1: J Bone Joint Surg Am. 2003 Sep;85-A(9):1647-55.  Severely impacted valgus proximal humeral fractures. Results of operativetreatment.Robinson CM, Page RS.Orthopaedic Trauma Unit, The Royal Infirmary of Edinburgh, Scotland.c.mike.robinson@ed.ac.ukBACKGROUND: The functional results associated with nonoperative treatment ofseverely impacted valgus fractures of the proximal part of the humerus are poor,and these injuries are difficult to treat with minimally invasive percutaneousfixation techniques. The aim of this study was to review the functional andradiographic results and complications of a new operative technique in a seriesof twenty-five patients. METHODS: Over a two-year period, we treated twenty-ninepatients with a severely impacted valgus fracture of the proximal part of thehumerus. Three patients were lost to follow-up and one died, leaving twenty-fivepatients who were available for the study. In all of the fractures, thehead-shaft angle had been tilted into > or = 160 degrees of valgus and thegreater tuberosity was displaced by >1 cm. All patients were treated with openreduction of the fracture, and the space created behind the humeral head wasfilled with Norian Skeletal Repair System (SRS) bone substitute. The fractureswere stabilized with either screws or buttress plate fixation. Associatedrotator cuff tears were repaired. All patients underwent functional outcomeassessment with use of the Constant, DASH (Disabilities of the Arm, Shoulder andHand), and SF-36 (Short Form-36) scores at one year, and twelve patients werefollowed for two years. RESULTS: All fractures united within the first year, allreductions were maintained, and no patient had signs of osteonecrosis of thehumeral head on the latest follow-up radiographs. At one year, the medianConstant score was 80 points and the median DASH score was 22 points. Thefunctional results continued to be satisfactory in the twelve patients who werefollowed for two years. The results in our series were better than thoseachieved in studies of nonoperative treatment of similar fractureconfigurations. There were six clinically relevant complications, although nonerequired a reoperation and all six patients had a satisfactory short-termfunctional outcome. CONCLUSIONS: Internal fixation of severely impacted valgusfractures of the proximal part of the humerus, supplemented by Norian SRS bonesubstitute to fill the proximal humeral metaphyseal defect, produces good earlyfunctional and radiographic outcomes. Additional follow-up will be required toassess whether these initially satisfactory outcomes are maintained over thelonger term.PMID: 12954821 [PubMed - indexed for MEDLINE]