Proximal Humerus Fractures: Are Locking Plates the Way to Go?

Dominique M. Rouleau, M.D., Msc., FRCSC
Assistant Professor, Université de Montréal
Hôpital du Sacré-Coeur de Montréal
Montréal, QC

Jonah Hébert-Davies, M.D.
Chief Resident, Université de Montréal
Hôpital du Sacré-Coeur de Montréal
Montréal, QC

Twenty-percent of proximal humerus fractures (PHF) will require surgical treatment4. Indications for surgery are based on patient needs and classically include: displaced tuberosities (5-10 mm or more), an absence of contact between head and diaphysis, neck angle outside of 100 to 160 degrees, humeral head split and fracture-dislocation4. For the vast majority of fractures involving the humeral neck, the use of proximal humerus locking plates is our preferred technique. These plates provide stable fixation and allow for early range of motion.

 

Before considering fixation, it is important to underline the importance of an acceptable reduction1,2. A locking plate applied to an unreduced fracture is unacceptable. For example, a fracture fixed in excessive varus has been shown to have a higher rate of secondary displacement and failure. To assist in obtaining an acceptable reduction, surgical preparation is mandatory. Standard shoulder radiographs (AP, lateral and axillary) are necessary and generally a CT-scan can further assist with fracture characterization. In the presence of a valgus-impacted fracture or a two-part neck fracture, the deltoid split approach may be better than the delto-pectoral approach5,6. Although, the deltoid split approach can put the axillary nerve at risk, palpation and protection of the nerve is necessary5,6. The delto-pectoral approach, however, is typically the work-horse approach for most proximal humerus fractures and fracture-dislocations.

Some pearls in obtaining reduction in a complex proximal humerus fracture include:

  • Longitudinal traction using a limb positioner may assist with the release and mobilization of fracture fragments.
  • Haematoma and sub-deltoid bursa are removed to assist with fracture fragment identification.
  • Release of the long head of biceps tendon can assist with exposure. The tendon can later be tenodesed.
  • Rotator interval can be open to remove intra-articular portion of biceps and to reduce humeral head.
  • Sutures placed through the rotator cuff insertion can be used to apply traction and rotation to fractured fragments.
  • With an unstable humeral head that has failed reduction techniques, a trans-articular Steinmann pin can be used to temporarily fix the head to the glenoid in an acceptable position while definitive fixation is carried out.

Fixation process:

  • Heavy sutures are passed through the suture-holes, which are typically found in most proximal humerus locking plates before applying the plate.
  • The plate is then placed just lateral to the biceps groove. The plate should be positioned sufficiently distal to the proximal end of the tuberosities to avoid impingement. The plate can be provisionally stabilized to the proximal humerus with temporary K-wires. A compressive cortical screw is then used to apply the plate to the diaphysis. At this point, plate position is verified with intra-operative fluoroscopy.
  • The humeral head and greater tuberosity are secured with locking screws. Screws longer than 40-45 mm are at greater risk of intra-articular penetration in our experience must be examined critically to ensure they are extra-articular. We typically recommend placing screws at least 5 mm short from the joint surface in all planes.
  • Most plating systems do not provide for screw fixation of the lesser tuberosity, therefore, high strength sutures are usually used. Also, sutures are used between plate and postero-superior cuff to secure the greater tuberosity.
  • After open reduction and internal fixation, the shoulder is placed through a full range of motion and examined under fluoroscopy to verify reduction and ensure that all screws are extra-articular. These fractures are often challenging and the initial intervention is often the only chance to assure an optimal outcome.

Despite an anatomic surgical reduction with stable fixation, PHFs don't always lead to excellent results1,2,3. Multiple complications may arise and reoperation rates are high (6-44%). Major causes for failure are: infection (5%), avascular necrosis (4-33%), screw cutout (5-20%) and loss of reduction (5-16%). To avoid missing infections, any cultures must specifically look for propionibacterium acnes, a common infecting organism after shoulder surgery. Also, regaining range of motion takes time and the differential diagnosis of a slow recovery include: capsulitis, screw penetration, avascular necrosis, infection, cuff tear and proximal biceps pathology. In conclusion, the locking plate for proximal humerus fractures offers good results in the majority of patients who are appropriately selected based on fracture characteristics, patient factors and bone quality.

References

  1. Schliemann B., Siemoneit J., Theisen C., Kösters C., Weimann A., Raschke M.J. Complex fractures of the proximal humerus in the elderly-outcome and complications after locking plate fixation. Musculoskelet Surg. 2012 Jan 28. [Epub ahead of print] PubMed PMID: 22287062.
  2. Brorson S., Rasmussen J.V., Frich L.H., Olsen B.S., Hróbjartsson A. Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: A systematic review. Injury. 2011 Oct 1. [Epub ahead of print] PubMed PMID: 21968245.
  3. Südkamp N.P., Audigé L., Lambert S., Hertel R., Konrad G. Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures. J Shoulder Elbow Surg. 2011 Dec;20(8):1207-16. Epub 2011 Sep 14. PubMed PMID: 21920779.
  4. Robinson C.M., Amin A.K., Godley K.C., Murray I.R., White T.O. Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma. 2011 Oct;25(10):618-29. Review. PubMed PMID: 21904170.
  5. Laflamme G.Y., Rouleau D.M., Berry G.K., Beaumont P.H., Reindl R., Harvey E.J. Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma. 2008 Mar;22(3):153-8. PubMed PMID: 18317047.
  6. Smith J., Berry G., Laflamme Y., Blain-Pare E., Reindl R., Harvey E. Percutaneous insertion of a proximal humeral locking plate: an anatomic study. Injury. 2007 Feb;38(2):206-11. Epub 2006 Oct 25. PubMed PMID: 17067606.
 

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