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The authors are from the Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
The authors have no relevant financial relationships to disclose.
Proximal humeral fractures account for approximately 4% to 5% of all fractures.1 They are the second most common upper-extremity fracture and the third most common fracture, after hip fractures and distal radial fractures, in patients aged older than 65 years.2 Up to 75% of the patients are women,3 and it is postulated that these fractures are related to osteoporosis.4
Fortunately, the majority of proximal humeral fractures are either nondisplaced or minimally displaced and can be treated with sling immobilization and physical therapy, with good results attained.4 Approximately 20% of displaced proximal humeral fractures will require operative treatment.5 Many surgical techniques have been described, but no single technique is recommended to be the standard of care. This broad range of techniques, including transosseous suture fixation, closed reduction and percutaneous fixation, open reduction and internal fixation with conventional and locked-plate fixation, and hemiarthroplasty, have been described with varying degrees of success.6â[euro]"12 Locked-plate technology and the use of osteobiologics play an increasingly important role in the treatment of displaced proximal humeral fractures, with both in vitro and clinical studies displaying improved outcomes compared with conventional techniques.13â[euro]"15
Various devices for internal fixation have unpredictable results at best, especially in patients with osteopenic bone and comminuted fractures. Several complications have been described in association with these techniques, including implant failure, loss of reduction, fracture nonunion or malunion, impingement syndrome, and osteonecrosis of the humeral head.16â[euro]"19
Faraj et al20 studied 131 consecutive operated patients with displaced proximal humerus fractures and reported results after 2-year follow-up. Ninety-two (70%) patients were interviewed. The overall complication rate was 39.1% (36/92), excluding the 39 patients not interviewed. The most frequently occurring complications were hemorrhage (3.3%), dislocation of the caput humeri and/or tuberculum majus (2.2%), persistent pain (3.3%), loss of reduction and screw cutout (6.5%), plate breakout (6.5%), subacromial impingement (11.9%), frozen shoulder (3.3%), rotator cuff rupture (1.1%), and infection (1.1%). Of the entire group of patients originally included in the study, almost 1 in 3 (29%) was reoperated due to one of the abovementioned complications.10
In a study by Owsley and Gorczyca,21 19 (36%) of 53 patients with displaced proximal humerus fractures treated...