SECONDARY RECONSTRUCTION OF DISPLACED THREE AND FOUR-PART PROXIMAL HUMERAL FRACTURES WITH LOCKING PLATE SYSTEM

Abstract

Introduction: Symptomatic neglected and displaced three and four-part proximal humeral fractures are often difficult to reconstruct. Replacements has been reported to give poor functional outcome and hence not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system.

Material and Methods: Between 2003 and 2005, 15 healthy active patients with displaced three to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months.

Surgical technique: In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by gradual mobilisation program.

Results: All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 preoperatively to 14 at follow up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient.

Conclusion: Successful reconstruction of three and four part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome.