Geriatric complex proximal humeral fracture: intraoperative locking plate problems and proposed solutions

Abstract

Background: Surgical treatment of complex proximal humeral fractures in the elderly is controversial. There are no clear criteria on whether to preserve the humeral head or replace it. The aim of this study was to evaluate the results of locking-plate internal fixation and to clarify the encountered intraoperative problems with their suggested solutions. Methods: The study included 34 patients older than 60 yr of age. Eighteen had three-part fractures and 16 had four-part fractures according to Neer’s classification. All patients had internal fixation with locking plates and according to the encountered problems additional procedures were added to obtain stable reduction and rigid fixation. The clinical evaluation depended on the objective Constant-Murley score (CMS) and the subjective Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: The mean follow up was 27.7±5.6 mo, and the mean age was 69.9±4.4 yr. The mean CMS was 70.9±14.8 points, and the mean DASH score was 28.2±17.8 points. Humeral head avascular necrosis occurred in three (8.8%) with significant reduction in CMS (P=0.001). Partial loss of initial reduction occurred in four patients (11.8%) with significant reduction in CMS (P=0.007). Secondary surgery was mandatory for six patients (17.6%). Conclusions: We believe that locking plate osteosynthesis with preservation of the humeral head is worth considering in elderly patients with complex injuries provided the surgeon and facility are prepared for any problems that may arise.