Long-term Results, Functional Outcomes and Complications after Open Reduction and Internal Fixation of Neglected and Displaced Greater Tuberosity of Humerus Fractures



1 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran

2 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

3 Iran University of Medical Scirences, Tehran, Iran


Background: Humerus fractures include 5% to 8% of total fractures. Non-union and delayed union of GT (GT) fractures is uncommon; however they present a challenge to the orthopedic surgeons. Significant controversy surrounds optimal treatment of neglected fractures. The purpose of this article was to perform a comparative study to evaluate the outcomes
of open reduction and internal fixation (ORIF) of neglected GT fractures.
We retrospectively evaluated the results of surgical intervention in 12 patients with displaced nonunion of GT fractures who were referred to our center. Before and minimally 25 months after surgery ROM, muscle forces, Constant Shoulder Score (Constant-Murley score) (CSS), Visual Analogue Scale (VAS), Activities of Daily Living (ADL) Score and American Shoulder and Elbow Surgeons (ASES) Score were all recorded. Additionally, the results were compared with undamaged shoulder.
Between March 2006 and January 2013, 12 patients underwent surgical intervention and followed for 36.2 months in average. All fractures healed. Anatomic reduction achieved only in 6 cases with no report of avascular necrosis or infection. All ROMs and muscle forces increased significantly (Mean Forward Flexion: 49.16 to 153.3, Mean Internal Rotation: 3 to 9, Mean External Rotation: -5 to 27.5) (P value<0.0001). All functional scores including CSS, VAS, ADL and ASES score improved significantly (Mean VAS: 6.5 to 1.3, Mean CSS: 29.83 to 86, Mean ADL: 6.6 to 27.1, Mean ASES: 28.6 to 88.9) (P value<0.0001).
ORIF for neglected and displaced GT fractures has satisfactory functional outcomes, despite of non-anatomical reduction of the fracture.


Main Subjects

1. Baron JA, Barrett JA, Karagas MR. The epidemiology
of peripheral fractures. Bone. 1996; 18(3
2. Baron JA, Karagas M, Barrett J, Kniffin W, Malenka
D, Mayor M, et al. Basic epidemiology of fractures of
the upper and lower limb among Americans over 65
years of age. Epidemiology. 1996; 7(6):612-8.
3. Gerber C. Reconstructive surgery following malunion
of fractures of the proximal humerus in adults.
Orthopade. 1990; 19(6):316-23.
4. Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional
outcomes of reverse shoulder arthroplasty compared
with hemiarthroplasty for acute proximal humeral
fractures. J Shoulder Elbow Surg. 2013; 22(1):32–7.
5. Carbone S, Tangari M, Gumina S, Postacchini R, Campi
A, Postacchini F. Percutaneous pinning of three- or

four-part fractures of the proximal humerus in elderly
patients in poor general condition: MIROS® versus
traditional pinning. Int Orthop. 2012; 36(6):1267–73.
6. Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S.
Predictive factors for functional outcome and failure
in angular stable osteosynthesis of the proximal
humerus. Injury. 2012; 43(2):153–8.
7. Muncibì􀆰 F, Paez DC, Matassi F, Carulli C, Nistri L,
Innocenti M. Long term results of percutaneous
fixation of proximal humerus fractures. Indian J
Orthop. 2012; 46(6):664–7.
8. Lu Y, Jiang C, Zhu Y, Wang M, Bowles RJ, Mauffrey
C. Delayed ORIF of proximal humerus fractures at
a minimum of 3 weeks from injury: a functional
outcome study. Eur J Orthop Surg Traumatol. 2014;
9. Siegel JA, Dines DM. Proximal humerus malunions.
Orthop Clin North Am. 2000; 31(1):35–50.
10. Healy WL, Jupiter JB, Kristiansen TK, White RR.
Nonunion of the proximal humerus. A review of 25
cases. J Orthop Trauma. 1990; 4(4):424–31.
11. Scheck M. Surgical treatment of nonunions of the
surgical neck of the humerus. Clin Orthop Relat Res.
1982; 167(1):255–9.
12. Court-Brown CM, McQueen MM. Nonunions of the
proximal humerus: their prevalence and functional
outcome. J Trauma. 2008; 64(6):1517–21.
13. Dines DM, Warren RF, Altchek DW, Moeckel B.
Posttraumatic changes of the proximal humerus:
Malunion, nonunion, and osteonecrosis. Treatment with
modular hemiarthroplasty or total shoulder arthroplasty.
J Shoulder Elbow Surg. 1993; 2(1):11–21.
14. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani
C. Proximal humerus fracture sequelae: impact of a
new radiographic classification on arthroplasty. Clin
Orthop Relat Res. 2006; 442(2):121–30.
15. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole
D. Tuberosity malposition and migration: reasons for
poor outcomes after hemiarthroplasty for displaced
fractures of the proximal humerus. J Shoulder Elbow
Surg. 2002; 11(5):401–12.
16. Antuña SA, Sperling JW, Sánchez-Sotelo J, Cofield RH.
Shoulder arthroplasty for proximal humeral nonunions. J
Shoulder Elbow Surg. 2002; 11(2):114–21.
17. Pinkas D, Wanich TS, DePalma AA, Gruson KI. Management
of mal-union of the proximal humerus: current concepts.
J Am Acad Orthop Surg. 2014; 22(8):491-502.
18. Duralde XA, Leddy LR. The results of ORIF of displaced
unstable proximal humeral fractures using a locking
plate. J Shoulder Elbow Surg. 2010; 19(4):480-8.
19. Constant CR, Murley AH. A clinical method of
functional assessment of the shoulder. Clin Orthop
Relat Res. 1987; 214(4):160–4.
20. 20) Richards RR, An KN, Bigliani LU, Friedman RJ,
Gartsman GM, Gristina AG, et al. A standardized
method for the assessment of shoulder function. J
Shoulder Elbow Surg. 1994; 3(6):347–52.
21. Paavolainen P, Bjorkenheim JM, Slatis P, Paukku P.
Operative treatment of severe proximal humeral
fracture. Acta Orthop Scand. 1983; 54(3):374-9.
22. Garg A, McQueen MM. Nerve injury after greater
tuberosity fracture dislocation. J Orthopaed Trauma.
2000; 14(2):117-8.
23. Martin TG, Iannotti JP. Reverse total shoulder
arthroplasty for acute fractures and failed
management after proximal humeral fractures.
Orthop Clin North Am. 2008; 39(4):451–7.
24. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR.
Operative treatment of malunion of a fracture of the
proximal aspect of the humerus. J Bone Joint Surg Am.
1998; 80(10):1484–97.