
Bony union was achieved in 37 cases (94.9%). The mean NSA was changed from 133.5° postoperatively to 131.0° at the final follow-up period, but this change was not statistically significant. Thirty-five cases (89.8%) had good radiographic results as determined by the Paavolainen method. The mean final VAS pain score, ASES score, and SSV were 1.3, 87.3, and 86.0%, respectively. There were no significant differences between the two groups with respect to radiographic and clinical outcomes. Eight cases (20.5%) had complications including 5 with shoulder stiffness, 1 experiencing nonunion by fixation failure, 1 malunion, and 1 migration of greater tuberosity.
Tension suture fixation using two washers with PHILOS plate for proximal humeral fractures yielded satisfactory radiographic and clinical results. It can be a treatment option that can reduce varus deformity and fixation loss.
Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases
2016, Revue de Chirurgie Orthopedique et Traumatologique
Dans les ostéosynthèses des fractures céphalobitubérositaires de l’extrémité supérieure de l’humérus, il n’existe pas de critères objectifs permettant de choisir entre le clou et la plaque. L’objectif de cette étude est d’identifier des critères radiologiques en faveur de l’une ou de l’autre technique.
Il s’agit d’une étude multicentrique comparative rétrospective à propos de 54 enclouages antérogrades et 53 plaques réalisées entre le 1^er janvier 2009 et le 31 décembre 2011 pour des fractures 4 céphalobitubérositaires de l’extrémité supérieure de l’humérus. Le suivi radioclinique minimum est de 18 mois. Les résultats fonctionnels sont évalués par le score de Constant pondéré et le taux de mauvais résultats défini par un score de Constant pondéré < 70 %. Les critères radiologiques sont évalués sur un bilan préopératoire et au dernier recul : déplacement initial et réduction de la tête humérale et des tubérosités, morphologie de la console interne (comminution du calcar, charnière postéromédiale, et taille de l’éperon métaphysaire), et survenue d’une nécrose.
Avec un recul moyen de 42 mois, les scores de Constant pondéré et le taux de mauvais résultats sont respectivement de 77 % et 48 % pour le groupe Clou et 81 % et 38 % pour le groupe Plaque (ns). La tête humérale est respectivement réduite en position anatomique, valgus et varus dans 57 %, 30 % et 13 % des clous et 58 %, 29 % et 13 % des plaques. Les tubérosités ont consolidé en position anatomique dans 72 % des clous et 70 % des plaques (ns). Seule la présence d’une charnière interne préopératoire a montré une influence sur les résultats fonctionnels des clous et des plaques avec respectivement un score de Constant pondéré (p = 0,05) et un taux de mauvais résultats (p = 0,02) de 82 % et 52 % pour le groupe Clou et 97 % et 9 % pour le groupe Plaque. Le taux de complications est comparable avec un taux de nécrose totale et d’effraction articulaire des vis épiphysaires respectivement de 17 % et 11 % pour les clous et 15 % et 11 % pour les plaques. Le taux de reprises chirurgicales est de 18,5 % pour le groupe Clou et de 30 % pour le groupe Plaque.
En cas de conservation de la charnière, nous recommandons l’ostéosynthèse par plaque. Dans les autres cas, les 2 techniques peuvent être utilisées en appliquant les règles générales de l’ostéosynthèse que sont la réduction des tubérosités, la correction du varus et la stabilisation de la console interne.
IV étude rétrospective.

View all citing articles on Scopus

View full text

Original articleEarly complications of operatively treated proximal humeral fractures

Section snippets

Methods

Medical complications

Complications in osteosynthesis group

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

Orthop Clin North Am

Changes in the incidence of fracture of the upper end of the humerus during a 30-year periodA study of 2125 fractures

Clin Orthop Relat Res

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

J Bone Joint Surg Am

Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs

J Bone Joint Surg Am

Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerusA clinical and electromyographic study

Acta Chir Scand

Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder

J Bone Joint Surg Br

Low agreement among 24 doctors using the Neer-classification; only moderate agreement on displacement, even between specialists

Int Orthop

Comminuted fractures of the proximal humerus

Clin Orthop Relat Res

The translated two-part fracture of the proximal humerusEpidemiology and outcome in the older patient

J Bone Joint Surg Br

Prognostic factors in prosthetic replacement for acute proximal humerus fractures

J Orthop Trauma

Original article
Early complications of operatively treated proximal humeral fractures