[4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment].

The operative treatment of dislocated fractures of the proximal humerus has been evolving in recent years. Replacement using endoprostheses often results in only moderate functional outcome, and with the high risk of aseptic necrosis with ORIF, new methods of minimally invasive stabilisation have been developed. These methods reduce the opening of the fracture site to a minimum and thereby limit the risk of iatrogenic damage to local vascularity and the rotator cuff. This study reviewed 18 patients operated on with minimal osteosynthesis for dislocated four-part fractures of the proximal humerus from March 1991 to October 1994. Only tension band wiring with resorbable cords from woven polydioxanone was applied. After an average follow-up of 26 months (20-37 months), 72% (n = 13) of the four-part fractures were rated as good and very good results according to the Neer Score. In 16.7%, a complete head necrosis occurred, requiring a prosthetic replacement. Two patients with partial necrosis (11.1%) had a good functional outcome. With regard to these results, we recommend head-preserving tension band wiring with resorbable cords and preservation of the articular surface. At the present time the procedure seems comparable with prosthetic replacement in respect of shoulder function.