title: Is it worth fixing proximal humeral fractures at increased vascular risk?
abstract: OBJECTIVE
  To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion.
  
  
  METHODS
  Prospective, consecutive, multicenter based.
  
  
  METHODS
  Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study.
  
  
  METHODS
  Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.
  
  
  RESULTS
  There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score.
  
  
  CONCLUSIONS
  Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.
  
  
  METHODS
  Level IV: prospective study.
authors.affiliation: Department of Orthopaedics and Traumatology, Clinical Epidemiology and Biometry research unit, Regional Hospital Center, Rennes-1 University, 2, rue Henri-Le-Guilloux, 35033 Rennes, France. herve.thomazeau@chu-rennes.fr
authors.forename: H
authors.initials: H
authors.lastname: Thomazeau
authors.forename: J
authors.initials: J
authors.lastname: Richou
authors.forename: T
authors.initials: T
authors.lastname: Benkalfalte
authors.forename: G
authors.initials: G
authors.lastname: Kerhousse
authors.forename: D
authors.initials: D
authors.lastname: Le Nen
authors.forename: D
authors.initials: D
authors.lastname: Veillard
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails; D005260:Female; D005471:Fluoroscopy; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D017759:Fractures, Malunited / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010020:Osteonecrosis / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D057772:Vascular System Injuries / Q000453:epidemiology