Three- and four-part fractures have poorer function than one-part proximal humerus fractures

Abstract

Background: Locking plates have become a commonly used fixation device in the operative treatment of three- and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures.

Questions/purposes: We compared functional scores, ROM, and radiographs in patients with one-part proximal humerus fractures treated nonoperatively to those in patients with displaced three- and four-part proximal humerus fractures treated with open reduction and internal fixation using locking plates.

Patients and methods: We retrospectively reviewed 142 patients with proximal humerus fractures treated with a standardized treatment algorithm over a 6-year period. Three- and four-part fractures were treated surgically while one-part fractures were treated nonoperatively. Functional scores, ROM, and radiographs were used to evaluate outcomes. American Shoulder and Elbow Surgeons and SF-36 scores were obtained at 12 months. Of the 142 patients, 101 (51 with three- or four-part fractures and 50 with one-part fractures) had a minimum followup of 12 months (average, 19 months; range, 12-64 months).

Results: The fractures united in all patients. At 1 year, the patients with one-part fractures had better SF-36 physical and mental scores and American Shoulder and Elbow Surgeons scores than the three- and four-part fractures. Both groups had similar shoulder ROM. Nine patients treated operatively had complications, four of which were related to screw penetration into the joint.

Conclusions: Patients with three- and four-part fractures should be advised of the likelihood of persistent functional impairment and a relatively higher risk of complications when treated operatively with locked plates.

Level of evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1A–F

(A) An AP view, (B) a scapular Y view, and (C) a Velpeau view of a 67 year-old woman who fell and sustained a displaced three-part fracture are shown. (D) An AP view in external rotation, (E) an AP view in internal rotation, and (F) an axillary view taken postoperatively show near-anatomic reduction of this patient’s proximal humerus.