Proximal humerus fractures in the elderly can be reliably fixed with a "hybrid" locked-plating technique

Abstract

Background: Controversy exists regarding the best treatment of proximal humerus fractures in the elderly. Recent studies of open reduction and internal fixation have demonstrated high complication rates.

Questions/purposes: We asked whether (1) open reduction and internal fixation could be performed with low rates of immediate and delayed complications, (2) reduction of these fractures could be maintained over time by evaluating long-term radiographs and visual analog pain scores, and (3) 6-week immobilization would lead to disabling stiffness by evaluating postoperative motion and functional scores.

Patients and methods: We retrospectively reviewed all 35 patients older than 75 years with displaced proximal humerus fractures treated using a "hybrid" technique between 2002 and 2008. All patients were immobilized for 6 weeks after surgery. Thirteen of the 35 patients either died or developed severe dementia during followup. The analysis included 22 patients followed a minimum of 1 year (mean, 3 years; range, 1-6.7 years).

Results: There were no early or late reoperations in this series. An acceptable reduction was achieved in 89% of the shoulders and maintained over time. All fractures healed. Osteonecrosis was noted on radiographs in 11% of the shoulders. Six weeks of immobilization did not lead to disabling stiffness. At most recent followup, mean active elevation was 141°, mean active internal rotation L1, mean active external rotation 36°, and mean American Society of Shoulder and Elbow Surgeons score 68.

Conclusions: Utilizing this approach, open reduction and internal fixation followed by 6-week immobilization results in a low rate of reoperation and good functional outcomes for elderly patients with proximal humerus fractures.

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

Fig. 1A–C

(A) Bony comminution that would impede stable seating of the humeral head on the shaft is removed and preserved. (B) Bone fragments that were previously removed from the humeral shaft are placed back into the fracture site for final reduction. (C) Traction sutures are utilized to gain control of the head fragment, which is reduced onto the shaft, ensuring adequate support of the humeral head after reduction.

Fig. 2

Provisional fixation of the reduction is obtained using a Kirschner wire. The reduction is maintained utilizing the rotator cuff traction sutures and is compared with contralateral shoulder films to avoid malreduction.

Fig. 3A–B

(A) The precontoured plate is carefully placed to avoid subacromial impingement. (B) Screws are placed, avoiding intra-articular screw penetration. Each screw length is assessed with fluoroscopic imaging.

Fig. 4

The chart demonstrates visual analog pain score at last followup. The light bar represents the operative extremity, while the dark bar represents the contralateral extremity. Values are expressed as mean (bars) and SD (error bars).