proximal humeral fractures aaos - ahn) ihumeral+fractures+aaos.pdf · surgical neck fracture with...

$: Proximal Humeral Fractures AAOS - AHN) iHumeral+Fractures+AAOS.pdf · surgical neck fracture with >30° of varus malalignment of the head rel-ative to the neck-shaft angle is a relative$
Fixed-angle Locked Platingof Two-, Three-, andFour-part ProximalHumerus Fractures

Proximal humerus fractures arerelatively common, accounting

for 5% to 9% of all fractures.1-3

These fractures can pose a challengefor the treating orthopaedist becauseof the generally osteoporotic natureof bone in the elderly and the rela-tive deforming forces of the sur-rounding muscles. Fractures areclassified according to the Neer cri-teria, and treatment is often guidedby the relative displacement of theanatomic fragments. Nondisplacedfractures have historically beentreated conservatively, with general-ly good outcomes.4 Displaced frac-tures with angulation of the articu-lar surface >45° and displacement ofthe major segments >1 cm have beentreated surgically, as have fractureswith substantial valgus impaction,all with mixed results.5-23

Surgical techniques have includ-ed percutaneous fixation, standardplate-and-screw fixation, intramedul-lary fixation with rods or pins, theuse of tension bands with and with-out plates or rods, standard platemodification into blade plate con-structs, and hemiarthroplasty.4-23

Many of these alternative open tech-niques were developed because of thehigh failure rates noted initially withstandard plating. The inherent diffi-culties with internal fixation haveled several authors to recommendhemiarthroplasty for the treatment ofmost three- and four-part humerusfractures.5,9,19,24,25 However, lockedplates allow for more secure fixationin compromised bone, thereby possi-bly leading to reduced incidence offailure of internal fixation. Newerplates also incorporate suture eyelets

that further enhance the fixationconstruct and resist deforming mus-cular forces. Additional investigationis necessary, but early results withlocked plate fixation for the treat-ment of proximal humerus fractureshave been encouraging. It is antici-pated that this technique will provideanother potentially viable alternativeto prosthetic replacement for thetreatment of these difficult injuries.

Indications andContraindications

The indications for fixed-anglelocked plating are evolving. We con-tend that open reduction and inter-nal fixation (ORIF) with a lockedplate is ideal for displaced two-partsurgical neck fractures, two-part ana-tomic neck fractures in the patientyounger than age 40 years, three-partsurgical neck fractures with involve-ment of the greater or lesser tuberos-ity, and most four-part fractures(Figure 1). Fracture-dislocations areusually associated with high-energyinjuries. These injuries are moreprone to complications, especiallydevascularization of the dislocatedhead fragment. As a result, fracture-dislocations are generally excludedfrom the treatment algorithm. In-stead, they are approached on a case-by-case basis. ORIF is generally re-served for persons younger than age40 years in an effort to save the headand avoid prosthetic replacement. Inour practice, fracture-dislocationswith complete denuding of all at-tached soft tissues are usually man-aged with hemiarthroplasty regard-less of patient age. A two-part

Brian L. Badman, MD

Mark Mighell, MD

Dr. Badman is Shoulder and ElbowSurgeon, OrthoIndy, Indianapolis, IN. Dr.Mighell is Shoulder and Elbow Surgeon,Florida Orthopedic Institute, Tampa, FL.

Dr. Mighell or a member of hisimmediate family has received researchor institutional support from and servesas a consultant to or is an employee ofHand Innovations. Neither Dr. Badmannor a member of his immediate familyhas received anything of value from orowns stock in a commercial company orinstitution related directly or indirectly tothe subject of this article.

Reprint requests: Dr. Badman,OrthoIndy, 252 Meadow Drive, Danville,IN 46122.

J Am Acad Orthop Surg 2008;16:294-302

Copyright 2008 by the AmericanAcademy of Orthopaedic Surgeons.

The video that accompanies

this article is “Locked Plating

for Proximal Humeral Frac-

tures,” available on the Orthopaedic Knowl-edge Online Website, at http://www5.aaos.

org/oko/jaaos/surgical.cfm

Surgical Techniques

294 Journal of the American Academy of Orthopaedic Surgeons

http://www5.aaos.org/oko/jaaos/surgical.cfm

surgical neck fracture with >30° ofvarus malalignment of the head rel-ative to the neck-shaft angle is arelative indication for fixed-anglelocked plating. Such plating is doneto avoid the risk of tuberosity im-pingement with shoulder abductionand the resultant loss of motion.26

Contraindications to ORIF with alocked plate include nondisplaced orminimally displaced fractures, mosthead-splitting fractures, and patientswho are unable to tolerate a surgicalprocedure because of underlying co-morbidities. Relative contraindica-

tions include anatomic neck frac-tures in the elderly and comminutedfractures with extension into theproximal metaphyseal bone segment.

Surgical Technique

A thorough history and physical ex-amination are essential in all pa-tients being evaluated for surgicalintervention. The surgeon shouldobtain preoperative radiographs, in-cluding true anteroposterior shoul-der, scapular lateral, and axillaryviews (Figure 2). In tolerant patients,internal and external rotation viewsof the humerus also may be helpful.Computed tomography is not oftennecessary, but it can prove beneficialin the more comminuted fracturewhen tuberosity size and positionare difficult to ascertain on standardradiographs. Magnetic resonance im-aging has not proved very beneficialbecause most proximal humerusfractures do not have an associatedrotator cuff tear.

AnesthesiaThe patient is given an inter-

scalene block, which reduces theamount of general anesthetic re-quired intraoperatively and substan-tially minimizes postoperative pain.The endotracheal tube should betaped and secured on the lip con-tralateral to the side of surgery so as

not to interfere with the surgical fieldand to avoid inadvertent dislodge-ment during retractor placement.

PositioningA systematic approach to patient

positioning is crucial for good intra-operative fluoroscopy. We use a reg-ular surgical table with a radiolucentfootplate. The table is rotated 180°so that the patient’s head is at thefoot of the bed, and the shoulderrests on the radiolucent footplate( video, 3:06). Most tables are rat-ed for 300 lb and can safely accom-modate patients in this position.Once the patient is under general an-esthesia, the patient’s bottom isplaced at the break of the table, andthe head is elevated 30° (modifiedbeach-chair position). A pillow isplaced under the knees for comfortand to minimize neural tension. Allprominences are well padded. Thehead is often supported on a jellydoughnut and taped in place with2-in silk tape. The bed is then rotat-ed 90° relative to the anesthesiolo-gist. The large C-arm is positionedparallel to the patient at the head ofthe bed, thereby avoiding inter-ference with the anesthesiologist(Figure 3). This simplifies the use offluoroscopy and allows an unob-structed view of the shoulder intra-operatively with minimal reposi-tioning of the C-arm. Imaging

Figure 1

Two-, three-, and four-part proximalhumerus fractures according to theNeer classification.

Figure 2

Preoperative anteroposterior (A), axillary (B), and scapular Y-view (C) radiographs of a four-part proximal humerus fracture in a66-year-old man.

Brian L. Badman, MD, and Mark Mighell, MD

Volume 16, Number 5, May 2008 295


should be obtained before preppingthe patient. If necessary, the patientshould be repositioned so that a goodimage can be obtained ( video,3:06-4:50).

ApproachA standard deltopectoral ap-

proach is used for exposure of theproximal humerus. The cephalicvein is routinely taken medially toprevent inadvertent injury during re-tractor placement. Gelpi retractorsare placed initially to assist subcuta-neous exposure, and the subdeltoidspace is developed. After release ofthe subdeltoid space, a Browne del-toid retractor (Innomed, Savannah,GA) is carefully placed under themuscle to facilitate exposure. A sec-ond Mayo stand may be used so thatthe arm can be placed into an ab-ducted posture to minimize the del-toid tension. Doing so also avoidsthe need for an assistant to hold thearm. The clavipectoral fascia is iden-tified and released.

The subcoracoid space is devel-oped next, and the axillary nerve is

identified by gentle palpation at theinferior margin of the subscapularismuscle. If necessary, up to 25% ofthe lateral conjoined tendon may bereleased off the lateral tip of the cor-acoid to facilitate exposure. To min-imize inadvertent stretch of themusculocutaneous nerve, the sur-geon should avoid placing self-retaining retractors under the con-joined tendon.

The biceps tendon is palpateddeep to the pectoralis major muscle.Often, fracture hematoma can ob-scure normal landmarks; thus, usingthis as a reference can assist in orien-tation. The biceps may be interposedin the fracture fragments and may re-quire mobilization. Care should betaken to avoid excessive disruptionand cauterization through the bicip-ital groove in an effort to preservethe ascending branch of the anteriorcircumflex humeral artery. Thisbranch is located laterally in thegroove and is the primary blood sup-ply to the head fragment. Preop-erative discovery of a fracture-dislocation should alert the surgeon

that the anatomy may also be greatlydistorted. As such, great care mustbe taken during dissection.

When the articular segment isdislocated and stripped of all soft-tissue attachments, hemiarthro-plasty is the treatment of choice.The rotator interval can be openedby following the course of the bicepstendon to its attachment at the supe-rior margin of the glenoid. Initial at-tempts are made to preserve the ten-don for use as a landmark for properplate placement. However, if the bi-ceps tendon is frayed or appears to beat risk of rupture, a subpectoral te-nodesis can be performed after defin-itive fixation. This will eliminate apotential source of pain and preventthe possibility of postoperative rup-ture.

The pectoralis is not routinely re-leased; rather, 20% of its upper bor-der may be cut to facilitate exposure( video, 4:54-6:40). In the event ofa fracture-dislocation, the head isgenerally located anterior and medi-al to the glenoid along the glenoidneck. In certain circumstances,

Figure 3

Side (A) and front-on (B) views of patient positioning for intraoperative fluoroscopy for proximal humerus fracture fixation.(Reproduced with permission from Badman B, Mighell M, Drake G: Surgical technique with fibular strut allograft and fixed anglelocked plating. Tech Should Elb Surg 2006;7:95-101.)

Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures




there may be a large Hill-Sachs de-fect of the humeral head fragment af-ter it is impaled on the anterior rimof the glenoid. In this situation, allreleases should be performed first,including release of the pectoralismajor tendon and lateral conjoinedtendon as well as release of the sub-coracoid and subdeltoid spaces. Akey elevator or a Cobb elevator canbe used to assist in prying and relo-cating the head fragment back intothe joint. Overzealous pulling on thefragment should be avoided, to pre-vent inadvertent injury to the neu-rovascular structures lying in closeproximity. When a diminished radi-al pulse is noted on preoperativeassessment in a patient with afracture-dislocation, it may be pru-dent to have a vascular surgeon im-mediately available at the time offracture relocation should a vascularinjury be encountered.

Fracture and TuberosityPreparation

The overall anatomy of the frac-ture is identified. To mobilize thefracture fragments, a Krackow stitchis placed with a no. 2 FiberWire (Ar-threx, Naples, FL) in the substanceof the subscapularis. If the lesser tu-berosity is a free fragment, the su-ture should be placed at the tendon-bone interface. Additional suturesare placed in the substance of theinfraspinatus and supraspinatus oraround the tendon-bone interface ofthe greater tuberosity if this is alsoa separate fragment ( video, 7:43-8:01). The suture fixation in the cuffcan then be used to mobilize the hu-meral head and tuberosities. Thesesutures will also aid in manipula-tion, compression, and reduction ofthe fracture and will ultimately helpcounter the natural deforming forc-es of the rotator cuff after they aretied to the fixed plate. To expose theshaft, the arm is taken off the Mayostand and extended. All fracture he-matoma is removed, and the canal isirrigated.

Fracture ReductionAfter adequate removal of frac-

ture debris, the head is reduced intoproper anatomic alignment. A fingercan be placed through the rotatorinterval into the joint to assist withproper orientation. Typically, thehead fragment falls into varuspositioning. With the assistance of akey elevator, the head can be elevat-ed back into proper alignment( video, 8:06-8:21). Typically, afterelevation of the head fragment, alarge metaphyseal void will exist asa result of the overall fracture com-minution. In this situation, we rou-tinely use a bulk structural allograft(ie, tricortical iliac crest graft, fibularcortical allograft) to help buttress thehead fragment and prevent loss of re-duction postoperatively. The graft isplaced intramedullary within theshaft of the proximal canal, and theshaft is reduced as the head is im-pacted onto the prominent allograft.Next, a 2-mm Kirschner wire (K-wire) is placed through the uppermargin of the head fragment, and thewire is driven through the articularcartilage into the glenoid to helpmaintain reduction of the head. Al-

ternatively, the humeral head can bepinned to the humeral shaft to helpmaintain reduction. The wire is bentto avoid interference with the appli-cation of the plate. Fluoroscopy isused to confirm proper head posi-tioning. If it is unacceptable, thewire is removed, and the head is ma-nipulated and pinned again until ac-ceptable reduction is established.

Once the humeral head is correct-ly positioned in the joint, the tuber-osities are brought beneath the headto buttress the articular segment.The traction sutures in the front andback of the rotator cuff are used toassist in reduction of the tuberosi-ties. The shaft is then reduced to theproximal segment and provinciallyheld in place with a 2-mm K-wire.The overall alignment is verifiedwith fluoroscopy. If there is a largegreater tuberosity fragment, anotherK-wire can be placed through theposterior shoulder below the poste-rolateral acromion and into the tube-rosity to help maintain reduction(Figure 4, A) ( video, 9:20-9:35).The tuberosities are then reducedaround the allograft (Figure 4, B)( video, 8:28-9:16). In situations of

Figure 4

A, Provincial pinning of the humeral head and greater tuberosity with 2-mmKirschner wires. B, Fibular strut allograft placed intramedullary for the patient with alarge metaphyseal void. This helps support the head fragment.







extreme comminution, we stronglyrecommend the use of a structuralallograft to fill the void that may per-sist. We have found this to be bene-ficial in maintaining postoperativealignment and preventing varus col-lapse of the head fragment in pa-tients with compromised bone.

PlatingOnce reduction is confirmed, an

appropriately sized internal fixationplate is selected. Several locking

plates by various manufacturers arecurrently available. In our experi-ence, design aspects important inplate selection include a low profileto minimize overhead impingement,divergent proximal locking screw op-tions to improve fixation in the headand reduce the risk of pullout, sutureeyelets on the plate that allow for sta-ble tuberosity fixation and compres-sion (Figure 5), and head screws that

match the anatomic neck-shaft angleof the proximal humerus. Generalrecommendations are to position theplate just lateral to the bicipitalgroove, with the upper portion of theplate sitting 2 to 3 cm distal to thetop of the humeral head (Figure 6)( video, 1:36-3:05; 9:40-9:49; 9:56-10:01). Most plates have a slottedgliding hole; this should be drilledfirst in its center to allow for minoradjustments in plate height. Typi-cally, this shaft screw is not locking,which allows the plate to be com-pressed to the bone. The shaft screwsgenerally measure 28 mm in length.The implant height is confirmed un-der fluoroscopy. Most plates haveseparate K-wire holes that allow forprovisional head fixation. We mostcommonly use the S3 plate (Hand In-novations, Miami, FL), which is po-sitioned appropriately when the pro-visional K-wire passes through thecenter of the humeral head (Figure 7)( video, 10:10-10:49; 11:19-11:28).The remaining proximal screw holesare then drilled and tapped throughthe cortex, and the appropriatelysized screws are inserted while main-taining reduction of the tuberosityfragments. We prefer to hand-tap thehead screw holes because it providesbetter tactile feedback when the tipencounters the thin cortical shell ofthe head. This prevents inadvertent

Figure 6

Lateral view of proper plate positioningfor proximal humerus fracture. Theplate is placed just posterior to thebicipital groove and 1 to 2 cm belowthe top of the humeral head.

Figure 7

Central placement of a Kirschner wirefor provincial plate fixation. The glidinghole is drilled to allow minoradjustments in plate height.

Figure 5

Commonly used proximal humerus locking plates. A, Philos plate (Synthes, Paoli, PA). B, S3 plate (Hand Innovations, Miami,FL). C, Numelock plate (Stryker, Mahwah, NJ).





articular penetration, which canoccur when using power tools(Figure 8) ( video, 11:28-12:25;12:27-12:38; 13:03-13:16).

Fluoroscopy may aid in appropri-ate screw sizing. With the S3 system,screws and pegs are offered for fixa-tion of the head fragment. In gener-al, screws are only used when treat-ing an anatomic neck fragment inwhich purchase in the bony segmentis critical for fixation. Otherwise,smooth pegs are preferred because ofthe danger of the hardware penetrat-ing the joint if the head collapsesinto varus. We feel that a smooth pegwould inherently cause less damageto the joint than would a threadedscrew. The peg also provides a great-er surface area for the head segmentto rest on and can theoretically pro-vide better support, similar to theway rebar reinforces concrete.

Tuberosity FixationTuberosity fixation to the plate is

the most critical step in providingoverall fracture stability. Much likethe principles used with shoulderhemiarthroplasty, fixation of the tu-berosities to the plate helps counterthe deforming forces of the contract-ing rotator cuff musculature. In ouropinion, the high failure rate notedwith traditional fixation was likelythe result of the unopposed pull ofthe rotator cuff and, to some extent,the absence of fixed-angle screws. Al-though fixed-angle screws alone maybe sufficient to counter these forcesin young healthy bone, most proxi-mal humerus fractures occur inpatients with compromised bone.By themselves, unicortical lockingscrews may not provide rigid enoughfixation to prevent pullout and frac-ture displacement.27 Avoidance of tu-berosity failure and ultimate fracturefailure necessitates that the pull ofthe rotator cuff be counterbalancedvia heavy suture or tape passedthrough the tendons or, preferably, ispassed around the tendon-bone inter-face of the tuberosities and tied to theplate. Plates with suture eyelets at

the proximal portion are advanta-geous in this regard for facilitatingfixation. Some plates require that thesutures be passed through the eyeletsbefore applying the plate to the bone.This can be time-consuming. In-stead, we recommend the use of aplate that allows for sutures to bepassed after the plate is secured tothe bone. The FiberWire sutures thatwere previously placed through thesubscapularis, supraspinatus, and in-fraspinatus are passed through theeyelets and secured to the plate (Fig-ure 9) ( video, 13:24-13:48; 14:12-14:21). We prefer to place at least twosutures through the posterior cuffand two sutures in the subscapu-laris. The remaining shaft screwsare then drilled, and the appro-priately sized screws are placed( video, 14:25-14:49). After tube-rosity fixation, the arm is rotated toassess fracture stability, and final flu-oroscopic imaging is obtained. It iscritical to obtain orthogonal viewsduring imaging to ensure that all

screws are appropriately sized( video, 14:52-15:09). The rotatorinterval is closed with a no. 2 Ethi-bond suture (Ethicon, Somerville, NJ)or FiberWire, and the wound is closedin standard fashion. Closure of therotator interval is critical to avoid in-stability.

PostoperativeManagement

The patient is placed in a shoulderimmobilizer. Frequently, a patient isadmitted 1 to 2 days postoperativelyfor pain relief and for 24 hours of in-travenous antibiotics. The immobi-lizer is strictly used for 2 to 4 weekspostoperatively, depending on intra-operative assessment of fracture sta-bility. For stable two-part fractureswith secure fixation, we often discon-tinue the immobilizer at 2 weeks andallow gentle pendulum and active-assisted forward elevation with thecontralateral extremity. Three- andfour-part fractures are usually keptrigidly immobilized for 4 to 6 weeks,with elbow and wrist range of motionencouraged. For all fracture types, for-mal therapy with a therapist is not

Figure 8

Humerus locking plate with proximalhead screws sequentially inserted.In general, the most proximal centralscrew is inserted first, followed by theproximal anterior, proximal posterior,distal central, distal anterior, and distalposterior screws.

Figure 9

Lateral view of the proximal humerusdemonstrating Krackow suturespassed through the rotator cuff andtied to the plate through the sutureeyelets.







Pearls• The patient’s head should be placed at the foot of the operating table, with the head in 30° of elevation.

This allows for better fluoroscopic imaging and easier fracture reduction ( video, 15:34-16:56).

• The fluoroscope is placed at the head of the bed, parallel with the operating room table. Good imagingshould be ensured before prepping the patient.

• A second Mayo stand may be used to help support the arm and assist with fracture reduction.

• Adequate releases of the subdeltoid and subcoracoid space should be performed. Release of up to 25% ofthe lateral conjoined tendon and the upper border of the pectoralis major tendon can be done to facili-tate exposure.

• A Browne deltoid retractor (Innomed) is vital in assisting with retraction of the deltoid and passing thesutures around the tendon-bone interface of the greater tuberosity.

• For three- and four-part fractures, the rotator interval should be released to the level of the glenoid.

• Krackow sutures should be placed in the subscapularis and infraspinatus tendons with a heavy suture,preferably a no. 5 or no. 2 FiberWire. If the tuberosities are detached fragments, the sutures should beplaced around the tendon-bone interface. This allows for control of the fracture and substantially assistswith reduction.

• The head is typically in the varus position, and the surgeon should use a key elevator to help reduce itinto proper alignment.

• Once the head is reduced, one or two 2-mm K-wires should be passed through the upper portion of thehead fragment into the glenoid to maintain proper reduction. The K-wire should be bent 90° to keep itout of the way for the remainder of the surgery.

• The surgeon should ensure that the fracture is reduced before plate application.

• The first screw placed should be in the gliding hole of the plate to allow for minor adjustments in im-plant height after fluoroscopic imaging. This screw is placed in compression and should be non-locking.

Pitfalls

• The biceps tendon should be identified. Devascularization and mobilization of the tendon should be avoid-ed, unless it is entrapped in the fracture site. When possible, the surgeon should preserve the ascendingbranch of the anterior circumflex artery, which lies at the lateral edge of the bicipital groove. When thereis significant degeneration of the biceps tendon, a subpectoral tenodesis can be performed. However, thesurgeon should make every effort to keep the tendon until the plate is attached to assist with proper platepositioning.

• For a patient with compromised bone quality in which a large metaphyseal void exists after elevation ofthe humeral head, the surgeon should consider the use of a tricortical iliac crest graft or a fibular corti-cal allograft placed intramedullary in the proximal canal of the shaft. This allows for structural supportof the articular head segment and reduces the risk of postoperative varus collapse.

• The greater tuberosity in an elderly patient is often a thin wafer of bone, making it nearly impossible toallow for adequate screw purchase. For this reason, heavy suture should be placed around the tendon-bonejunction. The suture should be secured to the plate to allow for adequate fixation.

• The deforming forces of the muscular cuff should be counterbalanced by securing the tuberosities to theplate via heavy suture (no. 2 or no. 5 FiberWire) passed through the tendon-bone interface of the subscap-ularis, supraspinatus, and infraspinatus using a Krackow stitch. This will help avoid fracture subsidenceand potential postoperative failure.

• The surgeon should avoid manufacturer plates that require passing of the tuberosity sutures before theplate can be secured to the humeral shaft.

• An internally rotated view of the shoulder with the arm abducted should be obtained to ensure that theposterior screws are not too long.

• To prevent early failure and allow for adequate wound healing, physical therapy should not be started tooearly.




begun until at least 4 to 6 weeks post-operatively, at which time passive-and active-assisted range of motionactivities are initiated. Unassisted ac-tive motion is allowed at 8 weekspostoperatively or when callus forma-tion is first noted radiographically(Figure 10). Strengthening is insti-tuted in the last phase of therapy, typ-ically beginning at 12 weeks.

Outcomes

The treatment of proximal humerusfractures with fixed-angled lockedplating still warrants caution be-cause of the lack of comparable da-ta with other treatment methods.However, several recent studieshave been encouraging. In a three-part fracture model, Weinstein etal28 found that the locking plate pro-vided better torsional fatigue resis-tance and stiffness than a bladeplate. Edwards et al29 noted that alocking plate was far superior to aproximal humerus nail in regard toboth varus bending and torsional sta-bility. Given that most proximal hu-merus fractures fail because of rota-tional and bending moments, suchadded stability could potentially pre-vent many of the failures noted withother implant types.30

Recently, several authors havepresented short-term results, withmixed outcomes. Kettler et al31 re-ported on 225 fractures treated withthe Philos plate. One hundred andseventy-six patients were availablefor review. Complications resultingfrom technical error included 24screw perforations (11%), 8 implantdislocations (4.5%), and 25 cases(14%) of initial malreduction of thehead and tuberosities. Other compli-cations included loss of reductionwith secondary screw perforations in14 cases (8%), two infections, twohematomas, partial osteonecrosis in9 cases (5%), and complete osteone-crosis in 5 (3%). Björkenheim et al32

reported their early clinical experi-ence of 72 patients treated with thePhilos proximal humerus locking

plate. At 1-year follow-up, twononunions were noted, and threepatients developed osteonecrosis.Forty-eight patients had anatomicfracture healing. Nineteen fractureswere noted to have mild postopera-tive settling; these subsequentlyhealed in mild varus positioning.Traction sutures were used to aid inthe initial reduction. However, theauthors did not comment on wheth-er they were tied to the plate to as-sist in maintaining the reduction.Patients in this study were startedon immediate passive range of mo-tion, with active motion started asearly as 4 weeks. Fankhauser et al33

reviewed their experience of 28 pa-tients with 29 proximal humerusfractures treated with the lockingproximal humerus plate. Twenty-four of these fractures were AO clas-sification type B or type C. All frac-tures healed. Five complicationswere noted, with one broken plateand four instances of loss of reduc-tion (one related to a deep infection).Two patients developed partial os-teonecrosis, one after deep infection.In this series, traction sutures wereincorporated into the plate, but ac-tive motion was initiated as early as2 weeks. The authors did not com-ment on the use of bone graft. Mostrecently, Owsley and Gorczyka34

presented their series of 53 patientstreated with a locking plate with aminimum follow-up of 1 year. Nine-teen patients (36%) had radiograph-ic signs of complications, with intra-articular screw cutout in 12 (23%),varus displacement in 13 (25%), andosteonecrosis in 2 (4%). A higher in-cidence (43%) of cutout regardless offracture type was seen in patientsolder than age 60 years. While tube-rosity sutures were utilized in allcases, structural allograft was not in-corporated. Furthermore, the radio-graphic example in the article of an“acceptable” reduction of a four-partvalgus impacted fracture shows clearevidence of a malaligned construct.If this was deemed acceptable in allcircumstances, this could be one ex-

planation for their relatively highfailure rate.

Summary

We believe that a reproducible stan-dard surgical technique is necessaryfor improved patient outcomes.Many of the plates that are currentlyavailable provide a fixed-angle devicewith multiple divergent screws, butmore is needed than an innovativeplate design to avoid complicationssuch as loss of reduction and screwcutout. The treating surgeon mustapproach a proximal humerus frac-ture as both a bony and a soft-tissueprocedure. Other surgeons have usedtraction sutures, but not all havecommented on their incorporationinto the plate. This is a critical stepthat should not be skipped because itallows the deforming forces of therotator cuff to be counterbalancedand neutralized via heavy suture thatis resistant to breakage and is tied tothe plate. We advocate passing thesesutures around the tendon-bone in-terface to provide a bony buttressand prevent the stitch from pullingthrough the soft tissue. We routinelyuse a structural allograft to fill themetaphyseal void that is frequentlyencountered after reduction of the

Figure 10

Postoperative anteroposteriorradiograph of a patient who underwentlocked plating for a four-part proximalhumerus fracture.



fragments. In so doing, the void thatwould usually allow for the articularhumeral head segment to collapseinto varus (resulting in screw pene-tration into the joint) is filled, en-abling the graft to buttress the headsegment and minimize subsidence.Ultimately, although the fixed-angleplate is a useful tool, it is not the solefactor in providing good outcomes.Basic principles of rigid fracture fix-ation, structural bone graft, andstrong, secure soft-tissue repairshould be followed.

References

Citation numbers printed in boldtype indicate references publishedwithin the past 5 years.

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