Clinical and radiographic outcomes after surgical treatment of proximal humeral fractures with head-split component

Background Subject of this study is the Head Split Fracture, a rare subgroup of the proximal humeral fractures in which the articular surface is affected by the fracture line. Due to its’ rarity there is only little information available on general outcome and risk factors for eventual treatment failure. Methods This retrospective study follows up 30 out of 45 patients meeting inclusion criteria (67%). The average follow-up time period was 49±18 months [12-83]. The initial treatment was open reduction and internal fixation (ORIF) in 24 patients, reverse total shoulder arthroplasty (RTSA) in 4 and hemiarthroplasty (Hemi) in 2. The follow-up examination included assessment of Range of motion (ROM), Subjective Shoulder Value (SSV), Simple Shoulder Test (SST) and Constant Score (CS) as well as the creation of biplanar radiographs. Presurgical as well as directly postsurgical images were analysed for fracture pattern and quality of reduction, follow-up images for eventual complications and revision surgeries. An attempt was made to associate clinical failure (adjCS <40) with potential preoperative and patient-specific risk factors. Results A radiologically detectable complication occurred in 83% of patients, 21/24 (88%) of which with primary ORIF, 3/4 (75%) with primary RTSA and 1/2 (50%) of which with Hemi. After primary ORIF, avascular head necrosis was the most common (42%), followed by malunion of the lesser tuberosity (33%) and screw protrusion (29%). Complications after arthroplasty were all tuberosity related. Revision surgery was performed in 29% of patients with ORIF and 0% of patients with arthroplasty. Revision to RTSA was done in 4 patients (16.7%), in 3 others (12.5%) screw protrusion made material removal necessary. The overall rate of clinical failures was 50%, 12/24 (50%) after treatment with primary ORIF, 1/4 (25%) after primary RTSA, and 2/2 (100%) after Hemi. There was no observable, significant association between potential risk factors and clinical failure. The clinical outcome scores were the highest in patients with initial ORIF and initial RTSA. A revision surgery was associated with a less satisfying clinical outcome, with a significant difference regarding SSV (p=0.014) and SST (p=0.028) and a trend regarding the adjCS (p=0.069). Conclusion The treatment with ORIF was associated with a high rate of complications and revision. RTSA showed similar clinical outcomes and complication rates. As complication for the latter were mostly tuberosity-related and did not lead to a revision surgery in this collective, RTSA seems to be an adequate treatment for elderly patients with this particular type of fracture.Die Head-Split Fraktur (HSF) ist eine Untergruppe der proximalen Humerusfrakturen, bei der die Frakturlinie die Gelenkoberfläche betrifft. Da es sich um eine seltene Frakturform handelt, gibt es kaum Informationen zu Outcome und Risikofaktoren für ein Therapieversagen. Methodik 30 von 45 Patienten (67%) mit HSF wurden in dieser retrospektiven Studie eingeschlossen. Die Nachsorgeuntersuchung erfolgte im Mittel nach 49±18 Monaten [12-83 Monate]. Die initiale Versorgung erfolgte bei 24 Patienten mit Plattenosteosynthese (ORIF), bei 4 mit inverser Schulterendoprothese (RTSA) und bei 2 mit Hemiendoprothese (Hemi). Erfasst wurden Bewegungsausmaß (ROM), Subjective Shoulder Value (SSV), Simple Shoulder Test (SST) und Constant Score (CS). Röntgenaufnahmen in zwei Ebenen wurden erstellt. Es erfolgte eine Analyse des Frakturmusters, Repositionsergebnisses, eventueller Komplikationen, Revisionseingriffe und klinischen Versagens (angepasster CS