Sat., 10/6/12 Upper Extremity Injuries, PAPER #88, 11:07 am OTA-2012
Four-Part Fractures of the Proximal Humerus: Outcomes of Surgical and Nonsurgical Management
Brian D. Solberg, MD; David A. Friedberg, MD; Dennis P. Franco, MD;
California Hospital Medical Center, Los Angeles, California, USA
Purpose: This study was undertaken to compare the mid/long-term outcomes of a cohort of patients followed prospectively after sustaining a four-part proximal humerus fracture treated conservatively, with locked plating or hemiarthroplasty.
Methods: This prospective, nonrandomized IRB-approved was conducted at multiple Level I and II trauma centers. 162 patients were followed prospectively after sustaining a Neer four-part proximal humerus fracture. Three treatment groups were identified: nonsurgical management, hemiarthroplasty, and repair using a locked plate. Patients were followed prospectively and outcomes were compared using the Constant scoring system. Radiographic measures included the development of osteonecrosis of the humeral head, progressive subsidence, and loss of fixation. Complications in each group and the rate of reoperation or conversion to hemiarthroplasty for each group were also assessed.
Results: 34 patients had nonsurgical management of their fractures, 79 had surgical repair using a locked plating construct, and 49 patients underwent hemiarthroplasty for Neer four-part fractures. There were no differences between groups with regard to age, sex, average follow-up, or AO and OTA fracture types (P >0.35). At an average follow-up of 58 months, Constant scores (CS) were similar (P = 0.24) for the hemiarthroplasty (59 ± 6) and nonsurgical management (61 ± 7), while patients who underwent repair with a locked plate (67 ± 6) had a significantly better clinical outcome (P = 0.02). Patients with initial varus displacement of the articular fragment had a worse outcome and higher conversion rate to hemiarthroplasty (CS 55 ± 7, 53% conversion) than patients with initial valgus displacement (CS 71 ± 8, 14% conversion) (P = 0.01 and 0.03, respectively). The overall rate of osteonecrosis was 34%, while the odds ratio (OR) was increased significantly with dislocation (OR = 2.4) and metaphyseal hinge length of less than 4 mm (OR = 8.4) (P = 0.04 and <0.01, respectively). The rate of reoperation was higher in the locked plating group (22%) than in the hemiarthroplasty group (14%, P = 0.03) while almost half (41%) of patients treated conservatively were eventually converted to hemiarthroplasty for pain relief.
Conclusion: Locked plating of Neer four-part proximal humeral fractures led to significantly better outcomes than hemiarthroplasty or conservative management despite having a higher complication rate. Fracture patterns with initial varus displacement of the articular fragment had worse overall outcomes and higher rate of conversion to hemiarthroplasty than valgus-impacted patterns. Osteonecrosis developed in roughly one in three patients but was not associated with worse outcomes than patients treated with hemiarthroplasty or conservative management.
Alphabetical Disclosure Listing (808K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.