Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis.

The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.

We report a retrospective review of outcome after shoulder hemiarthroplasty for proximal humerus fractures. All patients managed with shoulder hemiarthroplasty for proximal humerus fractures between 1997 and 2008 were included. Clinical notes were reviewed and surviving patients completed postal Oxford Shoulder Score (OSS) questionnaires. Results were analysed to assess whether there was a difference in outcome for those above the age of 70 years. A total of 96 patients were treated during this period. Female to male ratio was 3.36:1 with mean age 72 ± 9.6 (45–93) years at time of fracture. At time of review 30.2% of patients were dead. Two patients were lost to follow-up after discharge. Complete case notes were available in 68 patients. Response rate to the OSS was 67.2%. There were 20 patients below 70 years and 48 patients above 70 years of age. The ASA grade was II in 60% of patients. Mean follow-up was 52 months. There were 2 in hospital post-operative deaths due to medical complications. Mean OSS was 27 (3–47) of a maximum of 48, with no significant difference between groups. Overall complication rate was 27.9%, with no significant difference between groups. Ten year survival was 96.9% overall with no significant difference between groups. There appears to be no significant difference in functional outcome, complication rate, or implant survival between patients below or above the age of 70 years treated with primary hemiarthroplasty for fracture of the proximal humerus. This procedure however carries a high complication rate in this group of patients.

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year.

MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the ‘building-in’ of increased vigilance for wound infection pre-operatively.