- 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;
- Fixation Techniques:
-
synthes locking plate technique:
*
-
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.
Early Complications in Proximal Humerus Fractures (OTA Types 11) Treated With Locked Plates.
