Current concepts in locking plate fixation of proximal humerus fractures

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Abstract

Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

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Most cited references 85

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Displaced proximal humeral fractures. I. Classification and evaluation.

C S Neer (1970)

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The importance of medial support in locked plating of proximal humerus fractures.

Dean Lorich, John Barker, Yoram Weil … (2007)

The purpose of this study was to determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support. University medical center. Thirty-five patients who underwent locked plating for a proximal humerus fracture were followed up until healing. For the initial and final radiographs, 2 lines were drawn perpendicular to the shaft of the plate, one at the top of the plate and one at the top of the humeral head, and the distance between them was measured as an indicator of loss of reduction. Medial support was considered to be present if the medial cortex was anatomically reduced, if the proximal fragment was impacted laterally in the distal shaft fragment, or if an oblique locking screw was positioned inferomedially in the proximal humeral head fragment. Multivariate linear regressions were performed to determine the effects that age, sex, fracture type, cement augmentation, and medial support had on loss of reduction. The presence of medial support had a significant effect on the magnitude of subsequent reduction loss (P < 0.001). Age, sex, fracture type, or cement augmentation had no effect on maintenance of reduction. Eighteen patients were determined to have adequate mechanical medial support (+MS group), and the remaining 17 patients did not have medial support (-MS group). In the +MS group, the average loss of humeral head height was 1.2 mm, and 1 case of articular screw penetration occurred that required removal. In the -MS group (without an appropriately placed inferomedial oblique screw and either nonanatomic humeral head malreduction with lateral displacement of the shaft or medial comminution), loss of humeral height averaged 5.8 mm (P < 0.001). There were 5 cases in this group in which screw penetration of the articular surface occurred (P = 0.02), 2 of which required reoperation for removal. All fractures in both groups healed without delay, and none required revision to arthroplasty. Achieving mechanical support of the inferomedial region of the proximal humerus seems to be important for maintaining fracture reduction. Locked plates in general do not appear to be a panacea for these fractures and are unable to support the humeral head alone from a lateral tension-band position. However, there are several factors that are in the surgeon's control that may improve the mechanical environment. Achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.

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Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study.

M Kääb, H J Oestern, G. Konrad … (2009)

The treatment of unstable displaced proximal humeral fractures, especially in the elderly, remains controversial. The objective of the present prospective, multicenter, observational study was to evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with use of a locking proximal humeral plate. One hundred and eighty-seven patients (mean age, 62.9 +/- 15.7 years) with an acute proximal humeral fracture were managed with open reduction and internal fixation with a locking proximal humeral plate. At the three-month, six-month, and one-year follow-up examinations, 165 (88%), 158 (84%), and 155 (83%) of the 187 patients were assessed with regard to pain, shoulder mobility, and strength. The Constant score was determined at each interval, and the Disabilities of the Arm, Shoulder and Hand (DASH) score was determined for the injured and contralateral extremities at the time of the one-year follow-up. Between three months and one year, the mean range of motion and the mean Constant score for the injured shoulders improved substantially. Twelve months after surgery, the mean Constant score for the injured side was 70.6 +/- 13.7 points, corresponding to 85.1% +/- 14.0% of the score for the contralateral side. The mean DASH score at the time of the one-year follow-up was 15.2 +/- 16.8 points. Sixty-two complications were encountered in fifty-two (34%) of 155 patients at the time of the one-year follow-up. Twenty-five complications (40%) were related to incorrect surgical technique and were present at the end of the operative procedure. The most common complication, noted in twenty-one (14%) of 155 patients, was intraoperative screw perforation of the humeral head. Twenty-nine patients (19%) had an unplanned second operation within twelve months after the fracture. Surgical treatment of displaced proximal humeral fractures with use of the locking proximal humeral plate that was evaluated in the present study can lead to a good functional outcome provided that the correct surgical technique is used. Because many of the complications were related to incorrect surgical technique, it behooves the treating surgeon to perform the operation correctly to avoid iatrogenic errors.

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Author and article information

Contributors

Christoph J. Laux: 0041 / 44 / 255 11 11 , christoph.laux@me.com

Florian Grubhofer: florian.grubhofer@balgrist.ch

Clément M. L. Werner: cwerner@gmx.ch

Hans-Peter Simmen: hanspeter.simmen@usz.ch

Georg Osterhoff: georg.osterhoff@usz.ch

Journal

Journal ID (nlm-ta): J Orthop Surg Res

Journal ID (iso-abbrev): J Orthop Surg Res

Title: Journal of Orthopaedic Surgery and Research

Publisher: BioMed Central (London )

ISSN (Electronic): 1749-799X

Publication date (Electronic): 25 September 2017

Publication date PMC-release: 25 September 2017

Publication date Collection: 2017

Volume: 12

Electronic Location Identifier: 137

Affiliations

[1 ]ISNI 0000 0004 0478 9977, GRID grid.412004.3, Department of Trauma Surgery, , University Hospital Zurich, ; Rämistrasse 100, 8091 Zurich, Switzerland

[2 ]ISNI 0000 0004 0518 9682, GRID grid.412373.0, Balgrist University Hospital, ; Forchstrasse 340, 8008 Zurich, Switzerland

Article

Publisher ID: 639

DOI: 10.1186/s13018-017-0639-3

PMC ID: 5613450

PubMed ID: 28946902

SO-VID: cfe2f98d-c4a4-4321-8f17-07dc57442011

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 7 May 2017

Date accepted : 17 September 2017

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ScienceOpen disciplines: Surgery

Keywords: proximal humeral fracture,locking plate fixation,medial support,calcar screws,cement augmentation,bone graft

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ScienceOpen disciplines: Surgery

Keywords: proximal humeral fracture, locking plate fixation, medial support, calcar screws, cement augmentation, bone graft

Current concepts in locking plate fixation of proximal humerus fractures

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Most cited references 85

Displaced proximal humeral fractures. I. Classification and evaluation.

The importance of medial support in locked plating of proximal humerus fractures.

Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study.

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