title: Displaced proximal humeral fractures: when is surgery necessary?
abstract: BACKGROUND
  Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients.
  
  
  METHODS
  We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (≥65 years and <65 years) and fracture type (displaced 2-fragment and 3-4-fragment fractures).
  
  
  RESULTS
  A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p=0.01 and 74.0 vs. 54.7, p=0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p=0.02 and 68.7 vs. 55.9, p=0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p=0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3-4-fragment fractures.
  
  
  CONCLUSIONS
  The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories.
authors.affiliation: Faculty of Dentistry, McGill University, Montreal, Canada. Electronic address: isktamimi80@yahoo.com.
authors.forename: Iskandar
authors.initials: I
authors.lastname: Tamimi
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Guillermo
authors.initials: G
authors.lastname: Montesa
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Collado
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: David
authors.initials: D
authors.lastname: González
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Carnero
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Facundo
authors.initials: F
authors.lastname: Rojas
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Nagib
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Verónica
authors.initials: V
authors.lastname: Pérez
authors.affiliation: Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain.
authors.forename: Miguel
authors.initials: M
authors.lastname: Álvarez
authors.affiliation: Faculty of Dentistry, McGill University, Montreal, Canada.
authors.forename: Faleh
authors.initials: F
authors.lastname: Tamimi
mesh_terms: D000367:Age Factors; D001860:Bone Plates; D001864:Bone Wires; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D007103:Immobilization / Q000379:methods*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Age; Conservative treatment; Fracture type; Functional outcome; Kirschner wires; Locking plate; Proximal humeral nail; Proximal humerus fracture