Open reduction and internal fixation of displaced proximal humeral fractures using precontoured locking plates | advanced
- Indications centre on displaced 3-part and 4-part fractures in physiologically young patients with reconstructable bone stock — the Neer criteria of greater than 1 cm displacement or greater than 45 degrees angulation remain the practical thresholds that shift management from non-operative care to surgery.
- The deltopectoral approach protects the axillary nerve by staying lateral to the coracoid and identifying the nerve at the inferior border of subscapularis or on the deep surface of deltoid; the cephalic vein is preserved medially or laterally depending on surgeon preference but must be protected throughout.
- Medial calcar support and inferomedial screw placement are critical to prevent varus collapse — a single well-placed calcar or inferomedial support screw reduces failure rates dramatically in biomechanical studies.
- Greater and lesser tuberosity reduction must be anatomic before plate application; non-absorbable suture augmentation through the rotator cuff insertions provides additional stability and allows early motion even when bone quality is poor.
- “The Neer classification remains the language of communication: 2-part, 3-part, 4-part, valgus-impacted — the number of parts equals the number of displaced segments that require independent reduction.
- “The axillary nerve lies 5-7 cm distal to the acromion on the deep surface of deltoid; it is at risk during distal plate placement and during aggressive retraction of the deltoid.
- “Valgus-impacted 4-part fractures have a better prognosis for head vascularity than classic 4-part fractures because the medial periosteal sleeve remains intact — this pattern is often amenable to percutaneous or limited open techniques.
- “Locking plates allow fixed-angle constructs that tolerate early motion even in osteoporotic bone, but they do not replace the need for anatomic reduction and calcar support.
When & Why
The decision. Most proximal humerus fractures are minimally displaced and do well without surgery. ORIF with a locking plate is reserved for displaced 3-part and 4-part fractures in physiologically young patients with reconstructable bone stock, where preserving the native head gives the best long-term function. The Neer criteria — a segment displaced greater than 1 cm or angulated greater than 45 degrees — are the practical thresholds that move a fracture from non-operative care to surgery.
Minimally displaced fractures (less than 1 cm, less than 45 degrees) achieve good to excellent outcomes with early mobilisation in 80-90% of patients. A valgus-impacted 4-part fracture with an intact medial hinge does surprisingly well non-operatively — roughly 70% achieve satisfactory function without surgery. Requires disciplined physiotherapy and radiographic surveillance; loss of reduction occurs in up to 30% of displaced fractures treated non-operatively.
The reconstructive option for displaced 3-part and 4-part fractures in younger patients with good bone. Locking plates give fixed-angle stability that tolerates early motion even in osteoporotic bone; with anatomic reduction and calcar support, union rates of 85-95% are reported. Complications remain significant: screw cut-out 5-15%, avascular necrosis 5-20%, reoperation 10-25%.
Reserved for head-split fractures with greater than 40% articular involvement, severe osteoporosis with comminution that precludes stable fixation, or low-demand elderly patients with 4-part fractures. Reverse shoulder arthroplasty is increasingly favoured over hemiarthroplasty in the elderly because it bypasses tuberosity healing and gives more predictable function.
Indications — absolute
- Displaced 3-part proximal humerus fracture in a physiologically young patient with reconstructible bone stock.
- Displaced 4-part fracture with an intact medial periosteal sleeve (valgus-impacted pattern) in a patient under 60-65 years.
- 2-part surgical neck fracture with greater than 50% displacement or angulation greater than 45 degrees that fails closed reduction.
- Associated greater tuberosity displacement greater than 5 mm in a young active patient (risk of rotator cuff dysfunction and impingement). Indications — relative
- Valgus-impacted 4-part fracture in a patient over 65 with good bone quality and no head-split component.
- 3-part fracture with significant medial comminution where a locking plate can restore calcar support.
- Patient preference for anatomic reconstruction over non-operative care or arthroplasty after informed discussion. Contraindications — absolute
- Head-split fracture with greater than 40% articular surface involvement (consider hemiarthroplasty or reverse).
- Severe osteoporosis with comminution that precludes stable fixation (consider reverse shoulder arthroplasty).
- Active infection or open fracture with gross contamination. Contraindications — relative
- Age greater than 75 with low functional demand and acceptable alignment after closed reduction.
- Significant medical comorbidities that increase perioperative risk.
- Pre-existing rotator cuff tear arthropathy or glenohumeral arthritis favouring arthroplasty. What the evidence says. The PROFHER randomised trial is the key tempering study: in patients over 65 with displaced 2- and 3-part fractures, locking-plate fixation was no better than non-operative care in Oxford Shoulder Score at two years and carried more complications. This makes ORIF selective — strong for displaced 3- and 4-part fractures in physiologically young, reconstructible bone; non-operative care or arthroplasty for the low-demand elderly.
The Operation
The goal is to anatomically reduce the tuberosities and humeral head, restore the medial calcar, and stabilise the construct with a precontoured locking plate augmented by rotator-cuff sutures — all while protecting the axillary nerve and the blood supply to the head. The exposure is the deltopectoral approach, laid out step by step below.
Operative sequence — deltopectoral approach
- Beach-chair position, head secured, arm free or on a radiolucent arm board; support the scapula so the glenoid is perpendicular to the floor, with a bump under the ipsilateral scapula to improve access.
- Bring the C-arm in from the contralateral side so true AP, axillary and scapular-Y views can be obtained without moving the arm excessively; confirm the entire proximal humerus including the shaft is visible before draping.
- General anaesthesia with an interscalene block for postoperative analgesia. Hypotensive anaesthesia reduces bleeding but must be balanced against cerebral hypoperfusion risk in the beach-chair position.
- Prep the entire arm including the hand so the elbow can be flexed and extended to assess reduction and nerve function; drape so the coracoid, acromion and lateral humerus are accessible.
- Make a 12-15 cm incision from the coracoid process distally along the deltopectoral groove, curving slightly laterally toward the deltoid insertion if more exposure is needed.
- Identify the cephalic vein in the groove and develop the interval on either side; retract the vein laterally with the deltoid (most surgeons' preference) or medially with pectoralis.
- Divide the clavipectoral fascia lateral to the coracoid; identify the coracoid and the conjoined tendon, and place a self-retaining or Hohmann retractor under the deltoid laterally.
- The deltoid insertion on the humerus is released only 1-2 cm if additional exposure is required; the majority of the insertion is preserved.
- With the arm abducted 30-40 degrees, palpate the inferior border of subscapularis — the axillary nerve can be felt or seen crossing from medial to lateral at this level.
- Alternatively, palpate the deep surface of the deltoid 5-7 cm distal to the acromion.
- Place a vessel loop around the nerve or mark its position mentally; all subsequent distal dissection and plate placement must remain proximal to this landmark.
- Incise the rotator interval between supraspinatus and subscapularis.
- Tag the long head of biceps tendon with a stay suture — it is the landmark for the bicipital groove and the junction between the greater and lesser tuberosities.
- Identify the fracture lines: the greater tuberosity is usually displaced posterolaterally by supraspinatus and infraspinatus; the lesser tuberosity is displaced medially by subscapularis; the head fragment sits in varus or valgus depending on the pattern.
- Place heavy non-absorbable sutures through the supraspinatus/infraspinatus insertions on the greater tuberosity and through the subscapularis insertion on the lesser tuberosity — these are the reduction handles.
- Reduce the greater tuberosity first to the head fragment using the tagged sutures — the reduction must be anatomic, as even 5 mm of displacement blocks rotation. Hold it temporarily with a pointed reduction clamp or K-wires.
- Reduce the lesser tuberosity to the anterior aspect of the head.
- In 4-part fractures, reduce the head to the shaft while preserving the medial periosteal hinge. For valgus-impacted fractures the head is often already in acceptable valgus and the tuberosities are rotated around it and must be brought down to the shaft.
- The head should sit in slight valgus relative to the shaft — never over-reduce into varus to achieve calcar contact.
- Select a precontoured proximal humerus locking plate of appropriate length; it should sit 5-8 mm distal to the summit of the greater tuberosity and slightly posterior to the bicipital groove to avoid impingement.
- Secure the plate provisionally with K-wires through the proximal holes and confirm position on AP and axillary fluoroscopy.
- Place the inferomedial calcar screw first — this is the critical screw that supports the head and resists varus collapse; it is a locking screw directed inferomedially into the calcar region.
- Place the remaining proximal locking screws, ensuring none penetrate the articular surface — image in multiple planes after each screw.
- Place the distal shaft screws (usually 3-4 bicortical non-locking or locking screws) to secure the plate to the shaft.
- Pass the previously placed rotator cuff sutures through the suture holes (eyelets) in the plate or around the plate and tie them securely.
- This augments fixation and converts the deforming pull of the cuff into compressive forces across the fracture — especially important in osteoporotic bone where screw purchase in the head may be marginal.
- Obtain final fluoroscopy in true AP (Grashey), axillary and scapular-Y views; confirm anatomic reduction of both tuberosities, no intra-articular screw penetration (look for the 'light-bulb' sign on the axillary view), restoration of the medial calcar, and a head-shaft angle of approximately 130-140 degrees.
- Test stability by gently ranging the shoulder — the construct should allow at least 30-40 degrees of passive external rotation and 90 degrees of abduction without displacement.
- Close in layers; a drain is optional. Apply a sling with an abduction pillow.
Injury to the cephalic vein causes troublesome bleeding and postoperative swelling. Inadvertent division of the deltoid insertion too far distally weakens abduction, and dissecting through deltoid or pectoralis muscle means the interval has been missed. Identify the cephalic vein early and develop the deltopectoral interval cleanly before any deep work.
Accepting malreduction of the greater tuberosity because the plate appears to hold the head is a serious error — the tuberosity must be anatomic. Disrupting the medial periosteal sleeve during aggressive reduction manoeuvres increases the risk of avascular necrosis. Over-reducing into varus to achieve calcar contact is wrong; the head must sit in slight valgus relative to the shaft.
Identify the cephalic vein first and protect it with a vessel loop. Develop the interval bluntly with scissors and finger dissection. If the vein is adherent to deltoid take it laterally; if it mobilises more easily medially, take it medially. Avoid tearing it — bleeding from a torn cephalic vein is difficult to control and obscures the field.
Before placing any retractor or beginning distal exposure, find the axillary nerve. Pass a finger along the inferior border of subscapularis and feel the cord-like structure. Once its position is known, extending the exposure is safe. Never place a plate that extends more than 1 cm distal to the nerve without visualising and protecting it.
Reduce the greater tuberosity first using the cuff sutures as traction, aiming for it to sit exactly on the lateral aspect of the head with no gap and no step. Then reduce the lesser tuberosity to the anterior aspect. Only when both tuberosities are reduced should the head-to-shaft relationship be addressed. If the calcar is comminuted, use a small bone graft or the tip of the greater tuberosity as structural support.
After the plate is fixed, always augment with the rotator cuff sutures. Pass the supraspinatus and infraspinatus sutures through the plate eyelets or around the plate and tie them under tension. This converts the deforming forces of the cuff into compressive forces across the fracture, allows earlier motion and protects screw fixation in poor bone.
Relying on the AP view alone misses central screw penetration. Obtain a true axillary view after each proximal screw and look for the 'light-bulb' sign — the spherical head outline with no screw protruding. In osteoporotic bone tactile feedback is unreliable; if there is any doubt, shorten the screw rather than risk chondrolysis.
Aftercare & Complications
Rehabilitation
- Timing
- Week 0-4
- Focus & therapy
- Sling with abduction pillow; pendulum exercises and passive forward flexion to 90 degrees from day 3-5; active-assisted external rotation to 30 degrees (protected by suture augmentation); no active elevation against gravity; wound review at 10-14 days; radiographs at 2 and 4 weeks
- Timing
- Week 4-8
- Focus & therapy
- Discontinue sling if radiographs satisfactory; active-assisted to active range of motion in all planes; begin rotator cuff and deltoid isometrics; progressive resistance with theraband from week 6; radiographs at 6 and 8 weeks
- Timing
- Week 8-16
- Focus & therapy
- Full active range of motion expected by 8-10 weeks; progressive resistance of rotator cuff, deltoid and scapular stabilisers; functional and proprioceptive training; return to light work at 8-12 weeks, heavy manual work or sport at 4-6 months
Expected outcomes. With anatomic reduction and calcar support the union rate is 85-95%. Typical motion at one year is forward flexion 120-150 degrees and external rotation 30-50 degrees, with a Constant score of 60-80 points — better for 2- and 3-part fractures than for 4-part. Special situations
- Osteoporotic bone: use longer plates with more distal screw options, consider cement augmentation of screw holes, be more aggressive with rotator cuff suture augmentation, and keep a lower threshold for conversion to reverse arthroplasty if fixation is tenuous.
- Valgus-impacted 4-part fractures: the medial periosteal hinge is often intact — preserve it; percutaneous or limited open reduction may suffice, and the locking plate still allows early motion.
- Associated greater tuberosity fracture: anatomic reduction is mandatory — even 5 mm of displacement causes impingement and weakness — and suture augmentation is especially valuable. Complications
- Incidence
- 5-15%
- Recognition
- Progressive pain, loss of motion, crepitus; screw tip visible within the joint on axillary or AP radiograph
- Prevention & management
- Confirm screw position on true AP, axillary and scapular-Y views after each screw; use shorter central screws. Intraoperative — exchange for a shorter screw; postoperative — revision screw exchange or conversion to arthroplasty if chondrolysis has begun
- Incidence
- 5-20%
- Recognition
- Progressive loss of reduction on serial radiographs; head falls into varus; screws back out or cut superiorly
- Prevention & management
- Restore medial calcar continuity; place at least one inferomedial calcar support screw; augment with cuff sutures; consider graft or cement in severe osteoporosis. Early — revision ORIF; established collapse with arthritis — reverse shoulder arthroplasty
- Incidence
- 5-20% (higher in 4-part)
- Recognition
- Gradual collapse of the head with sclerosis and fragmentation; pain and stiffness out of proportion to early radiographs
- Prevention & management
- Preserve all medial soft-tissue attachments; avoid excessive stripping of the head; accept stable valgus-impacted patterns. Symptomatic treatment initially; collapse with arthritis — hemiarthroplasty or reverse depending on cuff integrity and age
- Incidence
- 2-5%
- Recognition
- Deltoid weakness or atrophy; sensory loss over the lateral shoulder; positive deltoid extension lag sign
- Prevention & management
- Identify the nerve before distal dissection; protect during retraction; do not extend the plate more than 1 cm distal to the nerve without visualisation. Most neuropraxias recover over 3-6 months; persistent deficit — exploration, neurolysis or grafting
- Incidence
- 3-8%
- Recognition
- Persistent pain and motion at the fracture site beyond 3 months; no bridging callus; varus or valgus malalignment
- Prevention & management
- Achieve stable anatomic reduction with calcar support; avoid excessive periosteal stripping; consider bone graft in comminuted fractures. Symptomatic nonunion — revision ORIF with graft; symptomatic malunion — corrective osteotomy or arthroplasty
- Incidence
- 10-30%
- Recognition
- Progressive loss of active and passive range, particularly external rotation and abduction; pain at end range
- Prevention & management
- Begin passive and active-assisted motion within the first week; protect tuberosity fixation with suture augmentation; use regional anaesthesia for early physiotherapy. Formal physiotherapy; manipulation under anaesthesia or arthroscopic capsular release if no improvement by 3-4 months
- Incidence
- 1-3%
- Recognition
- Erythema, warmth, drainage, elevated CRP and ESR; wound breakdown; sinus tract in chronic cases
- Prevention & management
- Meticulous soft-tissue handling; perioperative antibiotics; layered closure without tension. Superficial — oral antibiotics and wound care; deep — debridement with implant retention if stable and IV antibiotics; chronic — staged revision with antibiotic spacer
Viva & Exam Focus
CALCARCALCAR — medial support and reduction priorities
NEERNEER — classification and surgical thresholds
Location: the axillary nerve exits the quadrilateral space and courses transversely on the deep surface of the deltoid approximately 5-7 cm distal to the acromion. Risk: during the deltopectoral approach it is protected if dissection stays anterior, but extending the approach or placing a plate distally puts it at direct risk, as does aggressive deltoid retraction. The fix: identify it at the inferior border of subscapularis or by palpation on the deep deltoid surface before any distal dissection, mark its position, and keep all retractors and the distal plate proximal to it.
Location: the cephalic vein lies in the deltopectoral groove, separating the deltoid (lateral) from pectoralis major (medial). Risk: easily injured during incision or deep dissection, causing troublesome bleeding and postoperative swelling. Lateral retraction with the deltoid is preferred by many as it preserves medial drainage. The fix: identify the vein early, develop the interval on either side, and protect it with a vessel loop or gentle retraction throughout.
Location: the inferomedial calcar carries the ascending branch of the anterior circumflex humeral artery and the critical periosteal supply to the head. Risk: aggressive medial dissection, excessive varus reduction, or failure to restore calcar support leads to varus collapse, screw cut-out and avascular necrosis. The fix: preserve all medial soft-tissue attachments, reduce the head to restore medial cortical continuity, and place at least one inferomedial calcar screw.
Trap: accepting posterior or superior displacement of the greater tuberosity because the plate appears to hold the head. Consequence: even 5 mm of posterior displacement blocks external rotation and causes impingement; superior displacement blocks abduction. The fix: reduce the tuberosity under direct vision before plate application, hold it with suture augmentation through the supraspinatus and infraspinatus insertions, and confirm position with the image intensifier in multiple planes.
Trap: placing locking screws that penetrate the articular surface, especially in osteoporotic bone where tactile feedback is poor. Consequence: rapid chondrolysis, pain and early arthritis — the central and superior screws are most at risk. The fix: image in true AP, axillary and scapular-Y views after each screw; the 'light-bulb' sign on the axillary view confirms screws are extra-articular; use shorter screws if in any doubt.
Trap: relying on the locking plate alone in poor bone without calcar support or structural augmentation. Consequence: progressive varus, screw cut-out through the head and loss of reduction within weeks. The fix: always restore the medial calcar, use inferomedial support screws, consider bone graft or cement augmentation in severe osteoporosis, and plan for possible revision to arthroplasty if reduction cannot be maintained.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 62-year-old active man sustains a displaced 3-part proximal humerus fracture involving the surgical neck and greater tuberosity after a fall from standing height. The greater tuberosity is displaced 12 mm posteriorly and the head is in 30 degrees of varus. How do you decide between non-operative care, ORIF and arthroplasty?”
“You have just applied a proximal humerus locking plate to a 4-part valgus-impacted fracture in a 58-year-old woman. After placing the inferomedial calcar screw and three proximal locking screws, the image intensifier shows one screw tip appearing intra-articular on the axillary view. What do you do?”
“A 68-year-old woman with a 4-part proximal humerus fracture undergoes ORIF. At 3 months she has persistent pain and radiographs show progressive varus collapse with the head in 30 degrees of varus and the greater tuberosity displaced superiorly. What went wrong and what are the options now?”
Indications — Neer criteria
- Greater than 1 cm displacement or greater than 45 degrees angulation of any part defines a displaced fracture
- Displaced 3-part and 4-part fractures in physiologically young patients with reconstructible bone are the primary indications for ORIF
- Valgus-impacted 4-part fractures have a better vascular prognosis because the medial periosteal sleeve remains intact
- Head-split fractures with greater than 40% articular involvement favour arthroplasty over ORIF
- Patient age less than 65-70, good bone stock and high functional demand shift the balance toward reconstruction
Critical anatomy
- Axillary nerve: 5-7 cm distal to the acromion on the deep deltoid surface — identify before distal dissection or plate placement
- Cephalic vein: lies in the deltopectoral groove — preserve by developing the interval on either side
- Medial calcar: carries the ascending branch of the anterior circumflex humeral artery — preserve all medial soft-tissue attachments
- Greater tuberosity: supraspinatus and infraspinatus insertions — anatomic reduction mandatory (less than 5 mm displacement acceptable)
- Rotator interval: between supraspinatus and subscapularis — the long head of biceps is the landmark for the bicipital groove
Operative sequence
- Beach-chair position with the image intensifier from the contralateral side — confirm all views before incision
- Deltopectoral approach, protect the cephalic vein, identify the axillary nerve at the inferior subscapularis border
- Tag the rotator cuff insertions with non-absorbable sutures — these are the reduction handles
- Reduce the greater tuberosity anatomically first, then the lesser tuberosity, then the head to the shaft while preserving the medial hinge
- Apply the precontoured locking plate 5-8 mm distal to the greater tuberosity summit, slightly posterior to the bicipital groove
- Place the inferomedial calcar screw first — the critical screw preventing varus collapse
- Confirm all screws are extra-articular on true AP, axillary and scapular-Y views
- Augment with rotator cuff sutures through the plate eyelets — converts deforming forces into compression
Danger zones
- Axillary nerve: never place a plate or retractor distal to the nerve without visualisation
- Medial calcar: aggressive dissection or varus reduction disrupts the periosteal blood supply — increases AVN risk
- Greater tuberosity: accepting 5 mm of posterior or superior displacement blocks rotation and causes impingement
- Intra-articular penetration: central and superior screws most at risk — confirm on the axillary view after each screw
- Varus collapse: occurs when the calcar is not restored or the inferomedial support screw is omitted
Complications & prevention
- Screw cut-out: 5-15% — confirm position on multiple fluoroscopic views; shorten central screws if in doubt
- Varus collapse: 5-20% — restore the calcar, place an inferomedial screw, augment with sutures, consider graft in osteoporosis
- Avascular necrosis: 5-20% — preserve the medial periosteal sleeve, avoid excessive stripping, accept stable valgus-impacted patterns
- Axillary nerve injury: 2-5% — identify the nerve early, protect during retraction, limit distal plate extension
- Stiffness: 10-30% — begin passive motion within the first week, protect tuberosity fixation with suture augmentation
Rehabilitation
- Week 0-4: sling with abduction pillow, pendulum exercises, passive forward flexion to 90 degrees, active-assisted external rotation to 30 degrees
- Week 4-8: discontinue sling, active-assisted to active motion, begin rotator cuff and deltoid isometrics
- Week 8-16: progressive resistance strengthening, functional training, return to light work at 8-12 weeks
- Expected outcomes: union 85-95%, forward flexion 120-150 degrees, external rotation 30-50 degrees
- In osteoporosis: longer plate, cement augmentation, lower threshold for reverse arthroplasty if fixation is tenuous
Background & Evidence
Classification. The Neer system remains the working language for these fractures. A "part" is any segment displaced greater than 1 cm or angulated greater than 45 degrees; the number of parts drives both prognosis and the operative decision.
- Definition
- No segment displaced greater than 1 cm or angulated greater than 45 degrees
- Typical management
- Non-operative — sling and early mobilisation; 80-90% good to excellent outcomes
- Definition
- Surgical neck or a single tuberosity displaced; a surgical neck fracture with greater than 50% displacement or angulation greater than 45 degrees that fails closed reduction
- Typical management
- ORIF if displaced and unstable; a greater tuberosity displaced greater than 5 mm in a young active patient is fixed to avoid rotator cuff dysfunction
- Definition
- Head plus one displaced tuberosity
- Typical management
- ORIF with a locking plate in a physiologically young patient with reconstructible bone
- Definition
- Head plus both tuberosities displaced
- Typical management
- ORIF if reconstructible and young; arthroplasty for head-split, severe comminution or a low-demand elderly patient
- Definition
- Head impacted into valgus with an intact medial periosteal sleeve
- Typical management
- Better vascular prognosis — often amenable to percutaneous or limited open fixation; non-operative care gives roughly 70% satisfactory function when the medial hinge is intact
Surgical anatomy relevant to fixation
- Deltopectoral interval: the cephalic vein lies in the groove between deltoid (lateral) and pectoralis major (medial); the deltoid insertion is released only 1-2 cm if extra exposure is needed.
- Axillary nerve: exits the quadrilateral space and wraps around the surgical neck on the deep surface of deltoid, lying 5-7 cm distal to the acromion; motor branches supply the anterior and middle deltoid, with a sensory branch to the lateral shoulder.
- Blood supply to the head: the anterior circumflex humeral artery ascends in the bicipital groove and gives the arcuate artery that enters the head; the ascending branch runs along the medial calcar and provides critical perfusion through the periosteal sleeve. In 4-part fractures the head may be perfused solely through the medial periosteal attachments — aggressive medial dissection risks avascular necrosis.
- Rotator cuff insertions: supraspinatus on the superior facet of the greater tuberosity, infraspinatus on the posterior facet, and subscapularis on the lesser tuberosity; non-absorbable sutures through these insertions are powerful reduction aids and augment plate fixation. Why locking plates, and what the trials say. Locking plates provide fixed-angle stability that tolerates early motion even in osteoporotic bone. Biomechanical work shows an inferomedial calcar screw reduces varus collapse by more than 50%, and clinical series report union rates of 85-95% when anatomic reduction and calcar support are achieved — though complications remain significant (screw cut-out 5-15%, avascular necrosis 5-20%, reoperation 10-25%). The PROFHER trial tempers enthusiasm for surgery across the board: in patients over 65 with displaced 2- and 3-part fractures, locking-plate fixation was no better than non-operative care in Oxford Shoulder Score at two years and carried more complications. The take-home is selective — ORIF for displaced 3- and 4-part fractures in physiologically young patients with reconstructible bone; non-operative care or arthroplasty for the low-demand elderly.
References
Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial
- Multicentre randomised controlled trial of 250 patients over 65 years with displaced 2-part or 3-part proximal humerus fractures.
- No significant difference in Oxford Shoulder Score at 2 years between locking plate fixation and non-operative treatment.
- Surgery was associated with more complications and reoperations; non-operative care is a reasonable option in lower-demand elderly patients.
Proximal humeral fractures: a prospective multicenter study of 452 cases treated with locking plates
- Prospective multicentre cohort of 452 patients treated with locking plates for proximal humerus fractures.
- Union rate 95%, complication rate 19% (screw cut-out 5%, avascular necrosis 5%, infection 2%).
- Calcar support and anatomic tuberosity reduction were the strongest predictors of good outcome.
The importance of medial support in locked plating of proximal humerus fractures
- Biomechanical and clinical study demonstrating that inferomedial screw placement reduces varus collapse by greater than 50%.
- Absence of a calcar support screw was the strongest predictor of early failure in clinical series.
- Medial comminution and loss of calcar continuity dramatically increase the risk of mechanical failure.
Avascular necrosis after open reduction and internal fixation of proximal humerus fractures
- Retrospective review of 98 patients treated with ORIF for 3- and 4-part fractures.
- Avascular necrosis developed in 14% of 3-part and 28% of 4-part fractures; risk was strongly associated with disruption of the medial periosteal hinge.
- Preservation of the medial soft tissue attachments is the key modifiable factor in preventing head necrosis.
Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humerus fractures in elderly patients
- Comparative cohort study of 53 patients over 70 years with 3- or 4-part fractures treated with reverse versus hemiarthroplasty.
- Reverse arthroplasty provided superior forward flexion, external rotation and patient satisfaction at 2 years.
- Reverse arthroplasty is increasingly favoured in elderly patients with displaced 4-part fractures and poor bone quality.