- Discussion:
- indicated for displaced
surgical neck,
3 part, and
4 part fracture;
- Anterior Approach to Shoulder:
- incision is made along medial border of deltoid extending laterally to humeral shaft;
- cephalic vein protected;
- superior part of pectoralis may have to be divided;
-
deltoid detachment:
- when greater access to proximal humerus is required, more extensive removal of deltoid is required;
- deltoid muscle should be removed from clavicle by raising an osteoperiosteal flap laterally to the acromion;
-
reduction:
-
lesser tuberosity will be found attached to
subscapularis and the rotator cuff to the
greater tuberosity;
- often two are combined as a single fragment, with the long head of
biceps tendon running thru it;
- references:
-
The sub-deltoid approach to the metaphyseal region of the humerus.
-
The extended deltoid-splitting approach to the proximal humerus.
-
The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus.
-
Lessons learned from a case of proximal humeral locked plating gone awry.
- Fixation Techniques:
- Locking Plates: synthes locking plate technique: 
- surgical considerations:
- rotate the table 180 deg so that the foot portion of the table is under the patient's head;
- flouroscope is placed proximal to the head of the table, parallel with the table;
- reduction:
- homan retractor can be inserted into the fracture site to lever the fracture out of varus;
- indirect reduction can be achieved by securing the plate to the head fragment first and the shaft second;
- insert non locking screws through the proximal screw holes inorder to compress the head to contoured plate;
- this will bring the head fragment out of its varus position, and into anatomic alignment;
- note there is a need to optimally reduce and stabilize the fracture inorder to avoid late loss of reduction;
- if medial buttressing is insufficient, especially with a varus malreduction, there may be loss of reduction and subsequent
screw perforation or plate breakage;
- suture fixation:
- consider suture fixation at the tendon osseous juntion (supraspinatus and infraspinatus) for 3 and 4 part fractures;
- in study by Südkamp et al, additional sutures were used to stabilize the greater or lesser tuberosity in the cases of 110 frx (59%)
- suture fixation can not only augment the strength of fixation, but can be used as an initial step to achieve reduction and to ensure that the
plate remains flush against the cortical surface;
- references:
- Transosseous Suture Fixation of Proximal Humeral Fractures (letter to the editor)
- Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
- Transosseous Suture Fixation of Proximal Humeral Fractures
- plate position:
- plate is positioned at least 5 to 8 mm distal to the upper end of the greater tuberosity
- subacromial impingement may occur if the plate is positioned too far cranially
- ref: Lessons learned from a case of proximal humeral locked plating gone awry.
- screw insertion:
- penetration is more likely if the screws are placed too close to the articular surface or if the articular surface is penetrated during drilling;
- inferomedial screws:
- The importance of medial support in locked plating of proximal humerus fractures
- complications:
- Treatment of proximal humerus fractures with locking plates: A systematic review
- references:
- Outcome analysis following removal of locking plate fixation of the proximal humerus.
- Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation.
- Analysis of efficacy and failure in proximal humerus fractures treated with locking plates.
- Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome.
- Early Complications in Proximal Humerus Fractures (OTA Types 11) Treated With Locked Plates.
- Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures
- Outcome analysis following removal of locking plate fixation of the proximal humerus.
* 
-
blade plate technique:
- in the report by D. Ring et al, the authors describe their technique for using of blade plates and autogenous
cancellous bone graft to repair ununited fractures of the proximal humerus in 25 patients;
- healing was documented in 23 of 25 patients (92%);
- objective and subjective instruments documented substantial functional improvement in patients with healed fractures;
- results were classified as good or excellent in 20 of 25 patients, and few complications were encountered;
- references:
-
The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus
- David Ring, MD J Shoulder Elbow Surg 2001;10:501-7
- Semitubular blade plate fixation in proximal humeral fractures. Instrum KA: J Shoulder Elbow Surg 7:462-466, 1995
- Semitubular blade plate for fixation in the proximal humerus. Sehr JR, Szabo RM: J Orthop Trauma 2:327, 1989
- 68 year old female with a fracture dislocation of the proximal humerus surgical neck;
- because of the severe osteoporosis, the humeral shaft was pressed up and into the humeral head for added stability;
- a blade plate construct (using a semitubular plate) was applied into the lateral edge of the humeral head;
- the humeral head gradually reduced into the glenoid over 6 weeks;
***
-
T or L Plate:
- implants include:
-
T plate, L plate, standard
4.5 mm dynamic compression plate;
-
6.5 mm cancellous screw (both lag and fully threaded), & 4.5 mm cortical screws;
- DC plate may be placed laterally if there is sufficient room for two screws proximal to the frx;
- w/ oblique frxs of surgical neck fracture consider placing, a lag screw thru the plate across the fracture line;
- the main disadvantage of lateral plating is that the proximal screws often achieve a weak bite in the proximal humerus, which
can lead to hardware failure;
- in three and
four part frx types, the 5 hole T or L plate may be chosen;
- typically the plate is placed on the anterio-lateral surface of the humerus, just anterior to the deltoid insertion;
- more lateral plate insertion is only possible if the deltoid insertion is stripped;
- anterior limb of T usually crosses long head of the biceps;
- this can be prevented by use of L plate, which allows fixation of proximal fragment w/ 2 large cancellous screws in proximal fragment
with two large cortical screws into the shaft;
- lag screws are inserted from proximal to distal;
-
greater tuberosity fragment should be incorporated into fixation device or, alternatively, may be fixed w/ tension band wiring;
- as pointed out by Koval et al 1996, plate fixation is dependent on the quality of the patient's bone;
- in strong bone, plate fixation provides the strongest fixation, as compared to other methods;
- in osteopenic bone, there is a 3 fold decrease in fixation strength;
- in this case,
percutaneous pinning provides better fixation;
-
disadvantages:
- decreased fixation strength in osteoporotic bone (w/ possible loss of fixation), need for significant soft tissue dissection (which can lead to
avascular necrosis of frx fragments), subacromial impingement from the plate;
- references:
- Surgical Neck Fractures of the Proximal Humerus: A Laboritory Evaluation of Ten Fixation Techniques. KJ Koval MD J. Orthop. Trauma. Vol 40, No 5, 1996, p778.
- in the following example, a 60 year old female demonstrated a displaced proximal humerus frx with lateral displacement of the humeral head;
- treatment simply consisted of an antigluide plate, and at two years postop, there was a anatomic healing;
- Complications:
- hardware failure is a frequent complication w/ osteoporotic bone;
Plate fixation of proximal humeral fractures.
Open reduction and internal fixation of three- and four-part fractures of the proximal humerus.
Fixation of fractures of the proximal humerus with the PlantTan Humerus Fixator Plate: Early experience with a new implant.
