Surgical Treatment of Three and Four-Part Proximal Humeral Fractures

Background: Optimal surgical management of three and four-part proximal humeral fractures in osteoporotic patients is controversial, with many advocating prosthetic replacement of the humeral head. Fixed-angle locked plates that maintain angular stability under load have been proposed as an alternative to hemiarthroplasty for the treatment of some osteoporotic fracture types. 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 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.