Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery

Abstract

Objectives: To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively. Design: Retrospective multicenter analysis. Setting: Five level-one trauma centers. Patients/Participants: Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C). Intervention: All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation. Main Outcomes: The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. Results: Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery (P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery (P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 (P = 0.0001). Conclusions: In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.