Abstract
Background
For the treatment of proximal humeral fractures two major therapeutic principles can be employed: Intramedullary nailing (PHN) or locking plate osteosynthesis. Aim of this study was to evaluate and compare clinical and radiological long-term outcome of proximal humeral fracture stabilization using PHN or angular stable plating. In addition, we discussed advantages and disadvantages of both techniques and aimed at establishing criteria which operative technique should preferentially be utilized for selected fracture configurations.
Materials and Methods
In a prospective study between 2003 and 2010 we analyzed 72 patients with proximal humeral fracture who had been treated by PHN (44 patients) or angular stable plating (28 patients) in a European Level 1 Trauma Center. In the two cohort groups the following epidemiologic data was found. 46 patients were women, and 26 men with a mean age of 60.6 years (range 18–91). Follow-up was performed 38–82 months after accident, on average. Mechanism of injury was fall in 59, motor cycle accident in 4, bike accident in 8 patients, and fall from horse in 1 patient. Duration time between accident and operation was 2.8 days on average. Osteoporosis was previously known in 20 out of all evaluated patients (plate: 7/28; nail: 13/44). Fractures were classified using the Neer classification and Binary description system: There were 35 3-part fractures (PHN: 26; plate: 9) and 37 4-part fractures (PHN: 18; plate: 19), respectively. Functional and radiological outcome was assessed in a range of 38–82 months after trauma using Constant Score.
Results
No clinical symptoms after 3 years were observed in 40 patients, whereas in 32 patients clinical symptoms were evaluated related to pain and/or loss of function. Secondary revision after plate fixation had to be performed in 5 out of 28 patients and in 11 out of 44 patients in the PHN group. Functional outcome using the Constant score demonstrated a total score of 72.9 (ipsi-lateral side) vs. 88.4 (contra-lateral side) in all evaluated patients, on average. Complete metal removal was performed in 34 out of 72 patients (PHN: 17; plate: 17).
Conclusion
Both i.m. nailing and angular stable plating are adequate treatment options for proximal humeral fractures. No significant differences in outcome between implants regarding fracture healing, nonunion, and infection were found. Locked plating can be utilized for all distal humerus fracture including complex 4-part fractures. I.m. nailing provides favorable intramedullary stability and can be successfully implanted in multi-segmental fractures of the upper extremity. However, both systems require precise preoperative planning and advanced surgical experience. Clinical long-term outcome largely depends on surgical technique and not so much on the choice of implant.
