Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band

Thirty-five patients with four-part displaced proximal humeral fractures and fracture-dislocations were retrospectively reviewed from the years 1977-1990. Thirty-three patients were available for study. All fractures were treated by open reduction and internal fixation allowing early motion. Surgical technique was as atraumatic as possible with the goal of restoring normal anatomy of the proximal humerus with a minimal fixation system. The fixation device consisted of two modified Kirschner wires introduced through the tuberosities and reinforced by a tension band wiring. Neer's criteria were used to evaluate results. With a mean follow-up of 7 years, results were excellent and satisfactory in 21 cases, nonsatisfactory in 10, and poor in two. The most common complication was avascular necrosis (nine patients). All cases of fracture-dislocations corresponded with the nonsatisfactory and poor results. Because of our results, we conclude that in four-part displaced fractures, open reduction and internal fixation with our system of osteosynthesis should be indicated initially. Prosthetic replacement should be considered as primary treatment in cases with marked comminution of the humeral head, in fracture-dislocations, and in patients > 75 years of age.