Session VIII - Upper Extremity

*Does the Translated Surgical Neck Humerus Fracture Need Fixation?

Ashima Garg, MD, PhD; Margaret M. McQueen, MD, FRCS Ed (Orth), Charles M. Court-Brown, MD, FRCS Ed (Orth); Royal Infirmary of Edinburgh NHS Trust, Edinburgh, Scotland

Purpose: A prospective analysis of 126 patients with AO A3.2 translated surgical neck fractures was undertaken to examine the factors affecting outcome and, in particular, the need for fracture fixation.

Methods: One hundred-twenty-six patients with AO A3.2 proximal humeral fractures were prospectively reviewed over a five-year period. The average age was 72 years, and 39.7% were over 80 years of age. Treatment was decided by the admitting surgeon, but all patients were followed up for 1 year by two orthopaedic trauma surgeons. The patients were reviewed at 6weeks, 13weeks, 26weeks and 1 year, at which times recovery was assessed using Neer's outcome criteria and by assessing the abduction and flexion strength compared with the normal contralateral side. Nineteen patients defaulted or were unable to attend for follow up, and the results of 107 patients are therefore presented.

Results: The average Neer score at one year was 80.3. Closer examination showed good pain relief with an average score of 32.2. Strength, reaching and stability had all regained at least 80% of their normal values. However after one year flexion and abduction only averaged 63% and 52% of normal respectively. Extension averaged 87% of normal, but external and internal rotation were restricted at 74% and 66%. Abduction and flexion strength were also restricted to 65% of the contralateral side.

Assessment of the effect of age and fracture displacement showed that patients over 80 years of age had poorer results. Fracture displacement also affected outcome. Fractures with less than 33% displacement had an average Neer score at one year of 85 compared with 70 for those fractures with more than 100% displacement. A comparison between nonoperative and surgical management in those fractures with at least 66% displacement showed no difference in the average Neer score at 1 year.

Discussion: Surgeons frequently internally fix translated surgical neck fractures, usually citing fracture displacement as their reason for surgery. This study indicates that there is no benefit in surgical management in the majority of patients with this fracture. The reason for this is obvious when the epidemiology of the fracture is studied. Almost 40% of patients who sustain this fracture are over 80 years of age and are very osteoporotic. A review of the results of fixation showed that surgery was difficult and associated with poor reduction and cut out even when intramedullary techniques were used. We do not advocate surgery in patients of more than 60 years of age regardless of the degree of displacement.