4-part Fracture Dislocations Research Articles

Three-Part Fracture Dislocation and Four-Part Fracture Dislocation of the Proximal Humerus: How Different are the Glenoid Labrum and Capsular Injuries Between Them?

Anterior fracture dislocation of the shoulder may have associated injury to the glenoid labrum and/or capsule. There is a need to look at the possible patterns of capsulo-labral injuries intra-operatively and correlate them with pre-operative radiographs and CT scans. It can enable surgeons to predict the patterns of soft-tissue injuries in a specific fracture type. Patients operated for ORIF of 3- and 4-part anterior fracture dislocation between January 2017 and December 2022 were included in the study. The following data were collected: demographic details, fracture morphology and classification on radiograph and CT scan, neurovascular injury, the subtype of anterior dislocation, and intra-operative identifiable injury to glenoid labrum and/or capsule. A total of 24 cases (mean age 40 ± 10years) of anterior fracture dislocation of the shoulder were included in the study and were grouped based on Neer's classification. 12 patients had 3-part anterior fracture dislocation (3-part Group) with a mean age of 34 ± 9years, while 12 patients had 4-part anterior fracture dislocation (4-part Group) with a mean age of 46 ± 7years (p = 0.001). 10 out of 12 patients in the 3-part Group had the subcoracoid position of the dislocated head, whereas the head was present in 9 out of 12 patients of the 4-part Group at the preglenoid position (p = 0.003). The head position was at a mean distance of 1.85cm from the anterior glenoid rim in the 4-part Group, whereas the head was engaged at the anterior rim of the glenoid in the 3-part Group. The medial metaphyseal beak was present in 11 out of 12 patients in the 3-part Group, whereas it was absent in all the cases of the 4-part Group (p = 0.001). 92% of the included patients in our study had capsulo-labral injury. 11 out of 12 patients in the 3-part Group had labral injury compared to 10 out of 12 patients in the 4-part Group with severe capsular stripping (p = 0.001). The 3-part fracture dislocation with radiological findings such as the long medial metaphyseal beak and subcoracoid position of the dislocated head had a strong association with a glenoid labral injury, whereas the 4-part fracture dislocation type had a widely displaced preglenoid position of the dislocated head with an absent metaphyseal beak and had a strong association with a capsular type of soft-tissue injury. III.

P35: A Systematic review on the outcomes of the reverse shoulder arthroplasty versus hemiarthroplasty for the 3- and 4- part proximal humeral fractures in the elderly population

Abstract Background The hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA) are common surgical methods in of the proximal humerus management, where the surgical fixation is not feasible. Our aim is to analyse the most recent data to inform choices on best management for managing 3- and 4 -part fracture dislocations of the proximal humeral fractures in the elderly population. Methods The Medline, PubMed and Scopus databases were searched in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify the relevant literature to include for analysis. The inclusion criteria involved English language, functional outcomes, revision rates, hemiarthroplasty, and reverse total shoulder arthroplasty. The exclusion criteria were publications before 2018, systematic reviews and meta-analysis, other management options such as conservative management, surgical fixation, and total anatomical shoulder replacement. Results The data collected included study design and level of evidence, number of patients and patients’ characteristics, follow-up time post-surgery, functional outcomes, range of movement, Constant score, subjective scores including Disability of Arm and Shoulder (QuickDASH) and American Shoulder and Elbow Score (ASES), and revision rates. Conclusions The evidence suggests that RTSA is the new gold standard management for 3- and 4-part fracture dislocations of the proximal humerus in a selected group of patients over 65 years old with irreparable rotator cuff. The available literature is medium quality, requiring more robust evidence including prospective large cohort studies utilising unified objective and subjective functional outcome scores.

Reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical treatment for older adults with acute 3- or 4-part fractures of the proximal humerus: study protocol for a randomised controlled trial (PROFHER-2: PROximal Fracture of Humerus Evaluation by Randomisation – Trial Number 2)

BackgroundProximal humerus fractures (PHF) are common and painful injuries, with the majority resulting from falls from a standing height. As with other fragility fractures, its age-specific incidence is increasing. Surgical treatment with hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA) have been increasingly used for displaced 3- and 4-part fractures despite a lack of good quality evidence as to whether one type of arthroplasty is superior to the other, and whether surgery is better than non-surgical management. The PROFHER-2 trial has been designed as a pragmatic, multicentre randomised trial to compare the clinical and cost-effectiveness of RSA vs HA vs Non-Surgical (NS) treatment in patients with 3- and 4-part PHF.MethodsAdults over 65 years of age presenting with acute radiographically confirmed 3- or 4-part fractures, with or without associated glenohumeral joint dislocation, who consent for trial participation will be recruited from around 40 National Health Service (NHS) Hospitals in the UK. Patients with polytrauma, open fractures, presence of axillary nerve palsy, pathological (other than osteoporotic) fractures, and those who are unable to adhere to trial procedures will be excluded. We will aim to recruit 380 participants (152 RSA, 152 HA, 76 NS) using 2:2:1 (HA:RSA:NS) randomisation for 3- or 4-part fractures without joint dislocation, and 1:1 (HA:RSA) randomisation for 3- or 4-part fracture dislocations. The primary outcome is the Oxford Shoulder Score at 24 months. Secondary outcomes include quality of life (EQ-5D-5L), pain, range of shoulder motion, fracture healing and implant position on X-rays, further procedures, and complications. Independent Trial Steering Committee and Data Monitoring Committee will oversee the trial conduct, including the reporting of adverse events and harms.DiscussionThe PROFHER-2 trial is designed to provide a robust answer to guide the treatment of patients aged 65 years or over who sustain 3- and 4-part proximal humeral fractures. The pragmatic design and recruitment from around 40 UK NHS hospitals will ensure immediate applicability and generalisability of the trial findings. The full trial results will be made available in a relevant open-access peer-reviewed journal.Trial registrationISRCTN76296703. Prospectively registered on 5th April 2018

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review.

The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Retrospective analysis of proximal humeral fracture-dislocations managed with locked plates

Fracture-dislocation is the extreme variant of injury to the proximal humerus that occurs more commonly in young adults as a result of high-velocity trauma. We evaluated the functional and radiologic outcome of fixation of proximal humeral fracture-dislocations with locked plates. This was a retrospective review of 33 proximal humeral fracture-dislocations in 29 patients with a mean age of 35 years (range, 19-60 years) treated by open reduction and internal fixation with locked plates between January 2009 and December 2013. The fracture-dislocation in 85% was the result of high-energy trauma resulting in 3- or 4-part fracture-dislocation. The fracture-dislocation was anterior in 27 and posterior in 6. The average delay from injury to surgery was 7 days (range, 1-35 days), with a mean follow-up of 40 months (range, 24-66 months). All of the fractures united at an average of 15 weeks after surgery. At the final follow-up, the mean forward flexion was 129° (range, 100°-160°), and mean abduction was 128° (range, 100°-150°). The mean Constant score at the final follow-up was 78 points (range, 68-88 points). One case of complete osteonecrosis of the humeral head and 1 case of partial osteonecrosis of the humeral head were noted. Two cases of screw perforation of the humeral head were seen, with subsequent restricted range of motion improving after removal of the offending screws. Most young patients with 3- and 4-part proximal humeral fracture-dislocations can achieve good functional outcome after fixation with locked plates.

Open Reduction and Internal Fixation Versus Hemiarthroplasty in the Management of Complex Articular Fractures and Fracture-dislocations of the Proximal Humerus

Background This study compares open reduction and internal fixation (ORIF) versus hemiarthroplasty (HA) in the management of proximal humerus fracture-dislocations and complex articular humeral head fractures. Methods The records of consecutive patients with Neer 3- and 4-part fracture-dislocations, surgical neck fracture-dislocations with severe articular impaction, and any head-split fracture treated surgically at our institution were studied retrospectively. Constant–Murley scores, Disability of the Arm, Shoulder and Hand (DASH), American Shoulder and Elbow Surgeons Shoulder (ASES), and Short Form Health Survey (SF-36) scores were obtained and compared between ORIF versus HA treatment. Results Thirty patients were included in the analysis: 15 treated with ORIF were compared to 15 treated with HA with an average follow-up of 60 months. The mean Constant score (72 ± 15 vs 54 ± 19; P = .007), DASH score (13 ± 17 vs 29 ± 18; P = .006), ASES score (87 ± 13 vs 66 ± 22; P = .003), and SF-36 physical composite score (PCS) (50 ± 11 vs 40 ± 11; P = .02) all favored the ORIF group. Because of the potential confounding variable posed by including younger patients, we performed a subgroup analysis of patients older than 50 years. In this group, the Constant, DASH, ASES, and PCS scores remained significantly better in the ORIF group. Conclusion Results of this retrospective study show improved patient-reported outcomes and quality of life scores in patients undergoing ORIF for complex proximal humerus fractures as compared to patients undergoing HA, despite a higher revision rate in the ORIF cohort. When considering patients older than 50 years, outcomes after ORIF were better than HA.

Outcome of locking plate fixation for proximal humerus fractures

<p class="abstract"><strong>Background:</strong> The objective of the study was to evaluate functional outcome of open reduction and internal fixation with proximal humeral internal locking system (PHILOS) plate for proximal humerus fractures.</p><p class="abstract"><strong><span lang="EN-US">Methods:</span></strong><span lang="EN-US"> We reviewed 30 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2010 to 2015. There were 23 men and7 women with a mean age of 36 years (range 20-64).There were 22 patients in the age group of <60 years and 8 patients in the age group of >60 years. According to Neer classification system, 12, 11 and 4 patients had2-part, 3-part, and 4-part fractures, respectively and 2 patients had 4-part fracture dislocation. All surgeries were carried out at our tertiary care trauma center. Functional evaluation of the shoulder at final follow-up was done using Neer’s Evaluation Criteria.</span></p><p class="abstract"><strong><span lang="EN-US">Results:</span></strong><span lang="EN-US"> The mean follow-up period was 20 months (range 14-40 months). All fractures united clinically and radio logically. The mean time for radiological union was 13.2 weeks (range 9-26 weeks).At the final follow-up the mean Neer’s Evaluation Criteria was 90 (range 76-100). The results were excellent in 17patients, Satisfactory in 8 patients, Unsatisfactory in 4 patients and Failure in 1 patient. During the follow-up, 3 cases of varus malunion, 1 case of failure of fixation were noted. No cases of AVN, hardware failure, locking screw loosening, infection or nonunion were noted.</span></p><p class="abstract"><strong><span lang="EN-US">Conclusions:</span></strong><span lang="EN-US"> PHILOS provides stable fixation in proximal humerus fractures. In order to prevent the complications like avascular necrosis, knowledge of anatomy and vascular supply of head of humerus and good surgical dissection to preserve vascularity of humeral head is important.</span></p>

Surgical treatment of proximal humerus fractures using PHILOS plate

ObjectiveTo evaluate functional outcome and complications of open reduction and internal fixation with proximal humeral internal locking system (PHILOS) plate for proximal humerus fractures. MethodsWe reviewed 51 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2007 to 2012. There were 35 men and 16 women with a mean age of 38years (range 24-68). There were 41 patients in the age group of <60years and 10 patients in the age group of >60years. According to Neer classification system, 8, 15 and 23 patients had 2-part, 3-part, and 4-part fractures, respectively and 5 patients had 4-part fracture dislocation. All surgeries were carried out at our tertiary care trauma centre. Functional evaluation of the shoulder at final follow-up was done using Constant-Murley score. ResultsThe mean follow-up period was 30months (range 12-44 months). Two patients were lost to follow-up. Of the remaining 49 patients, all fractures were united clinically and radiologically. The mean time for radiological union was 12weeks (range 8-20 weeks). At the final follow-up the mean Constant-Murley score was 79 (range 50-100). The results were excellent in 25 patients, good in 13 patients, fair in 6 patients and poor in 5 patients. During the follow-up, four cases of varus malunion, one case of subacromial impingement, one case of deep infection, one case of intraarticular screw penetration and one case of failure of fixation were noted. No cases of avascular necrosis, hardware failure, locking screw loosening or nonunion were noted. ConclusionPHILOS provides stable fixation in proximal humerus fractures. To prevent potential complications like avascular necrosis, meticulous surgical dissection to preserve vascularity of humeral head is necessary.

Management of proximal humeral Neer 3-part and 4-part fracture dislocations with anatomic reconstruction locking plate

Objective To analyze the therapeutic effect of open reduction with internal fixation (ORIF) and anatomic reconstruction locking plate in treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus. Methods The study involved 30 patients with Neer 3-part and 4-part fracture dislocations treated with anatomic reconstruction locking plate from September 2004 to December 2007.Twenty patients had complete follow-up data.The treatment methods included locking proximal humeral plate (LPHP) in seven patients and proximal humeral internal locking system (PHILOS) in 13.There were 15 males and five females,at age range of 29-84 years (average 52.5 years),including nine patients younger than 65 years and 11 older than 65 years.According to Neer classification,there were 15 patients with 3-part fracture dislocations including 12 anterior and three posterior dislocations and five patients with 4-part fracture dislocations including four anterior and one posterior dislocations. VAS and Constant scoring system were adopted to evaluate the shoulder joint function postoperatively. Results All 20 patients were followed up for 36-71 months ( average 51 months),which showed avascular necrosis of humeral head in six patients (30％),plating loosening in two,screw penetration in six,nonunion in two and infection in two.The mean visual analogue score (VAS) was 2.55 poiuts and the mean Constant score for the shoulder was 80.8.According to the Neer shoulder functional evaluation standard,eight patients were graded as excellent,six as good,three as fair and three as poor,with excellence rate of 70％.Conclusions Although the anatomic reconstruction locking plate and ORIF can cause a high incidence of avascular necrosis of humeral head in the treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus,especially for the patients older than 65 years.However,there is no obvious correlation between necrosis of humeral head and shoulder function.Clinically,the method could be selected on the ba-sis of individual condition of the patients. Key words: Shoulder fractures; Fracture fixation, internal; Shoulder dislocation

Da Vinci System: clinical experience with complex proximal humerus fractures

The purpose of this study is to report the clinical and radiographic outcomes after open reduction and internal fixation of displaced proximal humerus fractures with the "Da Vinci System". It is a triangle-shaped cage whose opposite faces are pierced, and it represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. The new device is an interesting innovation to treat the difficult problem of fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization. According to the technique, authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage, and they are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. If the fracture line involves the proximal portion of the diaphysis, it is possible to use a short low profile plate. Between May 2005 and November 2009, we treated 71 patients (34 men and 37 women), even though we included in our study only 59 patients, who had a minimum follow-up of 12 months. The first patient has been treated in May 2005 and the last one in September 2008. The mean age was 60.8 years (minimum 27, maximum 78). There were 8 displaced 3-part fractures, 20 displaced 4-part fractures, 10 4-part fracture-dislocations, 5 head splitting, 12 unclassified multifragmentary fractures, 1 2-part fracture with multifragmentary calcar and 3 malunions of 4-part fracture. The functional results were evaluated by the Constant score. With a mean follow-up of 24 months (minimum 12, maximum 36 months), the mean Constant score was 80.25. The results were excellent or good in 48 cases, bad in 2 cases and satisfactory in 9; the mean active anterior elevation (AAE) was 160 degrees . All fractures but one healed; in one case, we had a deep infection after 80 days since the operation, treated with a preformed cement spacer.

Outcomes for open reduction and internal fixation of 4-part proximal humeral fractures

Objective To discuss the indications of plate fixation of 4-part proximal humeral fractures (PHFs) and evaluate the clinical results. Methods From Feburary 2004 to September 2007 twenty-one patients who sustained 4-part PHFs were treated by open reduction and plate internal fixation. The patients were classified into three groups according to Neer classification. There were 11 patients, whose ages were (53.4±9.3) years, in the abduction impacted 4-part PHFs group, 6 patients in the typical 4-part PHFs group with an average age of (55.8±4.5) years, and 4 patients in the 4-part fracture-dislocation group with an average age of (52.5 ± 3.7 ) years. Constant- Murley score (CMs) and simple shoulder test (SST) were used to assess shoulder function. Results Nineteen patients were available for follow up while two patients in the abduction impacted 4-part group were lost to follow-up. The mean follow-up period for the the abduction impacted 4- part PHFs group was (28.1±15.4 ) months. Their mean CMs was ( 81.0 ± 7.3 ), and SST was (9.6±1.0). CMs of the typical 4-part PHFs group was(72.2±9.4), while SST was (8.3± 1.5). They were followed up for (31.2±14.2) months on average. Greater tubercle absorption appeared in one patient in this group and his CMs and SST was 59.0 and 7.0 respectively. Patients of the fracture- dislocation group were followed up for(22.0±18.5) months. Their CMs was(40.5±11.2) and SST was (4.7±1.6). One patient in this group had humeral head osteonecrosis, two patients had greater tubercle absorption, and one suffered both. Conclusion Selection of proper treatment procedures is critical in the management of 4-part proximal humeral fractures. ORIF is an effective treatment for younger patients with abduction impacted fractures. For typical 4-part and fracture-dislocation PHFs anatomical reduction and rigid fixation are required.

Four-part fracture dislocation of the proximal humerus: an arthroscopic approach

The 4-part fracture dislocation of the proximal humerus remains an unsolved problem in young patients. The majority of 4-part fracture dislocations are best managed by humeral head replacement, although open reduction and internal fixation in young patients with good bone quality may be considered. Better results are obtained associated with limited exposure, careful soft tissue dissection, and stable fixation. We present an unpublished technique of reduction with arthroscopic assistance and percutaneous stabilization, which preserves the soft tissue around the fragments, avoiding the deltopectoral approach.

Four-segment classification of proximal humeral fractures: Purpose and reliable use

It is now more than 30 years since the first description of the 4-segment classification system for proximal humeral fractures was published. 46 Neer II., CS Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg Am. 1970; 52: 1077-1089 Crossref PubMed Google Scholar It is based on displacement of segments rather than fracture lines and depicts the pathoanatomy of the soft tissue as well as the bone (Figures 1 and 2). Fig. 2The 4-segment classification system and terminology for proximal humeral fractures and fracture-dislocations. In a 1-part fracture (minimal displacement) no segment is displaced more than 1.0 cm or angulated more than 45° regardless of the number of fracture lines. The terminology for displaced lesions relates a pattern of displacement (2-part, 3-part, or 4-part) and the key segment displaced. In the 2-part pattern, the segment named is the one displaced, including the 2-part articular segment (anatomic neck) fracture, the 2-part shaft (surgical neck) fracture of 3 types (A, impacted, B, unimpacted, and C, comminuted), the 2-part greater tuberosity fracture, the 2-part lesser tuberosity fracture, and the 2-part fracture-dislocations. In all 3-part displacements, one tuberosity is displaced and there is a displaced unimpacted surgical neck component that allows the head to be rotated by the tuberosity, which remains attached to it, including the 3-part greater tuberosity fracture, the 3-part lesser tuberosity fracture, and the 3-part fracture-dislocations. Of the 4-part fractures, the impacted valgus 4-part fracture (A) is less displaced and considered to be, in the continuum of lateral displacement, the precursor to B, the 4-part fracture (lateral fracture-dislocation) in which the head is dislocated laterally and detached from both tuberosities and from its blood supply. In fracture-dislocations, the fracture occurs with a true dislocation, which implies damage outside the joint so that neurovascular injuries and pericapsular bone occur more often. They are named according to the pattern of the fracture (2-part, 3-part, and 4-part) and the location of the head (anterior, posterior, inferior, etc). In 4-part fracture-dislocations, the head is detached from its blood supply. Displaced fractures of the articular surface, the impression and head-splitting fractures, are classified with fracture-dislocations because, while part of the articular cartilage is crushed or fragmented against the glenoid, other fragments are extruded from it. Large impression fractures usually occur with posterior dislocations, as drawn in the diagram, and head-splitting fractures usually extrude fragments both anteriorly and posteriorly. (Drawing A of the valgus-impacted 4-part fracture is used with permission from Jakob et al. Classification and aspects of the treatment of fractures of the proximal humerus. In: Bateman JE, Welsh RP, editors. Surgery of the shoulder. Toronto: Decker-Mosby; 1984. p. 330-43.) (Diagram modified and used with permission from Neer CS II. JBone Joint Surg Am 1970;52:1077-89 and from Neer CS II. Four-segment classification of displaced proximal humeral fractures. In: Chapter 9, Instructional Course Lectures of the American Academy of Orthopaedic Surgeons. Volume XXIV. St. Louis: Mosby; 1975. p. 160-8.) View Large Image Figure Viewer Download Hi-res image This system is widely used for preoperative and intraoperative decision making and for organizing material for outcome studies. 9 Bigliani LU Part I—fractures of the proximal humerus. in: 3rd ed. Fractures in adults. Volume 1. Lippincott, Philadelphia1991: 871-927 Google Scholar , 10 Bigliani LU Flatow EL Pollock RG Fracture classification systems. Do they work and are they useful? [correspondence]. J Bone Joint Surg Am. 1994; 76: 790-791 Crossref PubMed Scopus (7) Google Scholar , 23 Cuomo F. Fracture classifications systems. Do they work and are they useful? [correspondence]. J Bone Joint Surg Am. 1994; 76: 792 Crossref PubMed Scopus (8) Google Scholar , 44 Naranja Jr, R Iannotti JP Displaced three- and four-part proximal humeral fractures: evaluation and management. J Am Acad Orthop Surg. 2000; 8: 373-382 Crossref PubMed Scopus (109) Google Scholar , 55 Neer II, CS McIlveen SJ Remplacement de la tete humerale avec reconstruction des tuberosities et de la coiffe dan les fractures desplacees. Results et technique. Rev Chir Orthop. 1988; 74: 31-40 PubMed Google Scholar , 62 Schai P Imhoff A Pruss S. Comminuted humeral head fractures. A multicenter analysis. J Shoulder Elbow Surg. 1995; 4: 319-330 Abstract Full Text PDF PubMed Scopus (84) Google Scholar , 63 Schlegel TF Hawkins RJ Displaced proximal humeral fractures: evaluation and treatment. J Am Acad Orthop Surg. 1994; 2: 54-66 Crossref PubMed Google Scholar In 1987 the original article had the honor of being selected as “The Classic” and republished in its entirety in one of the leading orthopaedic journals in the United States. 50 Neer II., CS The classic. Displaced proximal humeral fractures. Part I. Classification and evaluation. Clin Orthop. 1987; 223 (By Charles S. Neer I 1970): 3-10 PubMed Google Scholar Further thought and experience have been given to the definitions of the categories, and some improvements have been made in roentgen technique.

Surgical Treatment of Complex Fracture of the Proximal Humerus

Sixteen patients aged 19 to 63 years (average, 52 years) were observed from 1.8 to 5.6 years (average, 3.8 years) after open reduction and internal fixation with or without external fixation of 3- and 4-part displaced fractures of the proximal humerus. There were 12, 3-part displaced greater tuberosity and surgical neck fractures with 6 concomitant dislocations. Four cases were 4-part fractures with 3 concomitant dislocations. Fixation was achieved with heavy sutures or wire that incorporated the rotator cuff tendon, tuberosities, and shaft combined with threaded pins or Hoffmann external fixation to enhanced stability for early rehabilitation. According to Neer's criteria, 14 (87%) of the 16 patients had satisfactory or excellent results. Two (13%) of the 16 had unsatisfactory results. The use of a technique of limited soft tissue dissection and internal fixation with or without external fixation achieved good fracture stability and a high percentage of satisfactory results. The limitations of the procedure include (1) patients who could not tolerate anesthesia, (2) complex displaced fractures in older patients with osteoporotic bone that cannot hold pins or external fixation, (3) older patients with 4-part fracture dislocations in which avascular necrosis of the humeral head occurs frequently and in which a subsequent endoprosthesis insertion is inappropriate if osteosynthesis fails, and (4) head splitting fractures. The described approach provides an alternative method for the treatment of complex displaced fractures of the proximal humerus.