Plating Of Proximal Humeral Fractures Research Articles

Locked Plating of Proximal Humeral Fractures: Is Function Affected by Age, Time, and Fracture Patterns?

Locking plate fixation of proximal humeral fractures improves biomechanical stability. It has expanded the indications of traditional open reduction internal fixation and become increasingly common for treating unstable, displaced proximal humeral fractures. Despite improved stability it is unclear whether these improve function and if so for which patients. We therefore determined patient function after a locked plating technique for the treatment of unstable proximal humeral fractures based on age, time, fracture pattern, and associated injures. We retrospectively reviewed 66 patients with 69 proximal humeral fractures treated with a locked proximal humeral plating technique from 2002-2006 using prospectively gathered data. Function was measured using the Short Musculoskeletal Function Assessment (SMFA), Disability of the Arm, Shoulder, and Hand (DASH), and SF-36 at 6, 12, and 24months. Fracture healing was determined radiographically and complication rates were determined from the medical records. At 2years, DASH scores were 26.5 and 37.4 for isolated and polytrauma patients, respectively. For age differences, DASH scores were 33.1 and 28.9 for ages younger than 60 and 60years old or older, respectively. At 2years, SMFA scores were higher (worse) in older compared with younger patients. Function, but not bother continues to improve in younger patients up to 2years. More severe fracture patterns performed worse in all SMFA indices at 2years. Polytrauma patients consistently experienced worse mobility than isolated injury patients at each time interval. With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. Long-term functional deficits persist. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Outcome analysis following removal of locking plate fixation of the proximal humerus

BackgroundConcerning surgical management experience with locking plates for proximal humeral fractures has been described with promising results. Though, distinct hardware related complaints after fracture union are reported. Information concerning the outcome after removal of hardware from the proximal humerus is lacking and most studies on hardware removal are focused on the lower extremity. Therefore the aim of this study was to analyze the functional short-term outcome following removal of locking plate fixation of the proximal humerus.MethodsPatients undergoing removal of a locking plate of the proximal humerus were prospectively followed. Patients were subdivided into the following groups: Group HI: symptoms of hardware related subacromial impingement, Group RD: persisting rotation deficit, Group RQ: patients with request for a hardware removal. The clinical (Constant-Murley score) and radiologic (AP and axial view) follow-up took place three and six months after the operation. To evaluate subjective results, the Medical Outcomes Study Short Form-36 (SF-36), was completed.Results59 patients were included. The mean length of time with the hardware in place was 15.2 ± 3.81 months. The mean of the adjusted overall Constant score before hardware removal was 66.2 ± 25.2% and increased significantly to 73.1 ± 22.5% after 3 months; and to 84.3 ± 20.6% after 6 months (p < 0.001). The mean of preoperative pain on the VAS-scale before hardware removal was 5.2 ± 2.9, after 6 months pain in all groups decreased significantly (p < 0.001). The SF-36 physical component score revealed a significant overall improvement in both genders (p < 0.001) at six months.ConclusionA significant improvement of clinical outcome following removal was found. However, a general recommendation for hardware removal is not justified, as the risk of an anew surgical and anesthetic procedure with all possible complications has to be carefully taken into account. However, for patients with distinct symptoms it might be justified.

A mechanical comparison between conventional and modified angular plates for proximal humeral fractures

The objective of this study is to present a modified angular blade plate for fixing 2-part and even 3-part fractures of the proximal humerus, as well as the results of the comparative mechanical test between the conventional angular blade plate and this new modified plate. The plates were tested in flexion and rotational trials in a wooden model that simulated a 2-part humeral fracture of the proximal extremity. The results (mean +/- SD) of bending strength and stiffness obtained after testing showed findings of 601 +/- 349 N and 0.5 +/- 0.2 N/mm, respectively, for the conventional plate and 4005 +/- 164 N and 3.9 +/- 0.7 N/mm, respectively, for the modified plate. The torsional stiffness test showed findings of 1.26 +/- 0.09 KN.mm degrees for the conventional plate and 1.74 +/- 0.21 KN.mm degrees for the modified plate. The test of torsional moment showed findings of 57.0 +/- 7.6 KN.mm for the conventional plate and 115.2 +/- 9.3 KN.mm for the modified plate. The test of angular displacement at the torsional moment showed findings of 50.8 degrees +/- 7.2 degrees for the conventional plate and 70.2 degrees +/- 2.6 degrees for the modified plate. The results of the mechanical trials of flexion and rotation were superior for the modified angular blade plate compared with the conventional angular blade plate.

The results of internal fixation of proximal humeral fractures with the PHILOS locking plate

Proximal and diaphyseal humeral fractures are common especially in the elderly, presenting as a challenging problem due to their high complication rates following surgical treatment. In this prospective study, we evaluated the results of patients treated with the PHILOS (Proximal Humeral Internal Locking System) locking plate, a new technique recently developed by the AO/ASIF. Forty-one patients who were treated with the PHILOS plate for proximal humeral fractures were evaluated in two age groups. Group A included 24 patients (12 males, 12 females; mean age 47 years; range 24 to 64 years) younger than 65 years, and group B involved 17 patients (4 males, 13 females; mean age 78 years; range 67 to 90 years) at or above 65 years. Radiographically, all fractures were classified according to the AO/ASIF system. Surgery was performed with the deltopectoral approach in 10 and two patients, and with a deltoid split in 14 and 15 patients in group A and B, respectively. Functional and radiographic results were evaluated after a mean follow-up of 15 months (range 6 to 28 months). The mean Constant scores were 95.0 (range 74 to 100) and 92.8 (range 72 to 100) in group A and B, respectively (p>0.05). After six months of surgery, Constant scores and functional outcomes were similar in patients operated on with the deltopectoral approach or deltoid split. There was neither nonunion nor implant failure. Complications included intra-articular screw penetration (n=1), displacement of the greater tuberculum (n=1) with oblique placement of the plate (n=1), insufficient reduction (n=4), and varus displacement of the humeral head (n=3). No avascular necrosis was seen. Locking plate system is superior over other means of fixation methods, particularly in osteoporotic fractures, because it allows early rehabilitation and does not result in implant failure.

Plating in Proximal Humeral Fractures.

Improved imaging, updated knowledge regarding humeral head perfusion and adapted fixation techniques with implants having better purchase also in osteopenic bone, have influenced the treatment of proximal humeral fractures in recent years. Demographic evolution and a more active population even among the older age groups will increase the incidence of this fracture, which is already the third most frequent fracture after hip and distal radius fractures in elderly patients. Long-term morbidity related to the treatment of these fractures like avascular humeral head necrosis, non-union, malunion, shoulder stiffness, persistent pain and functional disability are the challenging factors to be overcome. Plate osteosynthesis with angular stable implants have shown to address some of these problems and to broaden the spectrum of indication towards anatomic fracture stabilization even for severely displaced three- and four-part fractures instead of replacing the humeral head with an endoprosthesis, as long as a stable fixation is possible. Open access surgery is often needed for anatomic reconstruction of complex and displaced fractures. This calls for immediate postoperative mobilization with active-assisted ROM exercise to prevent subdeltoidal adhesions. Even though plating of proximal humeral fractures with angular stable implants has shown promising first clinical results, there still remain elevated complication rates especially in the elderly osteoporotic patient population. Recent clinical reports using angular stable plates provided only data with a low level of evidence to help in decision-making. The comparison with historical series using non-angular stable plates in respect to the long-term morbidity should help to better evaluate the value of locked plates inserted with less-extensive soft-tissue exposure.

Biomechanical evaluation of locked plating in proximal humeral fractures

The ideal method of fixation in proximal humeral fractures is not well established. Locked plating is a potential solution, but to date, there has been little support shown in the literature. We compared the biomechanical performance of a locked plate with that of an intramedullary humeral nail in a cadaveric model. Paired fresh-frozen cadaveric humeri (N = 5) were instrumented with either a locked plate or an intramedullary nail after creation of a 3-part osteotomy. Construct stiffness, cyclic loading behavior, and load to failure were evaluated. The locked plate was more stiff in valgus loading than the nail (P = .003). All other loading vectors showed no statistical differences in stiffness between the two constructs. The load to failure was 828 N for the plate and 901 N for the nail. The nail showed interfragmentary motion (degrees), or toggle, at zero load, whereas the plate did not. The locked plate, being stable at zero load, may prove useful in earlier pain-free rehabilitation of proximal humeral fractures.

Helical plating of the proximal humerus

The ideal treatment for fractures of the proximal humerus has not been definitively agreed upon. Several recent reports have described a technique of helical plating for proximal humeral fractures, in which the proximal plate is placed laterally on the greater tuberosity, and spirals 90 degrees distally to lie on the anterior surface of the humeral shaft. The purpose of this study was to evaluate the feasibility of helical plating using a less invasive surgical approach and placing screws percutaneously in the distal plate. Dissection of 10 cadaveric upper extremity specimens was performed, using an extended anterolateral acromial approach followed by percutaneous helical plating. With the plate secured, the neurovascular structures which crossed the anterior humerus superficial to the plate were exposed and identified. Only the musculocutaneous nerve crossed anterior to the plate and was at risk for percutaneous screw placement. The nerve location was found in a consistent location among the specimens. The danger zone for the nerve location was found to be at an average of 13.5 cm from the greater tuberosity (99% CI: 12.2-14.8 cm). Though clinical experience is necessary to validate this plating technique, it appears that avoiding this danger zone in which the musculocutaneous nerve crosses will allow safe percutaneous screw placement and permit minimally invasive plating of these fractures.