Following departmental and institutional review board approval, we retrospectively reviewed all 35 patients older than 75 years with displaced proximal humerus fractures using a “hybrid” technique between 2002 and 2008. There were 30 females and five males. The average age of the patients was 81 years (range, 75–95 years). No patients had a history of shoulder surgeries, and no patients had pre-existing arthritis. There were seven OTA A fractures, 20 OTA B fractures, and eight OTA C fractures. Twenty-one of these fractures were two-part fractures and 14 were three-part fractures according to the Neer classification [13
]. Of the 35 patients, five patients died within the first postoperative year; between the first postoperative year and the survey period, five additional patients died. Three patients were unable to complete the survey secondary to dementia. This left 22 patients for analysis. Of these 22 patients, three had OTA A fractures [14
], 13 OTA B, and six OTA C. OTA A fractures are extra-articular fractures in one location (tuberosity, impacted metaphysis, etc). OTA B fractures are extra-articular with bifocal involvement. OTA C fractures are intra-articular [14
]. Eleven were two-part fractures and nine were three-part fractures according to the Neer classification [13
]. Two fractures did not fit classic Neer subtypes and were classified as valgus impacted fractures as described by Jacob et al. [9
]. The fracture was in the left arm in 10 patients and the right arm in 12 patients. All patients were retired. Eleven patients characterized their preoperative activity as light, while five stated they were sedentary and six stated they engaged in moderate physical activity. The minimum followup was 1 year (mean, 3 years; range, 1.0–6.7 years). No patients were recalled specifically for this study; all data were obtained from medical records and radiographs.
All surgery was performed by the senior author (MT). A systematic approach was utilized in reducing and maintaining reduction of all fractures in this series [18
]. This began with a thorough review of preoperative imaging. Preoperative CT scans were obtained in most cases to understand the fracture morphology. In addition, contralateral shoulder radiographs were obtained to aid in assessing the reduction obtained intraoperatively. Before preparing and draping the patient, the ability to obtain high-quality fluoroscopic images was ensured, including an AP in the plane of the scapula with the arm held in external rotation to profile the greater tuberosity and a Velpeau axillary with the arm held in internal rotation to profile the lesser tuberosity.
A deltopectoral approach was utilized in all cases. A large bone reduction clamp was used to manipulate the humeral shaft. Rotator cuff traction sutures were placed to allow direct control over the tuberosities and indirect control of the head through the tuberosities when not fractured. In cases where the humeral head is detached from the tuberosities, a pin may be inserted and utilized as a joystick for control of the head segment; this was seldom required in the fractures included in this particular report. The fracture was then gently reduced. In surgical neck fractures, a small malleable retractor was used as a shoehorn to aid in reduction of the shaft under the head. In valgus impacted fractures, the humeral head was gently elevated, paying careful attention to preserving the medial hinge and associated blood supply. Considerable effort was taken to ensure adequate support of the humeral head after reduction. This was performed using the shaft (valgus “impaction osteotomy” of Fenlin), or in cases of extensive metaphyseal comminution and osteopenia, bone graft or bone graft substitute was used (Fig. ) [2
]. Bone graft was utilized in 15 cases (43%) in this series. This was autograft bone in seven cases and allograft in eight cases. Next, provisional fixation was obtained using a Kirschner wire (Fig. ). The reduction was then assessed utilizing fluoroscopy in the AP and Velpeau axillary views. Contralateral films were used to avoid varus malreduction. In all cases, the fracture was reduced, adequate support was obtained (especially medially), and provisional fixation was placed before application of the plate. Adequate medial support was defined as contact between the humeral head segment and the shaft segment at the medial calcar region, especially posteromedially. Thus, with this technique, the plate was used in the neutralization mode rather than as a reduction tool.
Fig. 1A–C (A) Bony comminution that would impede stable seating of the humeral head on the shaft is removed and preserved. (B) Bone fragments that were previously removed from the humeral shaft are placed back into the fracture site for final reduction. (C) Traction (more ...)
Provisional fixation of the reduction is obtained using a Kirschner wire. The reduction is maintained utilizing the rotator cuff traction sutures and is compared with contralateral shoulder films to avoid malreduction.
The plate was positioned low enough to avoid subacromial impingement. Long screws into the subchondral bone were avoided to decrease the risk of intra-articular penetration. The screws were placed by predrilling the lateral cortex and advancing the depth gauge without further predrilling to avoid placing screws close to the subchondral bone. All screws were scrutinized under fluoroscopy in varying degrees of internal and external rotation to ensure no intra-articular hardware. Rotator cuff traction sutures were utilized liberally to neutralize the varus deforming force of the supraspinatus (Fig. A). Because of the humeral head support obtained using the shaft, bone graft, or bone graft substitute, short screws and tension band suture fixation provided adequate stability to the humeral head fragment in all cases (Fig. B).
(A) The precontoured plate is carefully placed to avoid subacromial impingement. (B) Screws are placed, avoiding intra-articular screw penetration. Each screw length is assessed with fluoroscopic imaging.
All patients were immobilized for 6 weeks after the operation. Patients were placed into a shoulder immobilizer immediately postoperatively and were instructed to stay in the immobilizer at all times until their first visit at 6 weeks. Patients were allowed to remove the immobilizer for hygiene only. Assisted ROM was initiated at 7 to 12 weeks, with therapist-driven ROM exercises and sling use the remainder of the day. After 3 months or demonstration of radiographic healing, the sling was discontinued.
A chart review was completed to determine the clinical outcome. ROM assessed at clinic appointments was gathered, and surveys were sent to all 25 living patients. The survey (Appendix 1) included illustrated self-assessments of ROM, in which patients selected diagrams showing maximum ROM, and a visual analog pain scale (1–10, with higher numbers indicating more severe pain) and allowed calculation of the American Society of Shoulder and Elbow Surgeons (ASES) score [15
], the Simple Shoulder Test [12
], and the QuickDash [4
]. The QuickDash is a general study of upper-extremity function, with lower scores being better. The Simple Shoulder Test and ASES scores are shoulder-specific scores in which a higher score indicates better function. A second survey was sent to the 14 nonresponders within 2 months. Followup telephone calls were made to the five patients who did not respond to the second survey, and survey information was obtained via telephone.
Radiographs of the involved shoulders were assessed for union and ON. Healing was considered complete when there was evidence of both cortical continuity on all cortices and trabecular continuity in the AP radiographs of the shoulder in internal and external rotation, as well as in the axillary and scapular Y radiographs. ON was diagnosed when radiographs demonstrated subchondral bony defects with or without a crescent sign or articular collapse, as previously described [5
]. All radiographs were reviewed by the leading author (JDB) and a fellowship-trained shoulder and elbow surgeon (JSS) who was blinded to the clinical outcome of the patients, and consensus was achieved. There were no cases where healing could not be assessed. Reduction was considered satisfactory when the head-shaft angle was between 40° and 55° and there was anatomic reduction of the tuberosities within 5 mm.
We computed the average (± SD) for continuous variables.