title: Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures.
abstract: BACKGROUND
  Little is known about non-operative treatment of proximal humerus 4-part and severe displaced fractures as those are normally treated operatively. In this study, we present a historical collective of two level I trauma centers, where all humeral head fractures, despite displaced fractures, received non-operative treatment within a 10 years period. Functional and clinical results of 2-, 3- and 4-part fractures were compared to those after fixed angle intramedullary nailing by matched pair analysis.
  
  
  METHODS
  Between 2000 and 2010, 167 patients with 2-, 3- and 4-part humeral head fractures were treated non-operatively in two level I trauma centers in Rostock. Complete clinical, functional and radiographic follow-up were available for 41 patients in the retrospective analysis. The results were compared by matched-pair analysis to a prospective series of 143 patients treated by antegrade intramedullary nailing using a proximal humeral nail. Of these 143 patients complete radiological and clinical 12 months' follow-up was available for 117 patients. Thus, it was possible to built 41 pairs according to age, gender, and fracture type. Statistical significant differences in constant score (CS), pain, activity of daily living (ADL), range of motion (ROM) and muscle strength were evaluated by Wilcoxon test. Furthermore, x-ray analysis of fracture healing and complications were recorded.
  
  
  RESULTS
  Operative treatment was not superior to non operative treatment concerning functional results, even in displaced fractures. The only significant difference was found in 3-part-fractures, where better ROM was reached in the non-operative group (p = 0.05). In contrast, there was a tendency toward better activity of daily living (ADL) in intramedullary nailing, but this did not reach statistical significance. X-ray findings revealed better anatomical reconstruction with less valgus and varus displacements after surgery (15% versus 50%, p < 0.005). The complication rate of 37% was higher in the surgery group with a reoperation rate of 32%.
  
  
  CONCLUSIONS
  In our study, surgical treatment by fixed angle intramedullary nailing (Targon PH) seems not to be superior to non-operative treatment, regardless of fracture type. In 2-, 3- and 4-part fractures functional and clinical results were similar.
authors.affiliation: Department of Trauma, Orthopedic and Reconstructive Surgery, Munich University Hospital (LMU), Munich, Germany.
authors.forename: Mirjam
authors.initials: M
authors.lastname: Lange
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Brandt
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mittlmeier
authors.affiliation: Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Clinic Harlaching, Germany. Electronic address: Georg.Gradl@klinikum-muenchen.de.
authors.forename: Georg
authors.initials: G
authors.lastname: Gradl
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000379:methods; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D006801:Humans; D007103:Immobilization / Q000379:methods; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D015599:Trauma Severity Indices; D016896:Treatment Outcome
keywords: functional results; intramedullary nailing; non-operative treatment; proximal humeral fractures