Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
27(3) 1–7
ª The Author(s) 2019
PHILOS plate versus nonoperative Article reuse guidelines:
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treatment in 2-, 3-, and 4-part proximal DOI: 10.1177/2309499019875169
journals.sagepub.com/home/osj

humeral fractures: Comparison with

healthy control subjects

Emrah Çaliskan and Özgür Doğan

Abstract
Purpose: There is no consensus in the literature on nonoperative treatment of displaced and multipart fractures of
proximal humerus as those are normally treated operatively. Our aim was to compare the functional results of non-
operative management and open reduction internal fixation with the proximal humerus internal locking system of 2-, 3-,
and 4-part proximal humerus fractures, among themselves and with a healthy control group. Methods: Between 2014
and 2018, 92 proximal humerus fractures constituting a nonoperative group (n ¼ 47) and an operative group (n ¼ 45)
together with healthy control subjects (n ¼ 45) were analyzed in a tertiary care referral center. The American Shoulder
and Elbow Surgeons (ASES) shoulder score and visual analog scale (VAS) pain score were used for subjective functional
analysis. Range of motion and muscle strength were analyzed objectively for all patients and healthy control subjects.
Results: In 2-part fractures, VAS scores and hand grip strength were determined as lower in the nonoperative group
(p ¼ 0.033 and p ¼ 0.034, respectively). In 3- and 4-part fractures, there was no difference between the two groups in
terms of ASES and VAS scores. Patients who underwent surgery had more muscle strength than those in the nonoperative
group, but only arm extensor and forearm flexor muscle strengths were statistically significant for 3-part fractures.
In cases of 4-part fractures, objective functional results were similar between the two groups. Conclusions: With
insufficient functional results and high complication rates in surgery, nonoperative management is still the preferred choice
for proximal humerus fractures, especially in case of multipart fractures.

Keywords
dynamometer, nonoperative, operative, proximal humerus fracture, range of motion

Date received: 16 September 2018; Received revised 6 July 2019; accepted: 20 August 2019

Introduction is complicated, and surgeons base their decisions subjec-

tively on a list of factors such as general health status,
Following distal radius and hip fractures, proximal
preference of the surgeon, morphology of fracture, age, and
humerus fractures are the third most common fractures
with an incidence of 105 of 100,000.1,2 They are commonly
seen not only in elderly osteoporotic patients but also in
young patients.3–7 With expanded life spans, it is expected Department of Orthopedics and Traumatology, Ankara Numune
that proximal humerus fracture occurrence will also Research and Training Hospital, Ankara, Turkey
increase; thus, determining the optimum treatment
becomes much more important.8,9 Non-displaced or mini- Corresponding author:
Emrah Çalışkan, Department of Orthopedics and Traumatology, Ankara
mally displaced fractures could be treated well nonopera- Numune Research and Training Hospital, Baglica Mahallesi Duru Life Evleri
tively, but obtaining angular stability in displaced fractures Etimesgut, Ankara, Turkey.
is only possible by surgery. Management of these fractures Email: [email protected]

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2 Journal of Orthopaedic Surgery 27(3)

hand dominance.10,11 However, subjective and objective Surgical treatment

functional results may not be at the level desired and com-
All surgeries were performed in the beach chair position,
plication rates may reach 50%.12–14 This is why nonopera-
with a lateral deltoid split approach and using AO reduction
tive management is the only choice in these patients.
techniques by two surgeons experienced in upper extremity
However, there is very limited information in the literature
trauma. In all operations, PHILOS (Mescomed, Double
about the results of nonoperative management of displaced
Medical) plates were used. After surgery, immobilization
fractures. The purpose of this study was to compare the
was performed with a sling, and passive ROM exercises
functional results of nonoperative management in 2-, 3-,
were started the day after surgery with pendulum exer-
and 4-part proximal humerus fractures with those of open
cises. Patients without any wound problems were dis-
reduction internal fixation with the proximal humerus
charged 3–5 days postoperatively. The mean hospital
internal locking system (PHILOS; Mescomed, Double
stay was 3.3 + 1.2 days (range 2–6 days). Sutures were
Medical®, Turkey) and healthy controls.
removed between the 14th and 21st postoperative days.
Active mobilization started at 2–4 weeks postoperatively,
relying on the stability of the osteosynthesis and quality of
Materials and methods bone, and then patients were referred to outpatient phy-
siotherapy clinics. Physical therapy was terminated 6–8
Between 2014 and 2018, 135 patients with 2-, 3-, or 4-part
weeks after surgery. In the first month after the operation,
fractures, with 81 patients treated nonoperatively and 59
patients were seen weekly until the postoperative first
patients treated surgically, were analyzed retrospectively.
month. They were then seen once a month up to the third
In the nonoperative group, 12 patients were lost to follow-
month and were followed up 3 months later, 6 months
up, 11 patients refused to participate in the study, and 11
later, and yearly.
patients died; thus, there were a total of 47 patients. In the
Shoulder and elbow active ROM of all patients and the
operative group, 4 patients were lost to follow-up, 7
control group were measured using a universal long-arm
patients refused to take part in the study, and 3 patients
goniometer. Arm flexor, extensor, abductor, and adductor
died; there were thus a total of 45 patients. In both groups,
muscles; forearm flexor and extensor muscles; and hand
the average follow-up time was 25 months. To compare
grip strength were measured by dynamometer. All the para-
joint range of motion (ROM) and muscle strength, a con-
meters were measured three times, and average values were
trol group with similar age, sex, and body mass index
determined. All the measurements were performed by the
(BMI) was formed with 45 healthy individuals who had
same surgeon. Dominant sides were determined for all
applied to the orthopedics outpatient clinic of our hospital
three groups, and comparisons were done accordingly. For
for any reason other than upper extremity problems, who
subjective functional analysis, the American Shoulder and
had normal physical examination of the upper extremities,
Elbow Surgeons (ASES) shoulder score and visual analog
and who agreed to participate voluntarily in the study.
scale (VAS) pain score were used.15 Screw counts in the
Exclusion criteria for the study were pseudo-arthrosis,
humeral head and complications were also noted. In routine
pathological fractures, refractures, neuromuscular dis-
outpatient follow-up visits, patient complaints and physical
eases, open fractures, and coexisting fractures of the ipsi-
examination and radiological findings were recorded in the
lateral extremity. Approval was given by the institutional
computer system used in our hospital for documentation
review board, and informed consent was obtained from
purposes. These records were examined retrospectively,
each subject.
and complications were determined.

Nonoperative treatment Statistical analyses

The shoulder was immobilized in a sling for 3 weeks with Statistical analysis was performed using SPSS software.
passive ROM exercises starting after 2 weeks including The variables were investigated using visual (histogram,
pendulum exercises, followed by progressive exercises probability plots) and analytical methods (Kolmogorov–
against resistance. Active ROM exercises started at the Smirnov test) to determine whether they were normally
fourth week. After starting active ROM exercises, patients distributed. Since all the variables were not normally
were referred to physical therapy and rehabilitation. Phys- distributed, the Mann–Whitney U test was used to com-
ical therapy ended after 6–8 weeks. Closed reduction was pare ASES and VAS scores between the nonoperative
performed if needed at the initial evaluation by the treating and the operative groups. Kruskal–Wallis tests were also
surgeon. Patients came to the outpatient clinic once a week conducted to compare ROM, muscle power, and hand
within the first month. They were then seen once a month grip strength between the nonoperative, operative, and
until the third month and 3 months later after the third control groups. The Mann–Whitney U test was per-
month visit, then 6 months later, and then yearly follow- formed to test the significance of pairwise differences
up was performed. using Bonferroni correction to adjust for multiple
Çaliskan and Doğan 3

Table 1. Number of patients in nonoperative group, operative group, and healthy control group according to gender, mean age, and
subgroups of fractures.

Female Male Mean age (years) 2-Part fractures 3-Part fractures 4-Part fractures

Nonoperative group 33 (70.2%) 14 (29.8%) 58.4 (25–89) 12 (25.5%) 22 (46.8%) 13 (27.7%)

Operative group 27 (60%) 18 (40%) 53.2 (26–78) 11 (24.4%) 21 (46.8%) 13 (28.8%)
Healthy control group 28 (62.2%) 17 (37.8%) 53.9 (25–88)

Table 2. Comparison of ASES and VAS scores for both groups and nonoperative treatment was better shoulder abduction
according to fracture type. after nonoperative treatment, with 114.4 versus 88.6 in
ASES VAS
surgical treatment (p ¼ 0.033). When comparing muscle
2-Part strength, there was a tendency toward better results in the
operative group, but only arm extensor and forearm flexor
Nonoperative group 82.3 2.3 muscle strengths were statistically significant (p > 0.05)
Surgical group 93.2 1 (Tables 3 and 4).
p Score 0.062 0.033
3-Part
Nonoperative group 85.9 1.9 4-Part fractures
Surgical group 67.2 3.7
p Score 0.098 0.304 For 4-part fractures there were no significant differences
4-Part between the treatment groups regarding ASES (p ¼ 0.468)
Nonoperative group 70.3 2.6 and VAS (p ¼ 0.247) scores, ROM (p > 0.05), or muscle
Surgical group 77.8 2.2 strengths (p > 0.05). There was a tendency toward more
p Score 0.468 0.247 strength after PHILOS plates, but this was not statistically
ASES: American Shoulder and Elbow Score; VAS: visual analog scale. significant (Tables 3 and 4).

comparisons. An overall 5% type I error level was used Radiological results

to infer statistical significance. Displacement rates were 19% after surgery and 42.5%
after nonoperative treatment. Valgus displacements were
the most common displacements in both groups. There
Results was no difference between displaced and non-displaced
Patient characteristics according to subgroups are given in fracture healing in the PHILOS plate group (p > 0.05). In
Table 1. the operative group, there were valgus displacements in 6
(13.3%) patients, varus displacements in 2 (4.7%)
patients, and greater tuberosity displacement in 1 (2.4%)
2-Part fractures patient. Average ASES and VAS scores of the patients
For 2-part fractures, ASES scores were similar after non- who had radiological displacement were 76.04 (28.3–
operative treatment to those after PHILOS plates with 82 94.9) and 2.7 (1–8), respectively. In the nonoperative
versus 93 points (p ¼ 0.62). VAS scores were seen to be group, there were valgus displacements in 14 (29.7%)
lower in the nonoperative group (p ¼ 0.033) (Table 2). A patients, varus displacements in 2 (4.4%) patients, and
difference between the three groups was determined in greater tuberosity displacements in 4 (8.8%) patients. This
terms of shoulder internal rotation. It was higher in the group’s average ASES score was 86.03 (71.6–100), and
operative group than the nonoperative group (p ¼ 0.011). the average VAS score was 2.15 (1–4). No correlation was
There was no statistical difference in terms of arm and detected between radiological and functional results of
forearm muscle strength, but hand grip strength was iden- both groups (p > 0.05) (Table 5).
tified as lower in the nonoperative group (p ¼ 0.032). Thus,
in cases of 2-part fractures, patients treated nonoperatively Complications
had less pain but also had less hand grip strength and
limited shoulder internal rotation (Tables 3 and 4). One patient in the nonoperative group developed
pulmonary embolism on the seventh postoperative day.
The patient was treated with an anticoagulant agent (two
3-Part fractures times 0.4 ml/day enoxaparin sodium). In the nonoperative
For 3-part fractures, there were no differences between the group, non-union developed in one patient in the postopera-
treatment groups in terms of ASES and VAS scores (p ¼ tive ninth month. Although the patient was offered a non-
0.098 and p ¼ 0.304, respectively) (Table 2). The only union operation, he did not accept the operation and was
significant difference regarding ROM between operative followed up with routine clinical outpatient visits. Union
4 Journal of Orthopaedic Surgery 27(3)

Table 3. Comparison of shoulder ROM for 2-, 3-, 4-part fractures.

FE Extension IR ER Abduction Adduction

2-Part fractures
Nonoperative group 132.3 48.7 47.6 59.4 103.2 31.3
Surgical group 152.8 46.5 68.4 69.2 122.3 39.6
Control group 170.6 47.8 82.7 84.9 149.3 36
p Score 0.124 0.906 0.011 0.572 0.458 0.139
3-Part fractures
Nonoperative group 125.4 44.8 45.9 68 114.4 32.2
Surgical group 112 42.2 49.7 48.8 88.6 32.8
Control group 170.6 47.8 82.7 84.9 149.3 36
p Score 0.337 0.736 0.631 0.061 0.033 0.792
4-Part fractures
Nonoperative group 125.4 34 45.4 43.4 114.8 34.6
Surgical group 118.2 42.1 66.9 61.2 89.1 31.4
Control group 170.6 47.8 82.7 84.9 149.3 36
p Score 0.714 0.163 0.078 0.143 0.143 0.660

ROM: range of motion; FE: forward elevation; IR: internal rotation; ER: external rotation.

Table 4. Comparison. Comparison of muscle strength (in pounds) for 2-,3- and 4-part fractures.

Arm Arm Arm Arm Forearm Forearm Hand

flexors extensors abductors adductors flexors extensors grip

2-Part fractures
Nonoperative group 8.7 8.2 7.3 13.1 12.5 7.2 20.6
Surgical group 13.9 10.6 12.5 18.3 20.9 13.6 33.7
Control group 15.8 11.4 15.4 20.7 20.9 13.2 32.9
p Score 0.062 0.325 0.126 0.159 0.082 0.124 0.034
3-Part fractures
Nonoperative group 8.1 6.5 8.2 11.8 10.6 7.7 23.1
Surgical group 12.2 10.7 9.4 15 16.3 10.1 29.1
Control group 15.8 11.4 15.4 20.7 20.9 13.2 32.9
p Score 0.147 0.025 0.515 0.194 0.034 0.112 0.118
4-Part fractures
Nonoperative group 8.8 8 9.4 13.8 13.2 8.2 23.6
Surgical group 11.4 9.2 11.3 14.3 17.6 13.2 28.8
Control group 15.8 11.4 15.4 20.7 20.9 13.2 32.9
p Score 0.217 0.653 0.657 0.938 0.247 0.134 0.557

was observed in his fracture site radiologically in the 15th objective criteria, and healthy subjects were used as the
month. In the surgical group, two patients had wound infec- control group. The aim of this study was to compare the
tions, which were treated by oral antibiotics, and four functional and radiological results of nonoperative man-
patients had glenohumeral screw penetrations. Three of agement and open reduction internal fixation with PHILOS
these patients had a second operation, and the screws were plates of 2-, 3-, and 4-part proximal humerus fractures in a
changed for shorter ones. The fourth patient with gleno- retrospective fashion. We especially focused on nonopera-
humeral screw penetration also had a rotator cuff tear; the tive treatment of 3- and 4-part fractures, which is lacking in
penetrating screw was removed and the tear was repaired in the literature. Our most important finding was that the
a second operation. The highest complication rate was functional results of nonoperative treatment of type 4 frac-
determined in cases of 3-part fractures (33%). tures were similar to those with surgical treatment. The
subjective results such as ASES and VAS scores and objec-
tive results such as ROM and muscle power were found to
Discussion be similar in both operative and nonoperative groups.
To the best of our knowledge, this is the first study compar- While the shoulder abduction in 3-part fractures was found
ing subgroups of proximal humerus fractures treated by to be less in the operative group, there was a tendency
PHILOS plates or nonoperative methods in addition to toward better muscle power, and only arm flexor and fore-
healthy subjects. Functional results were evaluated with arm extensor muscle strength were statistically significant.
Çaliskan and Doğan 5

Table 5. Radiological results of both groups.

Valgus Varus Greater tuberosity Fracture

Patient numbers displacements ( ) displacements ( ) displacements (cm) ASES VAS type

Surgical group
1 10 89.9 1 2
4 10 81.6 1 2
5 10 78.3 1 3
7 13 73.3 4 3
12 23 81.6 2 4
15 20 66.6 6 3
18 23 28.3 8 2
23 1 94.9 1 3
44 11 89.9 1 4
Nonoperative group
2 12 78.3 4 3
3 10 91.6 2 2
5 14 84.9 1 2
8 14 96.6 1 3
11 18 90 1 3
14 1 88.3 2 2
17 18 79.9 2 3
18 2 78.3 4 4
20 19 83.3 2 3
23 20 71.6 1 2
24 1 94.9 2 2
27 15 100 1 3
28 20 90 3 3
30 21 81.6 2 2
31 23 76.6 3 3
34 2 90 3 4
37 25 76.6 3 2
38 27 95 2 2
40 30 88.3 2 2
46 13 84.9 2 2

ASES: American Shoulder and Elbow Score; VAS: visual analog scale.

The treatment of 2-part fractures is decided according to fractures, which are easy to reduce compared to 3- and
age, displacement, and angulation. Lange et al. in a study 4-part fractures, and also the lateral deltoid split approach,
using Targon nails found no difference between the results which does not harm the rotator cuff muscles, especially
of treating 2-part fractures surgically or nonoperatively,16 the subscapularis muscle. To compare the results, a healthy
similarly Fjalestad and Hole in their randomized controlled control group was established, similar in age and BMI to
trial, found no better results with surgical treatment than the operative and nonoperative groups of patients. This also
conservative treatment for patients with displaced proximal provided a statistically stronger study design.
humeral fracture at 2-year follow-up,17 while Tamimi et al., In 3- and 4-part fractures, similar to our results, both
who used percutaneous K-wiring in their study, determined Tamimi et al. and Lange et al. found no difference in the
that subjective functional results in the surgical group were functional results between two groups, but they determined
much better.10 In our study, although the ASES scores were better radiological results in the operative group and fewer
higher in the surgical group, this was statistically insignif- complications in the nonoperative group.10,16 In a prospec-
icant. On the other hand, VAS scores were lower in the tive randomized study comparing tension band wiring and
operative group and that was statistically significant. One nonoperative treatment, Zyto found no difference in func-
of the possible reasons for this difference may be the use of tional results but had better radiological results in the sur-
different implants in surgical stabilization. Lange et al. gical group, which is similar to our study.18 The studies of
found no difference in the objective functional results Tamimi et al.10 and Zyto18 did not consider 3- and 4-part
between two groups.16 We found that joint ROM, espe- fractures separately. In the study by Lange et al., however,
cially shoulder internal rotation, and hand grip strength 3- and 4-part fractures were considered separately.16 In
were higher in the operative group. This could be due to 3-part fractures, similar to the study of Lange et al.,16 we
gentle reduction maneuvers for the nature of 2-part found that shoulder ROM was less in the operative group,
6 Journal of Orthopaedic Surgery 27(3)

but only abduction was statistically significantly different. be involved in the study. On the other hand, PHILOS plates
For muscle strength, in the operative group, the arm flexor may have affected the surgical results positively or nega-
and forearm extensor muscles were significantly more tively. Intramedullary nails and reverse shoulder prostheses
powerful. There were no differences between the two can give more effective results in certain fractures.11 The
groups based on daily activity and pain scores. In 4-part second limitation is the lack of age restriction. It could give
fractures, similar to the study of Lange et al., we found that clearer results if the geriatric patient group and the younger
there was no difference between the two groups based on patient group are compared within themselves. The third
subjective and objective functional results.16 In contrast, limitation of the study was collecting the patients in a retro-
Olerud et al., based on their study of 60 patients who spective fashion. More reliable outcomes can be obtained
had 3-part fractures, found that in the PHILOS group, by prospective follow-up studies. The last limitation of our
subjective results were better but statistically insignificant study is that we used the Neer classification.22 It is based on
(p ¼ 0.64).19 the mechanism of injury or level of the fracture line; how-
Our aim in surgical treatment was to obtain anatomical ever, it does not consider the displacement of tuberosity,
reduction and begin early movement, thus obtaining func- and it also has poor intra- and inter-observer reliability. On
tional and radiological results as close to normal as possi- the other hand, surgeons continue to use this classification
ble. It is very hard to obtain anatomical reduction by system as it is helpful in guiding treatment and grouping
nonoperative treatment, especially in 3- and 4-part frac- fracture patterns for research purposes. Future studies can
tures. However, with the advancement of implant technol- be improved by increasing the number of patients and by
ogies, anatomical reduction is possible by surgery. prospective randomized clinical trials.
Radiologically anatomical reduction does not always result
in good functional outcomes, and conversely, functional
outcomes of some cases that do not have anatomical reduc-
Conclusion
tion can be satisfactory. In our study, we saw that ASES Nonoperative treatment in proximal humeral fractures, par-
and VAS scores were independent of anatomical reduction. ticularly in multipart fractures, appears to be an alternative
In the nonoperative group, a 3-part fracture patient who had to the surgical option. Targeted functional results can be
15 of varus displacement had the best ASES (100) and achieved without obtaining radiological anatomical
VAS (1) scores (Table 4, patient 27). Similarly, Rangan reduction.
et al. found no difference between surgical treatment com-
pared with nonsurgical treatment in terms of patient- Declaration of conflicting interests
reported clinical results over 2 years following fracture The author(s) declared no potential conflicts of interest with
occurrence in a randomized clinical trial of patients with respect to the research, authorship, and/or publication of this
displaced proximal humerus fractures. 20 Although the article.
PROFHER study was larger and better designed, similar
results were obtained with our data. This may be due to the Funding
comparison with the healthy control group and the use of The author(s) received no financial support for the research,
objective analyses, which makes our study more prone to authorship, and/or publication of this article.
reality in terms of daily life. In contrast, Poeze et al., based
on their study of 55 patients who had minimally displaced ORCID iD
proximal humerus fractures, found that in the nonoperative Emrah Çaliskan https://orcid.org/0000-0001-5500-6571
group, a transscapular (Y) radiograph seen in the first week
was a predictive finding for functional results.21 Factors References
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