title: Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures.
abstract: BACKGROUND
  Open reduction and internal fixation is one established method for treatment of displaced fractures of the proximal humerus. However, the timing of surgery and its effect on complications have not yet been investigated in the literature. Hence, aim of this study was to analyze the occurrence of complication following locked plating of proximal humeral fractures when surgery was delayed in comparison to early intervention.
  
  
  METHODS
  Between February 2002 and November 2010, 497 patients with displaced proximal humeral fractures were treated by open reduction and locked plating. 329 patients were available for follow-up with a minimum of 12 months after surgery. Outcome analysis included radiographic evidence of loss of fixation (> 10° of secondary displacement), screw-cutout and avascular head necrosis. Outcomes were analyzed with regards to age, gender and fracture pattern and were compared between time intervals in which the primary surgery had been conducted; early intervention (< 48 h), timely scheduled for surgery (3-5 days) and delayed intervention (>5 days).
  
  
  RESULTS
  Of 329 patients (68.4% women; median age at time of surgery: 69.9 years, 95% Confidence Interval (CI) 68.2, 71.2) the median time between fracture incident and surgical intervention was 3.2 days (95%CI: 3.1, 3.3). Surgery was performed in a 2-part fracture at a median of 3.3 days (95%CI: 3.2, 3.4) after trauma, in a 3-part fracture after 3.3 days (95%CI: 3.1, 3.4), in a 4-part fracture 2.9 days (95%CI: 2.8, 3.0), in head split type fracture 2.2 days (95%CI: 2.0, 2.4) and in dislocation type fracture 0.8 days after trauma (95%CI: 0.7, 0.9, p = 0.40). Loss of fixation was observed in 12.8% (n = 42 patients), of which in 4.9% (n = 16) screw cutout was evident and in 6.8% of cases (n = 20) avascular head necrosis was diagnosed. Patients in which complication was observed were treated at median 2.5 days after trauma (95% CI, 1.8, 3.2), in comparison, patients without evidence of complications were treated at a median of 3.2 days (95% CI, 2.8-3.8, p = 0.35). The odds ratio regarding occurrence of complications for patients treated <48 hours was 0,924, for patients in which surgery was performed 3-5 days after the incident the odds ratio was 0,836 and in patients treated > 5 days the odds ratio was 1,637.
  
  
  CONCLUSIONS
  Loss of fixation following open reduction and internal fixation of proximal humeral fractures was not more frequently observed when surgery was performed 3-5 days after the incident in comparison to early intervention (< 48 h). However, a delay of intervention > 5 days is related to significant increase of complications. Thus, if open reduction and internal fixation is indicated, reconstruction of the proximal humerus should be performed within 5 days of the fracture event. In head split and dislocated fracture types anatomic reconstruction completed within 48 h from the incident may be beneficial with regards to risk of avascular necrosis.
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Georg
authors.initials: G
authors.lastname: Siebenbürger
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Dustin
authors.initials: D
authors.lastname: Van Delden
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Helfen
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Florian
authors.initials: F
authors.lastname: Haasters
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Böcker
authors.affiliation: Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany. Electronic address: Ben.Ockert@med.uni-muenchen.de.
authors.forename: Ben
authors.initials: B
authors.lastname: Ockert
mesh_terms: D001860:Bone Plates; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery*; D011446:Prospective Studies; D012783:Shoulder Dislocation / Q000503:physiopathology / Q000601:surgery*; D012784:Shoulder Fractures / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
keywords: angular stable plating; complication; delay of intervention; locked plating; osteosynthesis; outcome; proximal humerus fracture; timing of surgery