Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate functional outcome, patient self-assessment, and radiographic outcome at 1 year in displaced three- and four-part proximal humeral fractures (OTA group 11-B2 and 11-C2). DESIGN: Randomized controlled trial. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: Fifty patients aged 60 years or older with displaced three- or four-part proximal humeral fractures and no previous shoulder injuries were randomized either to surgical treatment or to conservative closed treatment. Twenty-five patients were included in each group. Forty-eight patients completed 12-month follow-up. Two surgical patients died within 3 months. INTERVENTION: The surgically treated group had a standardized surgical treatment with open reduction and internal fixation using an angular stable plate and cerclages. Instructed physical therapy started the third postoperative day. The conservative treatment group had a standardized nonoperative treatment that included closed reduction if displacement between the head and metaphyseal shaft fragment exceeded 50% of the diaphyseal diameter. Physical therapy started on the fifteenth postoperative day. MAIN OUTCOME MEASUREMENTS: The main outcome was the mean difference in Constant score between the injured and noninjured shoulder at 12 months. The secondary outcomes were patient self-assessment (American Shoulder and Elbow Surgeons score) and radiographic ratings at 12 months. RESULTS: At 12 months, mean Constant scores favored conservative treatment by 2.4 points (nonsignificant; P = 0.62). There was no significant difference in mean patient self-assessment. However, radiographic outcomes were significantly better for surgically treated patients. CONCLUSION: There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients.

Rotator cuff tears in proximal humeral fractures: an MRI cohort study in 76 patients.

BACKGROUND: The aim was to evaluate if concomitant injury to the rotator cuff is important for functional outcome in proximal humerus fractures, and to relate loss of function to malunion of the fractures. MATERIALS AND METHODS: A total of 76 patients treated conservatively for proximal humerus fracture were included in this cohort study. Performing an MRI: examination at the time of injury and after 12 months, tears of the rotator cuffs were classified as partial- or full thickness. The fractures were classified, according to the AO classification, and the degree of tubercle displacement and humeral head inclination evaluated at 12 months. Constant score was used as outcome measure. RESULTS: Magnetic resonance imaging (MRI) examinations confirmed 22 rotator cuff tears (four full thicknesses) diagnosed at the time of injury, and 10 additional tears (three full thicknesses) at one year. Functional loss at one year significantly corresponded to the tears at the time of injury (P = 0.004), varus malunion of the head and displacement of tubercles (P < 0.001). INTERPRETATION: Partial- as well as full thickness tears of the rotator cuff are important for functional outcome. Skeletal deterioration seems even more important.

Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital.

INTRODUCTION: Patients with proximal humeral fractures are mostly elderly. In addition to the proximal humeral fracture, they often have other injuries related to poor bone quality. The surgical treatment of proximal humeral fractures in elderly patients with comminuted fractures is associated with several problems and a high frequency of complications. The aims of this study were to evaluate patients with a proximal humeral fracture treated in a hospital, assess the outcome of the fracture treatment, and decide whether surgical treatment of displaced proximal humeral fractures is superior to conservative treatment or not. MATERIALS AND METHODS: Patients with fractures of the proximal part of the humerus treated in our hospital were followed during two different periods (14 and 10 months). The study in the first time period was retrospective in design, while in the second period the patients were followed prospectively. Seventy patients, (71% women) with a mean age of 71 years, were included in the study. A functional test was performed within 12-14 months after the injury using a modified Rowe shoulder score. Surgical treatment was performed in 15 patients (21%). Neither the surgical approach nor the implants used for osteosynthesis were standardized. Fifty-five patients (79%) were treated conservatively with a modified Velpeau bandage or a sling. RESULTS: The fractures were classified according to AO into type A (27%), type B (58%) and type C (14%). Osteoporotic risk factors were present in many of the patients, mainly characterized by other skeletal injuries than the proximal humeral fracture (43%). In the group of complex, displaced, non-impacted fractures B2, B3, C2, C3 included (20 fractures), the group treated conservatively had a mean Rowe score of 48/75 (64% of maximum score) and SD 16.8, while in the surgically treated group the mean score was 28/75 (38% of maximum score) and SD 8.1. The difference between the two treatments was significant, with a p-value of 0.01 in favour of the conservatively treated group. CONCLUSION: The number of patients in each of the fracture groups was low, but surgery did not benefit the patients with complex, displaced fractures in this study.