Initial post-fracture humeral head ischemia does not predict development of necrosis

We evaluated the functional outcome and the occurrence of avascular necrosis in 51 consecutive patients (26 women) with intracapsular fractures of the proximal humerus treated with open reduction and internal fixation between February 1998 and December 2001. Mean age was 44 years (range, 21-60 years). Forty-one heads were initially perfused (group A), and 10 were ischemic (group B). Seven patients were lost to follow-up. Forty-four were evaluated using the Constant-Murley score and the Subjective Shoulder Value; 40 patients consented to a radiographic evaluation. The mean follow-up was 5 years (range, 3.3-7.3 years). In group A, 20 of 30 heads had no sign of structural alterations, 6 had signs of structural alterations of the cancellous bone, and 4 showed collapse of the subchondral bone plate of varying degrees. In group B, 8 of 10 heads were structurally altered, and 2 had collapsed. The median uncorrected Constant-Murley score was 80 (range, 37-98) for patients without structural alterations, 81 (range, 53-93) for patients with structural alterations, and 68 (range, 48-74) for patients with collapsed heads. The median Subjective Shoulder Value was 95 (range, 50-100), 90 (range, 50-100), and 55 (range, 40-80), respectively. Eight of 10 initially ischemic heads did not develop avascular necrosis, indicating that revascularization may indeed occur. The reason for late necrosis in some of the initially perfused heads remains unclear. Collapse was associated with a significantly worse clinical outcome. We conclude that osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained.