Session VI Upper Extremity

Operative Treatment of Malunions of Proximal Humerus Fractures

Mark W. Rodosky, MD, X. A. Duralde, MD, Patrick M. Connor, MD, Roger G. Pollock, MD, Evan L. Flatow, MD, Louis U. Bigliani, MD

The Shoulder Service, New York Orthopaedic Hospital, Columbia -Presbyterian Medical Center, New York, NY

Purpose: There are few reports on the surgical treatment of proximal humerus malunions. This study reviews our experience in managing this difficult problem.

Methods: Thirty-one shoulders in thirty patients were treated surgically for malunions of proximal humerus fractures. There were 20 females and 10 males. The malunions were in 14 right shoulders and 15 left shoulders, and one case was bilateral. The average age was 52 years (range 23-75 years). Twenty-nine patients (97%) complained of pain, weakness, and stiffness. Only one patient denied pain but underwent surgery for stiffness, weakness and functional deficits. Initial fracture treatment had been nonoperative in twenty cases and operative in eleven. These complex cases were classified according to the components involved. Fourteen shoulders had isolated greater tuberosity malunion and 13 had complex malunions involving the tuberosities and surgical neck, 4 had isolated surgical neck malunion. Two cases were further complicated by heterotopic bone formation. Angular and linear displacement were difficult to quantitate on x-rays since slight rotational changes affect measurements. Preoperative superior displacement of the greater tuberosity averaged 7mm, demonstrating that displacements less than 1cm can lead to significant pain and disability. Surgical treatment was designed to restore greater tuberosity clearance under the coracoacromioclavicular arch, and included release of scar, acromioplasty, and tuberosity osteotomy or ostectomy as needed. Twelve shoulders also required humeral head replacement.

Results: Follow-up averaged 4.6 years (range 1-13 years). Twenty-three patients (74%) had significant improvement in pain, and 27 (87%) improved function. However, only fifteen patients (48%) achieved active elevation greater than 140°. Patients whose initial fracture had been treated closed had better results than those who went on to malunion after an initial attempt at ORIF. Residual tuberosity prominence was poorly tolerated and led to impingement symptoms. The results are inferior to those of acute ORIF of proximal humerus fractures, and emphasize the importance of accurate initial assessment and treatment.

Conclusion: Operative treatment was technically difficult, but resulted in significant improvement in pain and function below the horizontal. Restoration of motion was not as reliable.