Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.