Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial

Abstract

Background: Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function.

Questions/purposes: We therefore performed a randomized controlled trial to compare (1) function, (2) strength, and (3) pain and disability in patients 65 years and older with four-part humeral fractures treated either nonoperatively or with hemiarthroplasty.

Methods: We randomly allocated 50 patients to one of the two approaches. There were no differences in patient demographics between the two groups. The Constant-Murley score was the primary outcome measure. Secondary outcome measures were the Simple Shoulder Test, abduction strength test as measured by a myometer, and VAS scores for pain and disability. All patients were assessed at 12 months.

Results: We found no between-group differences in Constant-Murley and Simple Shoulder Test scores at 3- and 12-months followup. Abduction strength was better at 3 and 12 months in the nonoperatively treated group although the nonoperatively treated patients experienced more pain at 3 months; this difference could not be detected after 12 months.

Conclusions: We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment.

Level of evidence: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–D

(A) AP and (B) lateral views show a valgus impacted four-part fracture. These (C) AP and (D) lateral views show varus four-part fractures as seen in the emergency room.

Fig. 2

A flow diagram shows the selection process of the patients through the study.

Fig. 3A–C

(A) An AP view of a nonoperatively treated left shoulder shows ON 12 months after trauma. (B) AP and (C) lateral views show a pseudarthrosis of the fracture, seen in Fig. 1C–D, 12 months after trauma.