Shoulder & Elbow.

ISSN 1758-5732

S RESEARCH ARTICLE

Suture fixation of displaced two, three and four part proximal

humeral fractures
Daniel Parfitt, Gordon Gillespie, Mark Lewis, Paul Roberts & Rohit Kulkarni
Royal Gwent Hospital, Gwent Healthcare NHS Trust, Newport, South Wales, UK

ABSTRACT
Received We present a case series study of 50 patients who sustained two, three and four part displaced proximal
Submitted 14 March 2009;
humerus fractures treated by open reduction and suture fixation. All patients presenting to our department
revised 5 April 2009, 6 April 2009,
9 April 2009; with these fractures were included in the study except for those with undisplaced fractures, head splitting
accepted 9 April 2009 fractures, isolated greater tuberosity fractures and those aged over 60 years of age with a four part fracture.
Keywords Patients were followed up for an average of 13 months from surgery. They were assessed clinically and
proximal humerus fracture, suture fixation radiologically. Clinical assessment consisted of Constant scoring, abduction measurement and patient
Conflicts of interest satisfaction.
None declared
The average Constant score at last follow-up was 80. Overall patient satisfaction was high. Radiological
Correspondence union was achieved on average in less than 3 months.
Daniel Parfitt, Specialist Registrar, Royal Gwent
Hospital, Gwent Healthcare NHS Trust, We conclude that suture fixation for this group of fractures is a highly effective treatment option.
Newport, South Wales, UK.
E-mail: dan.parfitt@btinternet.com
DOI:10.1111/j.1758-5740.2009.00012.x

INTRODUCTION Hawkins [8] described a method of fixation of these fractures

Fractures of the proximal humerus are common and represent
around 5% of all fractures seen in A& E departments. Approximately
half of all shoulder injuries presenting to hospital are fractures of
the proximal humerus [1]. Most of these fractures are minimally
displaced two-part fractures. However 15% of patients suffer
displaced three and four part fractures. The majority of the patients
who sustain these injuries are elderly with osteoporotic bone which
can compromise the methods of treatment [2].
Two and three part fractures which are undisplaced or
valgus impacted have been found to heal consistently with
conservative management with a collar-and-cuff sling followed
by a gradual return to mobility under physiotherapist supervision.
This treatment gives reasonable function and good Constant scores
at 1 year [2]. Early mobilization under supervision has been shown
to be beneficial for all fracture groups [3].
There is still much debate over the best method for treating
displaced two, three and four part fractures. If displaced fractures
are conservatively managed they usually unite, but in the
long-term tend to have a high degree of morbidity and poor
function. Persisting pain and stiffness are common, secondary to
avascular necrosis of the humeral head (AVN), malunion or non-
union. Displaced four part fractures are generally treated with
hemiarthoplasty [4] especially in older patients. However results
are often suboptimal [5,6]. In theory good reduction and adequate
fixation should allow early active movement and minimize the risk
of developing AVN. However this can still develop despite or even
because of surgical fixation [7].
which usesthesoft-tissuestructuresaswellasboneforstabilization.
This allows less disruption of the soft-tissue attachments with
the aim of preserving the fracture fragment vascularity. This
method involves two figure-of-eight tension-band wires being
passed through the fracture fragments, including the tendon of
subscapularis, in order to reduce the risk of cut-out. We used a
modified version of Hawkins’ technique in this study.
MATERIALS AND METHODS
Fifty patients with displaced two, three and four-part fractures
were treated at our department between 2002 and 2005. Fifteen
patients had two part fractures, 26 had three part fractures
and 9 had four part fractures. All patients had antero-posterior
axillary and trans-scapular plain radiographs and CT scans prior to
operative treatment to define the fracture pattern. Patients who
had undisplaced fractures, isolated greater tuberosity fractures
and head-splitting fractures were excluded from the study, as were
patients with four part fractures who were over 60 years of age.
Operative technique
Patientswerepositionedin thebeach-chairposition,andastandard
delto-pectoral approach was used. Care was taken to preserve soft-
tissue attachments by avoiding stripping the fracture fragments to
protect their vasculature.
The operative technique is demonstrated in Figs. 1–5. The
biceps tendon and bicipital groove were identified and two pairs

© 2009 The Author(s)

Journal Compilation © 2009 British Elbow and Shoulder Society. Shoulder & Elbow 2009 1, pp 35–39 35
 S Suture fixation of displaced two, three and four part proximal humeral fractures Parfitt et al.
of drill-holes were made either side of the bicipital groove in the Biceps tendon
shaft fragment close to the fracture.
Two no. 5 non-absorbable sutures were passed through the drill
holes.
A third pair of drill-holes were made on the proximal part of Subscapularis
the lateral humeral shaft and a third no. 5 suture was passed
through them. The fracture was reduced and the shaft fragment
was impacted into the head fragment.
A Verres’ needle was passed through the head fragment
from lateral to medial. It entered through the greater tuberosity
and exited through the subscapularis tendon. A wire loop was Pair of drill holes
introduced through the Verres needle and was used to pull one
of the sutures back through the head fragment. This process was
Fig. 1 Drill holes either side of biceps tendon at the bicipital groove.
repeated to pass the second suture through the head fragment.
The two sutures formed a ‘figure-of-eight’ over the anterior part of
Biceps tendon
the fracture site.
The third lateral suture was passed through the greater
tuberosity and distal supraspinatus tendon forming a lateral Subscapularis
‘figure-of-eight’ tension band.
The sutures were tightened and tied sequentially. Artificial bone
graft was used to fill bony defects where required. Patients with
two part fractures treated early in the series only received two Passed sutures
sutures, excluding the third lateral suture. It became clear early
on that a third suture provided a more stable fixation and was
adopted for all subsequent patients.
All patients had the same regimen of post-operative
physiotherapy, consisting of 2 weeks of pendulum exercises,
2 weeks of passive assisted mobilization followed by active Fig. 2 Sutures passed through the drill holes.
mobilization under the supervision of a specialist upper-limb
physiotherapist.
All patients had post-operative plain antero-posterior and trans-
scapular radiographs. When possible, axial radiographs were taken
prior to discharge. The patients were routinely X-rayed at follow-
up assessment. The films were evaluated by the authors to assess
fracture union, alignment and evidence of any radiological changes
of avascular necrosis developing of the humeral head. Figs. 6 and
7 demonstrate the radiological findings, pre (Fig. 6) and post
operative (Fig. 7), of a successfully treated patient.
Patients had independent evaluation by an extended scope
physiotherapist according to the Constant scoring system [9],
which assigns scores for pain, strength, range of movement and
ability to perform activities of daily living. The assessment was
carried out at 6 weeks, 3 months and 6 months post-operatively. Fig. 3 Pulling suture through head.
The contra-lateral shoulder was also evaluated.
The average Constant score at last follow-up was 80 (range 43 to
RESULTS 95). Thirty patients attained 100◦ or more of active abduction. Four
There were 15 two-part, 26 three-part and 9 four-part fractures patients had Constant scores below 50, three were elderly and one
(Table 1). The male : female ratio was 14 : 36 and the average patient was in his 50s. Despite their abduction and strength being
age was 65 (range 33 to 96) years. The average follow-up was low, all three were satisfied with the clinical result. Those with two
13 months (range 2 to 41 months). Four patients were lost to part fractures scored highest, with an average Constant score of
follow up. Each of the patients lost to follow up were elderly and 81. Patients with three part fractures scored an average of 79 and
unable to attend for review in the fracture clinic. In their cases the those with four part fractures scored an average of 78 (Table 2).
last recorded Constant score was used rather than their score on The average time to radiological union was 2.9 months (range
discharge. Further attempts to contact them at their residences 2 to 6). There were no non-unions. Thirty-two patients received
were unsuccessful. some form of bone graft. One patient early in the series healed

© 2009 The Author(s)

36 Journal Compilation © 2009 British Elbow and Shoulder Society. Shoulder & Elbow 2009 1, pp 35–39
 S Suture fixation of displaced two, three and four part proximal humeral fractures Parfitt et al.

Supraspinatus

Completed
‘figure of eight’
sutures
Biceps tendon

Fig. 4 Sutures passed to make ‘figure-of-eight’ pulling fragments

together. Fig. 5 Lateral ‘figure-of-eight’ suture placement.

with a significant varus malunion. The routine use of the lateral
tension suture improved the final alignment in subsequent cases.
Three patients developed a valgus malunion. However none of
these complained of any significant functional deficit as a result.
No patients developed radiological changes of avascular necrosis.
Forty-six of the 50 patients were satisfied or very satisfied with
the results of their surgery. Thirty-one patients had no pain at the
end of their follow-up. Fifteen patients had mild discomfort and two
suffered moderate discomfort. Three patients rated their outcome
as less satisfied or ‘poor’. Two of these patients had severe pain
due to sub-acromial impingement. One is awaiting sub-acromial
decompression, the other has declined further surgery.
One patient who initially had a two part fracture fell and
sustained further trauma to the operated shoulder causing fixation
failure. On re-exploration the fracture position had displaced but
the sutures were intact. The fixation was revised in the same
manner as the initial surgery with the addition of the third (lateral)
suture with a good subsequent result.
One patient developed a minor superficial infection which
settled completely with antibiotic therapy. There were no other
complications.
DISCUSSION
There are numerous operative ways to treat displaced two,
three and four part fractures all of which have advantages and
disadvantages.
Current surgical options include closed reduction and
percutaneous fixation using Kirschner wires or screws, closed
reduction with intra-medullary fixation, tension band wiring and
open reduction and internal fixation with a variety of implants.

Table 1 Average age, follow-up and scores per sub group

Number of parts and patients sex n Average age (years) Follow-up (months) Average abduction Average Constant score
Two part - male 4 53 14 151◦ 85
Two part - female 11 69 10 104◦ 80
Three part - male 3 71 5 111◦ 84
Three part - female 23 70 15 104◦ 78
Four part - male 6 61 17 101◦ 76
Four part - female 3 45 10 121◦ 83

Table 2 Summary of patient data

Fracture Age (years) Abduction Constant score

segments n (mean ± sd) Pain range (mean ± sd) Satisfaction Complications
2 15 63.7 ± 16.4 None 9 Moderate 6 61 to 180 81.0 ± 13.9 14 satisfied or very 1 re-fixation
satisfied 1 poor
3 26 70.5 ± 12.4 None 19 Moderate 91 to 180 78.9 ± 12.5 24 satisfied or very 2 impingement
5 Severe 1 satisfied 2 poor 1 infection
4 9 50.6 ± 12.0 None 5 Moderate 4 31 to 180 78.4 ± 17.3 9 satisfied or very None
satisfied

© 2009 The Author(s)

Journal Compilation © 2009 British Elbow and Shoulder Society. Shoulder & Elbow 2009 1, pp 35–39 37
 S Suture fixation of displaced two, three and four part proximal humeral fractures
Fig. 6 Pre-operative radiographs demonstrating displaced fracture.
Fig. 7 Post-operative radiographs demonstrating union.
Arthroplasty tends to be reserved for older patients with displaced
four part fractures.
With all these techniques it is generally possible to achieve
adequate reduction of the fracture fragments. However it is often
difficult to maintain this reduction until healing occurs. As these
injuries commonly occur in patients with osteoporotic bone fixation
can fail due to metalwork. The latter has been reported even with
the more recent locking implants [10,11]. The soft-tissue stripping
which is necessary for the application of internal fixation devices can
also compromise the primary blood supply to the humeral head.
Finally, the placement of metalwork on the lateral humeral neck and
shaft can give rise to problematic subacromial impingement [12]
which may necessitate a secondary procedure, either a subacromial
decompression or metalwork removal.
Suture fixation has been shown to be a safe and effective
method of treatment for two and three part fractures of the
proximal humerus [13,14]. This study demonstrated that two,
38 Journal Compilation © 2009 British Elbow and Shoulder Society. Shoulder & Elbow 2009 1, pp 35–39
Parfitt et al.
three and even four part displaced proximal humeral fractures can
be treated with suture fixation with excellent clinical results with
minimal complications. The risk of screw pull-out and metalwork
impingement associated with other treatment methods was
avoided. By using the tendon insertions of subscapularis and
supraspinatus in this technique of suture fixation we have not had
problems with material cut-out which has been described with
other methods of suture or wire repair. The routine addition of a
third lateral tension band suture (used initially with the three-part
fractures that involved the surgical neck and greater tuberosity)
increased the intra-operative stability of the repair and has led to
better alignment at union.
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