Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases.
No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other.



This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN).



After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group.



If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area.



IV, retrospective study.
Département d'orthopédie-traumatologie I, hôpital Trousseau, université François-Rabelais de Tours, avenue de la République, 37044 Tours cedex 9, France. Electronic address: gadea.f@gmail.com.
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Gadea
Département d'orthopédie-traumatologie I, hôpital Trousseau, université François-Rabelais de Tours, avenue de la République, 37044 Tours cedex 9, France.
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Favard
Département de chirurgie orthopédique et traumatologie du sport, hôpital de L'Archet, université de Nice-Sophia-Antipolis, 151, route de Saint-Antoine-de-Ginestière, 06202 Nice, France.
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Boileau
Département de chirurgie orthopédique et traumatologie, hôpital Bon-Secours, CHR Metz, 57038 Metz cedex, France.
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Cuny
Département de chirurgie orthopédique et traumatologie du sport, hôpital de L'Archet, université de Nice-Sophia-Antipolis, 151, route de Saint-Antoine-de-Ginestière, 06202 Nice, France.
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d'Ollone
Service de chirurgie orthopédique et de traumatologie du sport, hôpital Sud, CHU de Grenoble, 38434 Échirolles cedex, France.
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Saragaglia
Centre chirurgical Émile-Gallé, 49, rue Hermite, 54000 Nancy, France.
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Sirveaux
Société française de chirurgie orthopédique et de traumatologie, 56, rue Boissonade, 75014 Paris, France.
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails; D001860:Bone Plates; D001863:Bone Screws; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D005594:Fracture Fixation, Intramedullary / Q000379:methods*; D018460:Fractures, Comminuted / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D058430:Humeral Head; D008297:Male; D008875:Middle Aged; D010020:Osteonecrosis / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011859:Radiography; D000072177:Radiologists; D012086:Reoperation; D012189:Retrospective Studies; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000601:surgery*
4-part fracture; Antegrade nailing; Locking plate; Proximal humerus fracture; Shoulder