title: Nailing of three- and four-part fractures of the humeral head -- long-term results.
abstract: OBJECTIVE
  Long term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3-4 part fractures.
  
  
  METHODS
  137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27-93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome - absolute Constant score (CS(abs)) and relative Constant score (compared to the contralateral side - CS(rel)) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed.
  
  
  RESULTS
  125 fractures healed uneventfully. Mean long term CS(rel) was 81% of the unaffected side. Mean CS(rel) was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CS(rel) higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CS(rel) less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CS(rel) was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CS(rel) to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CS(rel) was 52% and the rate of complete necrosis rose to 60%.
  
  
  CONCLUSIONS
  Long term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed.
authors.affiliation: Department of Traumatology, Hospital Ceske Budejovice, Czech Republic. Electronic address: martinkloub@volny.cz.
authors.forename: Martin
authors.initials: M
authors.lastname: Kloub
authors.affiliation: Department of Traumatology, Hospital Ceske Budejovice, Czech Republic.
authors.forename: Karel
authors.initials: K
authors.lastname: Holub
authors.affiliation: Daphne CR-Institute of Applied Ecology, Ceske Budejovice, Czech Republic.
authors.forename: Simona
authors.initials: S
authors.lastname: Polakova
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary; D017102:Fracture Healing; D018460:Fractures, Comminuted / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D006810:Humeral Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D058430:Humeral Head / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010020:Osteonecrosis / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications; D011859:Radiography; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
keywords: 3–4 part fractures; Antegrade nail fixation; Humeral head fractures; Influence of the quality of reduction; Long term result; Osteonecrosis