Comparative Study of Management of Proximal Humerus Fractures In

Original Article

Comparative Study of ISSN No 2230-7885 CODEN JPBSCT Management of Proximal NLM Title J Pharm Biomed Sci

Humerus Fractures in Elderly Rahul Ravindra Bagul1*, Utkarsha Joshi2, by Conservative Method Vikram Kakatkar3, Versus Operative Locking Sanjay Deo4 1 Associate Professor, Department of Compression Plate Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, ABSTRACT Pune, India Background Proximal humeral fracture in patients more than 65 years old, represent 2 Assistant Professor, Department of the third most common fracture. Treatment of proximal humerus fractures, especially Orthopaedics, Padmashree Dr. D.Y. Patil displaced fractures, remains controversial. Conservative treatment has been preferred Medical College, Hospital and Research for most of the undisplaced or minimally displaced fractures. Over the years, availabil- Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, ity of improved fixation devices, popularised the treatment of these fractures by open Pune, India reduction and internal fixation. Operative treatment of proximal humerus fractures poses 3 Senior Resident, Department of Orthopaedics, a challenge because of complications like malunion, non-union and avascular necrosis. Padmashree Dr. D.Y. Patil Medical College, Objective To study the role of conservative treatment and operative treatment by locking Hospital and Research Centre, Dr. D.Y. Patil compression plate in the management of these fractures. To compare the results of Vidyapeeth, Pimpri, Pune, India conservative management versus locking plate osteosynthesis. To evaluate the results 4 Professor, Department of Orthopaedics, of treatment in terms of clinical and radiological union as well as functional outcome. Padmashree Dr. D.Y. Patil Medical College, Materials and methods In the present case study, we report our experience in 60 cases Hospital and Research Centre, Dr. D.Y. Patil in whom comparative study of management of proximal humerus fractures in elderly by Vidyapeeth, Pimpri, Pune, India conservative method versus operative locking compression plate was done.  Address reprint requests to Results As measured by Neer’s shoulder score, out of the 60 cases in our study, 8 (13.33%) *Dr. Rahul R. Bagul, Department of Ortho- had excellent functional outcome out of which 3 were treated conservatively and 5 were paedics, Padmashree Dr. D.Y. Patil Medical treated operatively, 29 (48.33%) had satisfactory outcome out of which 14 were treated College, Hospital and Research Centre, conservatively and 15 were treated operatively, 19 (31.67%) had unsatisfactory outcome Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, India out of which 10 were treated conservatively and 9 were treated operatively, and 4 (6.67%) E-mail: [email protected] cases were failures out of which 3 were treated conservatively and 1 were treated operatively.  Article citation: Rahul B, Utkarsha J, Vikram K, Sanjay D. Comparative study of KEYWORDS proximal humerus fracture, old age, locking compression plate, conserva- management of proximal humerus fractures tive treatment in elderly by conservative method versus operative locking compression plate. J Pharm Biomed Sci 2015;05(11):831–838. Introduction Available at www.jpbms.info A proximal humeral fracture is the fracture of the ball portion, lying at Statement of originality of work: The the upper end of the humerus or arm bone. The incidence of proximal manuscript has been read and approved by all humeral fracture is 4–5% of all fractures1. In patients more than 65 years the authors, the requirements for authorship have been met, and that each author believes that the old, they represent the third most common fracture, after hip and distal manuscript represents honest and original work. radius fractures2. They account for 30–40% of all humeral fractures in all age groups and 76% of all the humeral fractures among people 40 years Source of funding: None. of age or older3. Fractures in adolescents and younger adults usually occur Competing interest / Conflict of interest: due to high-energy injuries, mainly vehicular accidents, sports injuries, The author(s) have no competing interests for fall from height, or gunshot wounds. However fractures in the elderly are financial support, publication of this research, more common, which are usually low-energy osteoporotic injuries. More patents, and royalties through this collaborative 4–6 research. All authors were equally involved in than three quarters are a result of low-energy domestic falls . Treatment of discussed research work. There is no financial proximal humerus fractures has been greatly debated. This is because of the conflict with the subject matter discussed in the complexity of the fracture displacements and soft tissue injury. Prognosis manuscript. depends on degree of fracture displacement and damage to delicate blood 7 Disclaimer: Any views expressed in this supply of head of humerus . Conservative treatment has been preferred for paper are those of the authors and do not most of the undisplaced or minimally displaced fractures as the healing time reflect the official policy or position of the is short, infection is uncommon and prognosis is good8–10. The management Department of Defense. of comminuted displaced fractures, remains controversial9,11. The availability

Received Date: 22 August 2015 – Accepted Date: 23 September 2015 – Published Online: 16 November 2015 832 Rahul Ravindra Bagul of improved fixation devices, over the years, popularised the treatment of these fractures by open reduction and internal fixation. But, the precarious blood supply of the humeral head, puts its viability at risk, from the injury and from the soft tissue exposure to reduce the fracture and insert the implants12. In cases treated operatively, complications like malunion, non-union and avascular necrosis have been reported8,13,14. Therefore, operative treatment of proximal humerus fractures poses a challenge. With this background, we have taken up this comparative study including conservative and locked compression plating modalities for treatment of proximal humerus fractures. Fig. 1 X-ray shoulder joint, A-P view. MATERIALS AND METHODS In the present case study we are report our experience in 60 cases in whom comparative study of management of proximal humerus fractures in elderly by conservative method versus operative locking compression plate was done. The duration of this study was from April 2012 to April 2015. Inclusion criteria: · Patients of both sexes with age 50 years and above · Neer’s three part and four part fractures · Fracture dislocations Exclusion criteria: · Patients with age below 50 years · Compound fractures · Fractures with neurovascular injury

PRE-OPERATIVE A total of 60 cases of proximal humerus fractures were studied. On admission, a detailed history including the complaints of the patient and the mechanism of injury were noted. Clinical examination involved assessing pain, swelling, tenderness, crepitus and ecchymosis around the shoulder region. A detailed neurovascular examination of the brachial plexus and axillary artery was carried out. Associated injuries to the chest, abdo- men and other limbs were also noted. Radiographs of Fig. 2 X-ray shoulder joint, axial view. affected shoulder were taken in antero-posterior and axillary views. For primary treatment, immobilization closed reduction under general anaesthesia. Fracture was given in the form of simple cuff and collar sling. All dislocation was reduced under image intensifier con- routine investigations were done prior to anaesthesia fit- trol. Immediate immobilization was done using a ness. Pre-operative anaesthesia fitness was done. Patients shoulder arm pouch with immobilizer. Oral analgesics to be managed operatively were posted for planned and calcium supplements were given. Physiotherapy operative procedure. in the form of gentle passive range of motion and pendulum exercises was started after 3–4 weeks, once MANAGEMENT pain was reduced and the patient co-operated. At Conservative management 6 weeks and 3 and 6 months X-ray shoulder antero- posterior and axillary views were taken (Fig. 3). On Patients with minimally displaced fractures were given clinical and radiological assessment both active and a shoulder arm pouch with immobiliser (Figs. 1, 2). passive shoulder range of motion exercises were Patients with fracture-dislocations were subjected to started (Figs. 4–6).

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Fig. 3 X-ray shoulder joint, A-P view at 6 months. Fig. 5 Abduction.

Fig. 4 Internal rotation.

Operative management Following pre-operative X-ray shoulder antero-posterior and axillary views (Fig. 7) and baseline investigations, patients were posted for open reduction and internal fixation with locking compression plate.

Surgical technique A beach-chair position was given to the patient, follow- Fig. 6 Flexion. ing general anaesthesia. The C-arm was positioned prop- erly to view the proximal humerus. Scrubbing, painting and draping of the affected upper limb were done humeral shaft with cortical screws. An aiming device under aseptic precautions. Deltoid-splitting approach which diverged the screws in the head was temporarily was used to expose the proximal humerus. Care was attached to the upper part of the plate. Locking screws taken not to injure the axillary nerve. When the frac- were then inserted in the humeral head. After obtaining ture was exposed, the humeral head if dislocated, was a stable plate fixation, the K-wires and traction sutures relocated first into the glenoid under C-arm guidance. were removed. Suturing was done in layers, followed by Next, the head was reduced onto the shaft with the help sterile dressing. of K-wires and then using them as joysticks reduction was achieved in coronal, sagittal and horizontal planes. Remaining fragments were then reduced with the help Post-operative management of traction sutures placed in the rotator cuff insertions. Limb was immobilised in a shoulder arm pouch. Once an acceptable reduction was achieved, the lock- Immediate post-operative X-rays of shoulder in antero- ing compression plate was applied at least 1 cm distal posterior and axillary views were taken to assess to upper end of the greater tubercle and fixed to the reduction of fracture and stability of fixation (Fig. 8).

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Fig. 7 X-ray shoulder joint, A-P and axial views. Fig. 8 X-ray post-operative shoulder joint, A-P and axial views.

Intravenous antibiotics were given for the first 3 days and then shifted to oral antibiotics. Anti-inflammatory, analgesics drugs were also given. Post-operative dressings of the surgical wound were done on 2nd and 8th day. Sutures were removed on 12th post-operative day. Mobilisation of affected shoulder was started on the 3rd day with pendulum exercises as per the patient’s toler- ance. At 6 weeks and 3 and 6 months X-ray of the shoulder in antero-posterior and axillary views were taken (Fig. 9). On clinical and radiological assessment both active and passive shoulder range of motion exercises were started (Figs. 10–12). Results were then evaluated by the use of Neer’s shoulder score for each case recorded.

OBSERVATION AND RESULTS Our study included 60 cases of proximal humeral fractures which were managed in our hospital. Thirty patients were treated conservatively and 30 with locking compression plate. 1. Age distribution The mean age of the patients was 67.15 years. The youngest patient was 51 years old and the oldest patient was 91 years old. Fig. 9 X-ray post-operative shoulder joint, A-P and axial views at 6 months. 2. Sex distribution In our study, out of the 60 patients, 38 were male and 22 4. Distribution according to classification were female. Male to female ratio was 19:11. According to Neer’s classification, 33 patients belonged 3. Side distribution to the 3 part fracture group out of which 13 were In our study, we had 26 patients with right sided proximal treated conservatively and 20 were treated operatively, humerus fractures and 34 patients with left sided fractures. 21 patients belonged to the 4 part fracture group out of

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Fig. 12 Abduction.

7. Trauma-treatment interval In our study, the mean duration of trauma- treatment interval was 4. 48 days, with minimum duration of 1 day and maximum duration of 11 days. 8. Follow up period The mean duration of follow up in our study was 24.27 Fig. 10 Internal rotation. months with minimum follow up of 24 months and maximum of 27 months. 9. Clinical union The mean time duration for clinical union in our study was 12.94 weeks, with minimum of 10 weeks and maximum of 18 weeks. 10. Radiological union The mean time duration for radiological union in our study was 19.52 weeks, with minimum of 17 weeks and maximum of 23 weeks. 11. Complications During the follow up period, 6 patients treated conservatively and 3 patients treated operatively had shoulder stiffness, 3 patients treated operatively had post-operative infection (5%) and 1 patient treated operatively had Fig. 11 External rotation. implant loosening. Two patients treated conservatively and 2 patients treated operatively had malunion. There which 14 were treated conservatively and 7 were treated were no incidences of non-union or osteonecrosis in operatively and 6 patients belonged to the fracture dislo- our study. cation group out of which 3 were treated conservatively 12. Range of motion and 3 were treated operatively. At the end of functional recovery, all the patients were 5. Mode of injury assessed for range of motion. They had restriction of In our study, 31 patients had domestic fall, 26 patients abduction, forward flexion, extension and rotation. had road traffic accident and 3 patients had assault. The mean flexion obtained at the end of our study was 132.63° in the conservative group and 140.3° in the oper- 6. Associated injuries ative group. The mean abduction was 140.53° and 145.4° Out of the 60 cases in our study, 10 had associated injuries, in the conservative and operative groups, respectively. The 2 cases had head injury, 2 cases had rib fractures, 1 case had mean external rotation was 14.5 and 16.56 in the con- clavicle fracture and 1 had pelvic fracture, all of which were servative and operative groups, respectively (Figs. 7–12). managed conservatively. One patient had tibia shaft fracture and another patient had femur shaft fracture, which were 13. Evaluation of results by Neer’s shoulder score treated with intra-medullary interlocking nails. One patient At the end of clinical and radiological union and func- with both bone forearm fracture was treated with dynamic tional recovery, the results were evaluated by Neer’s compression plates and one patient with olecranon fracture shoulder score. The mean scores observed were 33.42 was treated with K-wires and tension band wiring. units for pain, 23.4 units for function, 16.05 units for

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Table 1 n eer’s shoulder score. Table 2 n umber of patients. No of pts. Category Mean score Conservative Operative Study (conservative vs. operative) Pain 33.42 33 33.83 Olerud et al. 2011 30 vs. 30 Function 23.4 23.33 23.47 Fjalestad et al. 2012 25 vs. 25 ROM 16.05 15.73 16.37 Olerud et al. 2011 28 vs. 27 Anatomy 8.07 8.13 8 Boons et al. 2012 25 vs. 25 Total 80.94 80.2 81.67 Stableforth 1984 16 vs. 16 Zyto et al. 1997 20 vs. 20 ROM and 8.07 units for anatomy. The mean total Neer’s score was 80.94 units (Table 1). Present study 30 vs. 30 15. Functional outcome Out of the 60 cases in our study, 8 (13.33%) had excellent functional outcome out of which 3 were treated conser- Table 3 a ge incidence. vatively and 5 were treated operatively, 29 (48.33%) had Mean age Study satisfactory outcome out of which 14 were treated con- (conservative vs. operative) servatively and 15 were treated operatively, 19 (31.67%) Olerud et al. 2011 74.9 vs. 72.9 had unsatisfactory outcome out of which 10 were treated conservatively and 9 were treated operatively and 4 Fjalestad et al. 2012 73.1 vs. 72.2 (6.67%) cases were failures out of which 3 were treated Olerud et al. 2011 77.5 vs. 75.8 conservatively and 1 was treated operatively. Boons et al. 2012 76.4 vs. 79.9 Stableforth 1984 70.1 vs. 65.6 Discussion Zyto et al. 1997 75 vs. 73 Fractures of the proximal humerus are one of the most commonly occurring fractures. Incidence of these frac- Present study 68.77 vs. 65.53 tures is 73 per one lakh population, with 75% found in the elderly. About 80–85% of these fractures can be treated conservatively, while the remaining 15–20% system. The results of our study were compared with sim- which are significantly displaced, require some form of ilar studies performed by other authors. internal fixation15. They have been described two centu- 1. Number of patients ries back, even before the invention of radiology and have The number of patients is comparable to studies con- shown various trends in their management. The incidence ducted by Olerud et al.22,24, Fjalestad et al.23, Boons et al.25, of proximal humeral fractures has increased in the last Stableforth et al.26 and Zyto et al.27 (Table 2). few years due to changes in lifestyle and increase in the number of road traffic accidents9,16. The best management 2. Age incidence for these injuries is still uncertain. Earlier, these fractures In our study, the average age was 67.15 years, with the were managed by plaster cast techniques, slings and mean age for conservative group being 68.77 years and slabs17. But, recent advances in understanding of the anat- that of operative group being 65.53 years. These find- omy, development of good surgical skills and availability ings are comparable with other similar studies by differ- of better instrumentation have led to various modalities ent authors as given in Table 3. for their treatment18,19. Due to awareness of their com- 3. Sex incidence plexity and complications, these fractures have stimulated The study of literature has revealed predominance of prox- a growing interest in finding the optimal treatment. With imal humeral fractures in females in an elderly age group. the aim of getting rapid healing and early restoration This has been evident in other published studies. In our of function, open reduction and internal fixation is the study, the male to female ratio was 19:11 with 63.4% preferred modality of treatment8,20. Studies have shown males as compared to 36.6% females. The higher inci- that both non-operative and operative treatments give dence of males in our study can be explained by the higher favourable results. Hence there is uncertainty regarding involvement of males in day-to-day activities and also in treatment9,21. An anatomical reduction and good rehabil- road traffic accidents in comparison with females (Table 4). itation are predictors of a good functional outcome. In our institution, we have studied 60 patients of proximal 4. Side involved humeral fractures, with 30 patients treated conservatively Our study included 26 (43.4%) right sided and 34 (56.6%) and 30 patients treated with locking compression plate left sided proximal humeral fractures. Our findings are and assessed the outcome using Neer’s shoulder scoring comparable with the findings of Zyto et al. (Table 5).

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Table 4 Sex incidence. Table 8 Complications. Study Male vs. Female Complications (conservative Study Olerud et al. 2011 19% vs. 81% vs. operative) Olerud et al. 2011 14% vs. 86% Olerud et al. 2011 16.66% vs. 76.67% Stableforth 1984 24.7% vs. 75.3% Olerud et al. 2011 35.71% vs. 37.07% Zyto et al. 1997 12.5% vs. 87.5% Boons et al. 2012 24% vs. 52% Present study 63.4% vs. 36.6% Zyto et al. 1997 25% vs. 40% Present study 26.67% vs. 30%

Table 5 Side involved. Study Right Left These findings are comparable with the complications Zyto et al. 1997 35% 65% in other similar studies (Table 8). Shoulder stiffness was present in 9 cases and they Present study 43.4% 56.6% were started with rigorous physiotherapy programme. Two of these cases did not comply with the same and progressed to arthritis and failure outcome. Table 6 Follow up duration. Post-operative infection was present in 3 cases, all Study Duration (months) of whom presented early and had superficial infection Olerud et al. 2011 24 which subsided with systemic antibiotics and regular sterile dressings. Olerud et al. 2011 24 Malunion was found in 4 cases in our study. But they Fjalestad et al. 2012 12 were within the acceptable range with no significant Stableforth 1984 6–48 limitations in the patients activities of daily living. Present study 12.27 Implant loosening was present in 1 patient, which appeared at 4 months after the surgery. Patient was advised a revision surgery, but was unwilling for the same. It accounted for failure outcome. Table 7 Range of motion. Flexion Abduction Ext Rotn 8. Results Study (C vs. O) (C vs. O) (C vs. O) Out of the 60 cases in our study, 8 (13.33%) had excellent Olerud et al. 2011 111 vs. 120 106 vs. 114 NA functional outcome out of which 3 were treated conservatively and 5 were treated operatively, 29 (48.33%) had Olerud et al. 2011 95 vs. 93 87 vs. 86 NA satisfactory outcome out of which 14 were treated con- Boons et al. 2012 94 vs. 98 87 vs. 77 19 vs. 17 servatively and 15 were treated operatively, 19 (31.67%) 132.63 vs. 140.53 vs. 14.5 vs. had unsatisfactory outcome out of which 10 were treated Present study 140.3 145.4 16.56 conservatively and 9 were treated operatively and 4 (6.67%) cases were failures out of which 3 were treated C: conservative, O: operative. conservatively and 1 were treated operatively. The difference in the functional outcomes between 5. Follow up two groups by the Chi square test was not statistically In our study, the mean follow up duration was 12.27 significant (P = 0.662). months, which is consistent with follow up durations of Our results were similar to the study conducted by other similar studies (Table 6). Olerud et al.22. In their study, the results obtained using constant score were 61 for operative group versus 58 6. Range of motion for conservative group, with a P value of 0.64, and those The mean flexion obtained at the end of our study was obtained by DASH score were 26 versus 35 for operative 132.63° in the conservative group and 140.3° in the oper- and conservative groups, respectively, with a P value of ative group. The mean abduction was 140.53° and 145.4° 0.19, thus showing no statistically significant difference in the conservative and operative groups, respectively. The between the two groups. mean external rotation was 14.5 and 16.56 in the con- In the study by Fjalestad et al.23 the mean constant servative and operative groups, respectively. These findings score favoured conservative treatment by 2.4 point with are consistent with the results of other studies (Table 7). a P value of 0.62, indicating no significant difference 7. Complications between the two groups. In our study of 60 cases, complications were found in Thus we conclude that both conservative and sur- 17 cases, of which 8 were present in the conservative gical treatment of fractures of the proximal humerus in group (26.67%) and 9 in the operative group (30%). elderly patients have equally good functional outcomes.

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However conservative treatment, although suitable in 14. Sturzenegger M, Fornaro E, Jakob RP. Results of surgical elderly patients with a sedentary lifestyle, often results treatment of multifragmented fractures of the humeral head. in malunion and shoulder stiffness. Arch Orthop Trauma Surg. 1982;100(4):249–259. 15. Neer CS. Displaced proximal humeral fractures. I. Classification References and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–1089. 16. Nordqvist A, Petersson CJ. Incidence and causes of shoulder 1. Horak J, Nilsson BE. Epidemiology of fracture of the upper end girdle injuries in an urban population. J Shoulder Elbow Surg. the humerus. Clin Orthop Relat Res. 1975;(112):250–253. 1995;4(2):107–12. 2. Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral 17. Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology fractures. Bone. 1996;18(3 Suppl):209S–213S. of humeral shaft fracture. J Bone Joint Surg Br. 1998;80(2):249–53. 3. Rose SH, Melton LJ 3rd, Morrey BF, Ilstrup DM, Riggs BL. 18. Pritsch M, Greental A. Closed pinning for humeral fractures. Epidemiologic features of humeral fractures. Clin Orthop Relat JBJS. 1997;79-B (Supp III). Res. 1982;(168):24–30. 19. Robinson C, Page RS, Hill RM, Sanders DL, Court-Brown 4. Court-Brown CM, Garg A, McQueen MM. The epidemiology of prox- CM, Wakefield AE. Hemiarthroplasty for treatment of proximal imal humeral fractures. Acta Orthop Scand. 2001;72(4):365–71. humeral fractures. J Bone Joint Surg Am. 2003;85-A(7):1215–23. 5. Lind T, Krøner K, Jensen J. The epidemiology of fractures of the 20. Kristiansen B, Christensen SW. Plate fixation of proximal humeral proximal humerus. Arch Orthop Trauma Surg. 1989;108(5):285–7. fractures. Acta Orthop Scand. 1986;57(4):320–23. 6. Kristiansen B, Barfod G, Bredesen J, Erin-Madsen J, Grum 21. Horak J, Nilsson BE. Epidemiology of fracture of the upper end B, Horsnaes MW, et al. Epidemiology of proximal humeral of the humerus. Clin Orthop Relat Res. 1975;(112):250–53. fractures. Acta Orthop Scand. 1987;58(1):75–7. 22. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal 7. Muller ME, Allgovere M, Schneidere R, Willenegger H. Manual fixation versus nonoperative treatment of displaced 3-part of Internal Fixation: Techniques Recommended by AO/ASIF proximal humeral fractures in elderly patients: a randomized Group, 3rd ed. Berlin: Springer-Verlag; 2002. pp. 438–41. controlled trial. J Shoulder Elbow Surg. 2011;20(5):747–55. 8. Neer CS. Displaced proximal humeral fractures. II. Treatment of 23. Fjalestad T, Hole MØ, Hovden IA, Blücher J, Strømsøe K. Surgical three-part and four-part displacement. J Bone Joint Surg Am. treatment with an angular stable plate for complex displaced 1970;52(6):1090–103. proximal humeral fractures in elderly patients: a randomized 9. Mills HJ, Horne G. Fractures of the proximal humerus in adults. J controlled trial. J Orthop Trauma. 2012;26(2):98–106. Trauma. 1985;25(8):801–5. 24. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. 10. Jacob RP, Kristiansen T, Mayo K, Ganz R, Muller ME. Classification Hemiarthroplasty versus non-operative treatment of displaced and aspects of treatment of fractures of the proximal humerus. 4-part proximal humeral fractures in elderly patients: a randomized In: Bateman JE, Welsh RP (eds): Surgery of the Shoulder. controlled trial. J Shoulder Elbow Surg. 2011;20(7):1025–33. Philadelphia: BC Decker Inc.; 1984. pp. 330–43. 25. Boons HW, Goosen JH, van Grinsven S, van Susante JL, van Loon 11. Cofield RH. Comminuted fractures of the proximal humerus. CJ. Hemiarthroplasty for humeral four-part fractures for patients Clin Orthop Relat Res. 1988;230:49–57. 65 years and older: a randomized controlled trial. Clin Orthop 12. Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral Relat Res. 2012;470(12):3483–91. fractures: management techniques and expected results. Clin 26. Stableforth PG. Four-part fractures of the neck of the humerus. Orthop Relat Res. 1993;(292):13–25. J Bone Joint Surg Br. 1984;66(1):104–8. 13. Knight RA, Mayne JA. Comminuted fractures and fracture- 27. Zyto K, Ahrengart L, Sperber A, Törnkvist H. Treatment of dislocations involving the articular surface of the humeral head. displaced proximal humeral fractures in elderly patients. J Bone J Bone Joint Surg Am. 1957;39-A(6):1343–1355. Joint Surg Br. 1997;79(3):412–17.

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