Percutaneous fixation of displaced proximal humeralfractures: Indications based on the correlationbetween clinical and radiographic results

Emilio Calvo, MD,a Ignacio de Miguel, MD,a Juan J. de la Cruz, PhD,b and Nestor Lopez-Martın, MD,a Madrid, Spain

We evaluated 74 patients with displaced proximalhumeral fractures (mean age, 70.9 years) treated withclosed reduction and percutaneous pinning. Fractureswere classified radiographically following Neer’ssystem, and the quality of reduction was assessedaccording to Kristiansen and Kofoed. Patients were alsoevaluated clinically with the Constant scale. Overall, thereduction was good in 72% of fractures, but theprobability of obtaining a satisfactory reduction ofdisplaced tuberosities was significantly lower incomparison to the humeral head. Four-part fracturesobtained the worst radiographic results. The meanConstant scores were 65.8 6 18 points for the injuredshoulder and 79.5 6 9.1 points for the opposite shoulder.Clinical results correlated with the quality of reduction.Closed reduction and percutaneous pinning should bereserved for 2-part fractures, but the technique canalso beused in 3-part fractures in elderly patients, in whom anincomplete reduction can yield satisfactory clinicalresults. (J Shoulder Elbow Surg 2007;16:774–781.)

Displaced fractures may account for 51% of proxi-mal humeral fractures.3 Because conservative man-agement of displaced proximal humeral fracturesoften results in malunion and poor shoulder function,surgical treatment is recommended.16,17,23,26 Closedreduction and percutaneous pinning offer advantagesover open techniques that limit the exposure, minimiz-ing surgical trauma and reducing the risk of necro-sis.11,13,19 However, the procedure is technicallydemanding, and there is controversy as to what de-gree of fracture displacement can be anatomically re-

From the aDepartment of Orthopaedic Surgery and Traumatology,Fundacion Jimenez Dıaz, and bDepartment of Preventive Medi-cine and Public Health, Universidad Autonoma.

Reprint requests: Emilio Calvo, MD, Department of Orthopaedic Sur-gery and Traumatology, Fundacion Jimenez Dıaz, Avda ReyesCatolicos, 2, 28040, Madrid, Spain (E-mail: ecalvo@fjd.es).

Copyright ª 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

1058-2746/2007/$32.00doi:10.1016/j.jse.2007.03.019

774

duced and whether the fragments can be adequatelystabilized with this procedure.10,19,20-22,25 Moreover,a direct correlation between functional result and thequality of reduction of proximal humeral fractureshas not been demonstrated, and the degree of incom-plete anatomic reduction that can be accepted is yet tobe established.1,11

The purpose of this study is to evaluate the degree ofanatomic reduction that can be obtained in displacedproximal humeral fractures treated with closed reduc-tion and percutaneous pinning, as well as to correlatethe reduction achieved with the clinical result to definethe type of fractures that can be satisfactory managedwith this technique.

METHODS

Inclusion and exclusion criteria

Between July 2001 and August 2004, 74 patients withdisplaced fractures of the proximal humerus were treatedacutely by closed reduction and percutaneous pinningwith Kirschner wires at our institution by the same surgeon(E.C.). Fractures were described as displaced if angulationwas greater than 45� or separation between fragmentswas greater than 1 cm. All patients were evaluated preoper-atively and postoperatively with at least 2 perpendicularshoulder radiographic views (anteroposterior and Y alar oraxillary views) to define the fracture type and to assess thequality of reduction achieved. They were also examined clin-ically at a minimum follow-up of 12 months to evaluate thecorrelation between clinical and radiographic outcomes.Radiographic and clinical evaluations were performedby a blinded observer (I.d.M.) to ensure an objective as-sessment.

Exclusion criteria included fractures in patients with openphyses, as well as those who underwent conservative treat-ment, open reduction, or joint arthroplasty. Because clinicalresults in the operated shoulder were compared with the op-posite shoulder, patients diagnosed with any pathologiccondition in the opposite shoulder were also excluded. Allpatients gave informed consent, and our institutional reviewboard approved the study.

Surgical technique

Patients were operated on under general anesthesia, inthe supine position, with the affected shoulder situated

J Shoulder Elbow Surg Calvo et al 775Volume 16, Number 6

away from the operating table. This positioning allowedeasy access to the image intensifier located cranially. Ante-roposterior and axillary views of the proximal end of the hu-merus were easily obtained without interfering with theassistant, who manipulated the fracture to enable reduction.For impacted fractures with an anterior angulation in the cor-onal plane, reduction was performed following a modifica-tion of the technique described by Jaberg et al.11 Theshoulder was abducted to 20� to 40�, maintaining a slightlongitudinal traction. The anterior angulation was correctedby pressuring the anterior aspect of the proximal humeralshaft. In medially translated fractures, a post connected tothe surgical table was used as a fulcrum in the medial sideof the fracture while the arm was in adduction to reducethe displacement of the humeral shaft. A 4-mm awl was intro-duced to reduce percutaneously the displacement of thetuberosities or the humeral head when necessary. Thisprocedure enabled the surgeon to reduce and maintain se-quentially the displaced fragments until they were fixedwith Kirschner wires. A minimum of 3 pins was used. Percu-taneous pin placement options included retrograde lateral,retrograde anterior, retrograde anterolateral, antegradethrough the humeral head, antegrade posterolateral throughthe greater tuberosity, and antegrade superomedial throughthe lesser tuberosity, depending on the fragments displaced.Once the fracture was fixed, the stability of the fragmentswas assessed under fluoroscopy. Postoperatively, the armwas immobilized in a sling for 4 weeks.

Radiographic evaluation

Preoperatively, fractures were classified as 2-, 3-, or 4-part fractures and type II, III, IV, V, or VI injuries accordingto Neer.18 In addition, the presence of metaphyseal commi-nution, valgus impaction of the humeral head, and medialtranslation of the humeral diaphysis was also recordedwhen present to assess their potential effect on the outcomeof surgical treatment. Medial translation was categorizedinto 4 degrees based on the percentage of the diameter ofthe surgical neck of the proximal humerus in the anteroposte-rior view in accordance with the description of Court-Brownet al4 (0%-33%, 34%-66%, 67%-100%, and >100%).

Postoperative radiographic evaluation was done at theend of the first week to ensure that the reduction was main-tained and at 4 weeks to ascertain fracture consolidation.Generally, radiographic union of the fracture was obtainedby this time, so the Kirschner wires were removed with thepatient under local anesthesia on an outpatient basis, anda physical therapy program was started. Rehabilitation con-sisted of pendulum exercises of the shoulder and passive mo-bilization until the sixth postoperative week. Active physicalexercises were progressively instituted at the seventh week.Serial radiographs were obtained at 6, 12, and 24 monthspostoperatively.

The quality of fracture reduction and the degree of resid-ual deformity were evaluated on standard anteroposteriorand Y alar and axillary postoperative radiographs and re-lated to the type of fracture according to Neer.18 The qualityof reduction was defined in accordance with the criteria de-fined by Kristiansen and Kofoed.15 Good reduction was de-fined as correction of positioning to minimal displacementbased on the Neer criteria (1 cm of separation or 45� of an-

gulation).18 If the position of fragments had improved, ob-taining good bony contact, reduction was rated as fair. Ifreduction was impossible and an unchanged or even worseposition resulted, reduction was considered poor. Failure oftreatment was defined as a change in method because ofpoor reduction or redisplacement. To quantify the degreeof residual deformity, the number of defects (angulationand displacement) in the reduction achieved was computed.For that purpose, we used a numeric scale in which each de-fect (angulation and displacement) was scored as 1 point iflower than 45� of angulation or 1 cm of displacement and as2 points if greater than these values. If the angulation anddisplacement were lower than 20� and 0.5 cm, respectively,the quality of reduction was considered excellent and scoredas 0 points. Because the number of reduction defects wassummed, the higher the score based on this scale, the poorerthe reduction achieved. As all of the displaced fragments ofthe fracture (head and tuberosities) were scored, the score ineach case ranged from a minimum of 0 (in perfectly reducedfractures) to 12 points (in 4-part fractures with maximum dis-placement of the head and both tuberosities).

Besides the quality of reduction, the probability of obtain-ing a satisfactory reduction of the fracture depending onthe anatomic fragments specifically displaced was alsoassessed. To estimate this probability, the fragments displacedin the preoperative radiographic study (humeral head,greater tuberosity, or lesser tuberosity) were compared withthe individual score corresponding to each specific fragmentin the number of reduction defects evaluated postoperatively.In addition, the presence of metaphyseal comminution orvalgus impaction and the degree of medial translation inthe preoperative study were also compared with the postop-erative radiographic result.

Postoperative radiographs also assessed the presence ofpin migration, fracture redisplacement, nonunion, mal-union, or avascular necrosis. Nonunion was defined as theabsence of consolidation 3 months after surgery. If the frac-ture showed a displacement of any fragment over 1 cm or45�, it was considered malunited. Avascular necrosis wasdetermined to be present if there was destruction of the tra-becular architecture, loss of bony substance in the articularsegment, the presence of diffuse sclerotic areas in the subar-ticular region, or deformation of the articular surface. Bonestructure was compared with either the contralateral radio-graph or the neck of the ipsilateral scapula.19

Clinical evaluation

Clinical evaluation of the results was done in accordancewith the Constant score at a minimum of 1 year postopera-tively.2 Because handedness does not affect gross functionof the shoulder, these measurements were expressed as theraw score and as a ratio (represented as a percentage) ofthe normal, opposite side.7 The clinical result was relatedto the severity of fracture according to Neer,18 to the qualityof reduction in accordance with Kristiansen and Kofoed,15

and to the degree of residual deformity assessed on theradiographs taken at each review.

Statistical analysis

The c2 test was used to compare proportions (with theFisher test when necessary), and the Student t test and

776 Calvo et al J Shoulder Elbow SurgNovember/December 2007

Table I Distribution of fractures and quality of reduction achieved

Quality of reductiony

Fracture type* Good Fair Poor Failure Totalz

Group IITwo-part anatomic neck 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Group IIITwo-part surgical neck 22 (81.5%) 3 (11.1%) 1 (3.7%) 1 (3.7%) 27 (54%)

Group IVTwo-part greater tuberosity 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Three-part greater tuberosity 13 (81.3%) 3 (18.8%) 0 (0%) 0 (0%) 16 (32%)

Group VTwo-part lesser tuberosity 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Three-part lesser tuberosity 1 (100%) 0 (0%) 0 (0%) 0 (0%) 1 (2%)

Groups IV and VFour-part fracture 0 (0%) 4 (80.0%) 0 (0%) 1 (20.0%) 5 (10%)

Group VITwo-part fracture-dislocation 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Three-part fracture-dislocation 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Four-part fracture-dislocation 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)Head-splitting fracture 0 (0%) 0 (0%) 0 (0%) 1 (100%) 1 (2%)

*Fracture types are grouped according to Neer.18

yThe quality of reduction is based on the criteria of Kristiansen and Kofoed.15 Data are expressed as absolute value and percent of patients in each group.zData are expressed as absolute value and percent of patients with each fracture type in the global series.

analysis of variance were used to compare means if the vari-ables adjusted to a Gaussian distribution. Means were com-pared by use of Mann-Whitney U or Kruskal-Wallis tests ifdata did not follow a normal distribution. The association be-tween outcome and prognostic factors was tested via Pear-son correlation. Differences with a 2-tailed P < .05 wereconsidered significant. Analyses were performed with theSPSS statistical software system (version 11.0; SPSS,Chicago, IL).

RESULTS

We enrolled 74 patients in the study, but 23 were ex-cluded. Fifteen patients were too frail to attend the out-patient clinic for follow-up or had died from causesunrelated to the fracture, and eight were not evaluatedbecause of insufficient follow-up. Because the clinicalresult was expressed as a ratio between the operatedshoulder and the contralateral shoulder, 1 additionalpatient diagnosed with rotator cuff arthropathy in theopposite side had to be excluded. Of the 50 patients fi-nally studied, 46 were women and 4 were men. Themean age was 70.9 6 10.8 years (range, 45-89years). The left humerus was affected in 25 patientsand the right in 25. In most cases, the fracture was pro-duced by a simple fall. In 6 cases, it was the result ofa high-energy trauma, usually a motor vehicle accident.

Radiographic evaluation

Table I shows the distribution of fracture patternsof the series analyzed and the quality of reduction

achieved in each fracture group. The overall qualityof reduction was good in 36 patients (72%), fair in10 (20%), and poor in 1 (2%) (Figure 1). Additionalsurgical treatment was required for 3 fractures (6%)because of poor reduction or redisplacement, andthese were considered failures.

The mean score for residual deformity was 2.16 61.8 points (range, 0-8 points) when all of the reductiondefects were considered. Table II shows the degreeof residual deformity together with the fracture typeaccording to Neer.18

Statistical analysis demonstrated that the number offragments displaced in the fracture showed a trend to-ward correlating inversely with the quality of reduction(ie, the higher the number of fragments, the worse thequality of reduction) (P ¼ .081), as well as that thisnumber showed a statistically significantly direct cor-relation with the residual deformity (ie, the higher thenumber of fragments, the higher the residual defor-mity) (P<.001). This means that the higher the severityof the fracture, the worse the quality of reduction andthe higher the residual deformity after surgical treat-ment. However, analysis of the postoperative radio-graphic study showed interesting differences whenthe fragments displaced preoperatively (humeralhead, greater tuberosity, or lesser tuberosity) werestudied individually (Table III). The score representingthe residual deformity due to postoperative malposi-tioning of the humeral head was significantly lowerthan the number of reduction defects due to poor re-duction of the lesser (P < .02) or greater (P < .001)

J Shoulder Elbow Surg Calvo et al 777Volume 16, Number 6

Figure 1 A, Preoperative anteroposterior view of a 2-part valgus-impacted medially translated proximal humeralfracture. B, The postoperative radiograph shows that the quality of reduction is good without residual deformity(score of 0).

tuberosities. This implies that the probability of obtain-ing a satisfactory reduction with this technique is sig-nificantly superior for fractures in which the humeralhead is displaced than for fractures with displacementof the tuberosities (Figure 2).

Assessment of the initial radiographs indicated that17 fractures (34%) showed metaphyseal comminutionand that the humeral head was impacted in valgus in 5cases (10%). In 20 patients (40%), the humeral diaph-ysis was translated medially. The overall degree of me-dial translation, according to Court-Brown et al,4 waslower than 34% in 8 patients (16%), 34% to 66% in 7(14%), 67% to 100% in 2 (4%), and greater than100% in 3 (6%). The presence of any of these condi-tions did not have any significant effect on the qualityof reduction or on the residual deformity.

Clinical evaluation

The mean Constant score in the operated shoulderafter a mean follow-up of 13.6 months (range, 12-26months) was 65.8 6 18 points, whereas the meanscore in the opposite, healthy shoulder was 79.5 6

9.1 points. Therefore, the mean ratio of the operatedshoulder to the opposite shoulder was 82.3 6 19.3.

Table IV shows the clinical results based on the Con-stant score together with the cases allocated to groupscorresponding to the number of fractured parts in ac-cordance with the Neer classification.18 Statisticalanalysis showed a highly significant correlation be-tween the quality of the reduction obtained accordingto Kristiansen and Kofoed15 and the clinical resultmeasured as a ratio of the operated shoulder to thecontralateral shoulder (P < .001) (Figure 3). Therewas also an inverse correlation between the degreeof residual deformity and the clinical outcome(P < .05) (Figure 4). Finally, there was a trend towardan association between the type of fracture and theclinical result (P ¼ .69).

Complications

The most common complication was migration of atleast 1 Kirschner wire, which occurred in 18 cases(36%). However, pin migration resulted in loss of re-duction of the fracture in 5 patients (10%) and was

778 Calvo et al J Shoulder Elbow SurgNovember/December 2007

severe enough that revision surgery was considered in2 patients. Repeated closed reduction and percutane-ous pinning yielding a final satisfactory result wereperformed in 1 patient, and the other underwent hemi-arthroplasty. Nonunion developed in 1 shoulder witha fracture of the surgical neck. Two patients had super-ficial pin tract infections that resolved after the removalof the implant. Radiographic signs of avascular necro-sis were found in 4 patients (8%) with multifragmen-tary or complex fractures. This usually consisted ofcyst formation and sclerosis of the humeral head,with collapse of the humeral head being more infre-quent. Criteria for malunion were met in at least 1 ofthe displaced fragments in 14 patients (28%). How-

Table II Distribution of fractures and score of residual deformity aftersurgical treatment

Fracture type* Scorey

Group III: Two-part surgical neck 1.6 6 1.2Group IV: Three-part greater tuberosity 2 6 1.5Group V: Three-part lesser tuberosity 2 6 0Groups IV and V: Four-part fracture 4.4 6 2.5Group VI: Head-splitting fracture 6 6 0

*Fracture types are grouped according to Neer.18

yTo score the residual deformity, angulation and displacement were consid-ered independently, and each fragment (humeral head, greater tuberosity,and lesser tuberosity) was scored individually. The final score for each casewas the sum of the scores allocated to each fragment. An angulation between20� and 45� was scored as 1 point and greater than 45� was scored as 2points. A displacement between 0.5 and 1 cm was scored as 1 point andgreater than 1 cm was scored as 2 points. If the angulation and displacementwere lower than 20� and 0.5 cm, respectively, the quality of reductionwas considered excellent and scored as 0 points. Data are expressed asmean 6 SD.

Table III Residual deformity after surgical treatment related to specificfragment displaced

Fragment displaced No. of cases* Scorey

Humeral head 50 (100%) 1.2 6 1.1Greater tuberosity 7 (14%) 1.6 6 1.4Lesser tuberosity 23 (46%) 1.4 6 1

*Number of cases represents all of the shoulders with preoperative displace-ment or angulation of each fragment. Data are expressed as absolute valueand percent.yScore of residual deformity after surgical treatment corresponding to eachfragment. Angulation and displacement were considered independently,and each fragment (humeral head, greater tuberosity, and lesser tuberosity)was scored individually. The final score for each case was the sum of thescores allocated to each fragment. An angulation between 20� and 45�

was scored as 1 point and greater than 45� was scored as 2 points. A dis-placement between 0.5 and 1 cm was scored as 1 point and greater than1 cm was scored as 2 points. If the angulation and displacement were lowerthan 20� and 0.5 cm, respectively, the quality of reduction was consideredexcellent and scored as 0 points. Data are expressed as mean 6 SD.

ever, this complication was usually well toleratedfrom a clinical point of view, and no further surgerywas necessary.

DISCUSSION

Open reduction–internal fixation is usually recom-mended in displaced 2- and 3-part proximal humeralfractures, whereas hemiarthroplasty is commonly ac-cepted for the management of 4-part fractures andcomplex fracture-dislocations.17,18 However, the levelof evidence supporting these guidelines is poor, andthe treatment of displaced proximal humeral fracturesremains controversial.8,16 In 2- and 3-part fractures,there is good evidence that the anatomy is betterrestored with reduction and fixation, as well as thatbetter pain relief and functional range of motion areachieved, when compared with conservative treat-ment, but studies have failed to establish a correlationbetween the degree of anatomic restoration andthe functional outcome.1,11,16,17,19,23,26 Regarding4-part fractures, hemiarthroplasty is recommendedbased on the risk of avascular necrosis, but thefunctional results of this procedure are not universallysatisfactory.9,24

Closed reduction with percutaneous fixation of dis-placed proximal humeral fractures constitutes a mini-mally invasive technique that offers the advantagesof reduced surgical trauma, which is important inthese fractures that more commonly affect elderly pa-tients, and limits soft-tissue dissection, preserving theblood supply to the humeral head.11,13,19 However,it seems reasonable to assume that the probability ofreconstructing the humerus anatomically might belower with this technique than with open reduction.Several authors have stated that this limitation doesnot constitute a major drawback because satisfactoryfunctional results can be achieved without full re-estab-lishment of anatomic congruity.1,11,16,17,19,23,26 Thegood overall clinical results of our series confirm thatdisplaced proximal humeral fractures can be ade-quately managed with closed reduction and percuta-neous fixation, and these clinical findings comparefavorably with those reported in the literature.11,21,22

Only Resch et al19 reported better Constant scores ina population significantly younger than ours.

Despite the satisfactory results achieved, it is evi-dent in this study that clinical results correlate withthe quality of reduction obtained. Thus, it is necessaryto define in which fractures the reduction that can beobtained is good enough to furnish a satisfactory clin-ical outcome. According to our results, a satisfactoryradiographic and clinical result can be reproduciblyachieved with closed reduction and percutaneouspinning in 2-part fractures. These findings coincidewith those reported by other authors, but the main

J Shoulder Elbow Surg Calvo et al 779Volume 16, Number 6

Figure 2 A, Three-part valgus-impacted proximal humeral fracture. B, Apparently good reduction was obtained inthe postoperative anteroposterior radiographic view. C, The axillary view demonstrates poor reduction due to dis-placement of the greater tuberosity (score of 2). The reduction obtained in the humeral head fragment is excellent.

controversy resides in 3-part fractures. Whereas somehave reported good clinical results after treatment of 3-part fractures with closed reduction and percutaneousfixation,19,22 others recommend that these fracturesbe more reliably managed with open reduction orhemiarthroplasty.10,21,25 According to our radio-graphic data, we do not recommend closed reductionand percutaneous pinning in 3-part fractures becauseof difficulties in managing excessive displacement ofthe tuberosities. The importance of achieving a satis-factory reduction of the greater tuberosity has been

pointed out in the literature, especially in young pa-tients.6 However, our series was mainly composed ofelderly patients with low physical demands, in whomthis technique yielded satisfactory results from a clini-cal point of view despite an incomplete reduction ofthe greater tuberosity. For this reason, we considerthat closed reduction and percutaneous fixation mayconstitute a valid alternative for 3-part fractures in el-derly patients whereas young patients should be man-aged with open reduction. Regarding 4-part fracturesand head-splitting fractures, percutaneous fixation is

780 Calvo et al J Shoulder Elbow SurgNovember/December 2007

Table IV Distribution of fractures, quality of reduction, and Constant score after surgical treatment in prospective group

Quality of reductiony

Fracture type* Good Fair Poor Failure Total Constant score Constant ratioz

Two part-fracture 22 (81.5%) 3 (11.1%) 1 (3.7%) 1 (3.7%) 27 (54%) 68.1 6 6.1 81.6 6 20.7Three part-fracture 14 (82.4%) 3 (17.6%) 0 (0%) 0 (0%) 17 (34%) 74.1 6 10.6 88.6 6 10.6Four-part and head-splitting fracture 1 (16.7%) 4 (66.7%) 0 (0%) 1 (16.7%) 6 (12%) 68.0 6 3.5 67.6 6 26.2Constant score 70.1 6 15.5 61.2 6 14.2 35.0 6 0 23.5 6 4.9 65.8 6 2.5Constant ratio 87.3 6 14.9 77.9 6 16.3 41.7 6 0 31.6 6 0.2 82.3 6 19.3

*Fracture types are grouped based on number of fragments according to Neer.18

yThe quality of reduction is based on the criteria of Kristiansen and Kofoed.15 Data for fracture type and quality of reduction are expressed as absolute value andpercent of patients in each group.zConstant ratio is expressed as percent of the opposite shoulder. Data for Constant score and Constant ratio are shown as mean 6 SD.

not recommended because of its high failure rate, andother alternatives should be considered.

One major drawback of closed reduction and per-cutaneous pinning in proximal humeral fractures isthe possibility of migration of the Kirschner wires,with the inherent risk of fracture redisplacement.14

Because the probability of pin migration is higher inosteoporotic bone, some authors have designeddevices aimed to lock the pins,20 whereas othersadvocate open reduction and internal fixation withmore rigid implants.10,13,21 Most of the patients inour series had osteoporosis, and although the numberof fractures with pin migration was high, only in a com-paratively small number did migration result in a lossof reduction. Therefore, osteoporosis does not seem

Figure 3 Statistical analysis showed a highly significant correlationbetween the quality of the reduction and the clinical result (P<.001).The x-axis shows the reduction obtained according to Kristiansenand Kofoed,15 and the y-axis shows the clinical result measuredas a ratio of the operated shoulder to the contralateral shoulder.

to constitute a contraindication for this procedure,but it is advisable to monitor these patients closely todetect pin failure before fracture displacement occurs.

It has been suggested that fractures with metaphy-seal comminution carry a higher risk of pin migrationand loss of reduction.11,20 Because we could not es-tablish any effect of this variable on the radiologic orclinical results of our patients, we do not think that itshould be considered a less favorable indication forclosed reduction and percutaneous pinning.

The presence of medial translation may render dif-ficulties for the closed reduction of the fracture be-cause the fulcrum effect of the medial periosteum that

Figure 4 Graph showing prediction of clinical result score basedon residual deformity after closed reduction and percutaneous pin-ning. There is an inverse correlation between the degree of residualdeformity and the functional result measured as a ratio of the oper-ated shoulder to the contralateral shoulder. The x-axis shows thescore representing the residual deformity, and the y-axis showsthe clinical result measured as a ratio of the operated shoulder tothe contralateral shoulder.

J Shoulder Elbow Surg Calvo et al 781Volume 16, Number 6

is frequently used to reduce the fracture is lost.12,19 Forthis reason, Resch et al20 recommend that those pa-tients who have severe medial translation should bemore appropriately treated by open reduction and in-ternal fixation. Court-Brown et al4 described thesefractures and stated that they account for 12.7% ofall proximal humeral fractures, and our series confirmsthat medial translation may be present at some degreein 40% of displaced proximal humeral fractures. Wedeveloped a technique especially oriented at reduc-ing these difficult fractures with satisfactory results,and we did not find any deleterious effect of medialtranslation in the reduction achieved or in the clinicalresults.

Regarding other problems, the rate of complica-tions associated with closed reduction and percutane-ous pinning of proximal humeral fractures in this studywas low. The infection rate was lower than 5%, in ac-cordance with the more recently published series,5,22

and usually resolved after pin removal. The rate ofavascular necrosis was also in accordance with otherinvestigations, in which percentages ranging between0% and 26% have been documented,10,12,19 andusually consisted of cyst formation and sclerosis ofthe humeral head, which were well tolerated froma functional point of view. On the other hand, the inci-dence of malunion in this series was high because cri-teria to define malunion were very strict and based onthe score allocated for residual deformity.

In conclusion, the technique of closed reductionand percutaneous fixation is regarded as a reasonablealternative treatment for displaced proximal humeralfractures. Because the clinical result depends on thequality of the reduction obtained, it is important tocarefully select those fractures in which an adequatereduction can be achieved. Despite the procedure be-ing technically demanding, satisfactory reduction andsufficient fixation can be accomplished in 2-partfractures. Although the probability of obtaining ananatomic reduction in 3-part fractures is significantlylower because of difficulties in managing tuberositydisplacement, the technique can also be used in el-derly patients, in whom an incomplete reduction canyield satisfactory clinical results. Ineligibility criteria in-clude 4-part fractures, head-splitting fractures, andfracture-dislocations.

REFERENCES

1. Chen CY, Chao EK, Tu YK, Ueng SWE, Shih CH. Closed man-agement and percutaneous fixation of unstable proximal humerusfractures. J Trauma 1998;45:1039-45.

2. Constant CR, Murley AHG. A clinical method of functional assess-ment of the shoulder. Clin Orthop Relat Res 1987:160-4.

3. Court-Brown CM, Garg A, McQueen MM. The epidemiology ofproximal humeral fractures. Acta Orthop Scand 2001;72:365-71.

4. Court-Brown CM, Garg A, McQueen MM. The translated twopart proximal humeral fracture. Epidemiology and outcome inthe older patient. J Bone Joint Surg Br 2001;83:799-804.

5. De la Hoz Marın, Hernandez Cortes P, Tercedor Sanchez J.Surgical treatment of three-part proximal humeral fractures. ActaOrthop Belg 2001;67:226-32.

6. Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ,Bigliani LU. Open reduction and internal fixation of two-part dis-placed fractures of the greater tuberosity of the proximal part ofthe humerus. J Bone Joint Surg Am 1992;73:1213-8.

7. Gallagher MA, Zuckerman JD, Cuomo F, Ortiz J. The effect of age,speed and arm dominance on shoulder function in untrained men.J Shoulder Elbow Surg 1996;5:25-31.

8. Gibson JNA, Handoll HHG, Madhok R. Interventions for treatingproximal humeral fractures in adults. Cochrane Database SystRev 2003:CD000434.

9. Hawkins RJ, Switlyk P. Acute prosthetic replacement for severefractures of the proximal humerus. Clin Orthop Relat Res1993:150-60.

10. Herscovici D, Saunders DT, Johnson MP, Sanders R, Di Pasquale T.Percutaneous fixation of proximal humeral fractures. Clin OrthopRelat Res 2000:97-104.

11. Jaberg H, Warner JJP, Jakob RP. Percutaneous stabilization of un-stable fractures of the humerus. J Bone Joint Surg Am 1992;74:508-14.

12. Jackob RP, Miniaci A, Anson P, Jaberg H, Osterwalder A, Ganz R.Four-part valgus impacted fractures of the proximal humerus. J BoneJoint Surg Br 1991;73:295-8.

13. Kocialowski A, Wallace WA. Closed percutaneous K-wire stabi-lization for displaced fractures of the surgical neck of the humerus.Injury 1990;21:209-12.

14. Koval KJ, Blair B, Takei R, Kummer FJ, Zuckerman JD. Surgical neckfractures of the proximal humerus: a laboratory evaluation of tenfixation techniques. J Trauma 1996;40:778-83.

15. Kristiansen B, Kofoed H. Transcutaneous reduction and externalfixation of displaced fractures of the proximal humerus. J Bone JointSurg Br 1988;70:821-4.

16. Misra A, Kapur R, Maffulli N. Complex proximal humeral fracturesin adults—a systematic review of management. Injury2001;363-72.

17. Neer CS II. Displaced proximal humeral fractures. Part II. Treat-ment of three-part and four-part displacement. J Bone Joint SurgAm 1970;52:1090-103.

18. Neer CS II. Displaced proximal humeral fractures. Part I. Classifi-cation and evaluation. J Bone Joint Surg Am 1970;52:1077-89.

19. Resch H, Povacz P, Frohlich R, Wambacher M. Percutaneous fix-ation of three- and four-part fractures of the proximal humerus.J Bone Joint Surg Br 1997;79:295-300.

20. Resch H, Hubner C, Schwaiger R. Minimally invasive reductionand osteosynthesis of articular fractures of the humeral head. Injury2001;32(Suppl 1):SA25-32.

21. Sanz Reig J, Bendala Tufanisco C, Lizaur Utrilla A, CebrianGomez R. El enclavado percutaneo en el tratamiento de las frac-turas desplazadas en dos y tres fragmentos de la extremidad prox-imal del humero. Rev Ortop Traumatol 2003;47:26-30.

22. Soete PJ, Clayson PE, Costenoble VH. Transitory percutaneous pin-ning in fractures of the proximal humerus. J Shoulder Elbow Surg1999;8:569-73.

23. Stableforth PG. Four-part fractures of the neck of the humerus.J Bone Joint Surg Br 1984;66:104-8.

24. Willems WJ, Lim TEA. Neer arthroplasty for humeral fracture. ActaOrthop Scand 1985;56:394-5.

25. Williams GR, Wong KL. Management of proximal and distal hu-merus fractures. Two-part and three-part fractures. Open reductionand internal fixation versus closed reduction and percutaneouspinning. Orthop Clin North Am 2000;31:1-21.

26. Young TB, Wallace WA. Conservative treatment of fractures andfracture-dislocations of the upper end of the humerus. J Bone JointSurg Br 1985;67:373-7.