Main Article Content
OBJECTIVE: To report functional and radiological outcomes of open reduction andinternal fixation of proximal humeral fracture with anatomical LCP using 6 stepwiseintraoperative criteria in surgical procedures.
MATERIALS AND METHODS: A total of 30 proximal humeral fractures whichwere treated with open reduction and internal fixation with anatomical LCP ofproximal humerus at a Level 1 and a Level 2 trauma center between January 2012 toDecember 2015 were collected. All patients were operated using the sametechnique in the supine position on a radiolucent table. The surgical approach was deltopectoralapproach. The operation was strictly done following 6 stepwise intraoperativeprocedures, this included: Step 1) reduction and fixation of head fragments. Thereference image in the true AP fluoroscopic view named “beetle car” appearance wasapplied in all cases; Step 2) plate positioning with the humeral head, according torecommendation of implant surgical instructions; Step 3) fix the plate to the humeralhead; Step 4) plate positioning to the shaft; Step 5) fix the shaft to the plate includingadditional locking head screws, head and calcar fixation and; Step 6) secure the suturesof the cuff to the plate. All patients received a similar physical therapy program followinginternal fixation. According to the Neer’s classification, there were 13 two-partfractures, 12 three-part fractures and 5 four-part fractures. The functional outcomes,Constant scores, and radiological outcomes (head-shaft angle and complications) wereanalyzed. The mean follow-up time was 18 months.RESULTS: At the end of the follow-up period, all fractures united with acceptablealignment. The mean Constant score for the injured side was 86 points (range 42–92).Head-shaft angle minor varus (115-124) in 5 patients, normal (125-145) 22, minor valgus(146-155) 1 and major valgus (>155) in 2 patients. 2 patients (6.6 %) had complicationswhich was confirmed by radiologic assessment. It was also found that one case hadsecondary intraarticular screw penetration and another had secondary varus duringfollow up. Both of the cases had severe osteoporosis, but no reoperation was required.
CONCLUSION: This study reports on the functional and radiological outcomes ofopen reduction and fixation of displaced proximal humeral fracture with anatomicallocking compression plate using these developed 6 stepwise operative procedureswhich showed reasonable good to excellent outcomes with low complications. Thisstudy strongly suggested that the 6 stepwise surgical procedures should be strictlyfollowed in the correct order as a surgical strategy to prevent complications arisingfrom the operative technique of internal fixation of the complex proximal humeralfracture. from the operative technique of internal fixation of the difficult proximal humeralfracture.
This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2. Zyto K, Ahrengart L, Sperber A, To¨ rnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br 1997;79:412-7.
3. Neer 2nd CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am1970 ;52:1077-89.
4. Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg Br 1984;66:104-8.
5. Court-Brown CM, Garg A, McQueen MM. The epidemio- logy of proximal humeral fractures. Acta Orthop Scand 2001;72:365-71.
6. Park MC, Murthi AM, Roth NS, et al. Two-part and three- part fractures of the proximal humerus treated with suture fixation. J Orthop Trauma 2003;17:319-25.
7. Robinson CM, Page RS, Hill RM, et al. Primary hemiarthroplasty for treatment of proximal humeral frac- tures. J Bone Joint Surg Am 2003;85:1215-23.
8. Brunner F, Sommer C, Bahrs C, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 2009;23:163-72.
9. Fankhauser F, Boldin C, Schippinger G, et al. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 2005:176-81
10. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007;21:676-81.
11. Clavert P, Adam P, Bevort A, et al. Pitfalls and complica- tions with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 2010;19(4):489-94.
12. Solberg BD, Moon CN, Franco DP, et al. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma 2009;23:113-9.
13. Solberg BD, Moon CN, Franco DP, et al. Surgical treat ment of three and four-part proximal humeral fractures. J Bone Joint Surg Am 2009;91:1689-97.
14. Bigorre N, Talha A, Cronier P, et al. A prospective study of a new locking plate for proximal humeral fracture. Injury 2009;40(2):192-6.
15. Faraj D, Kooistra BW, Vd Stappen WA, et al. Results of 131 consecutive operated patients with a displaced proxi- mal humerus fracture: an analysis with more than two years follow-up. Eur J Orthop Surg Traumatol 2011; 21(1): 7-12.
16. Ruchholtz S, Hauk C, Lewan U, et al. Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. J Trauma 2011;71 (6):1737-44.
17. Brorson S, Frich LH, Winther A, et al. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop 2011;82(4): 475-81.
18. Soliman OA, Koptan WM. Four-part fracture disloca- tions of the proximal humerus in young adults: results of fixation. Injury 2013;44(4):442-7.
19. Soliman OA, Koptan WM. Proximal humeral fractures treated with hemiarthroplasty: does tenodesis of the long head of the biceps improve results? Injury 2013;44(4):461-4.
20. Clavert P, Adam P, Bevort A, et al. Pitfalls and complica- tions with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 2010;19(4):489-94.
21. Konrad G, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical tech- nique. J Bone Joint Surg Am 2010;92(Suppl.1pt 1):85-95.
22. Ruchholtz S, Hauk C, Lewan U, et al. Minimally insive polyaxial locking plate fixation of proximal humeral fractures: a prospective study.J Trauma 2011;71(6):1737- 44.
23. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.
24. Hertel R. Fractures of the proximal humerus in osteopo- rotic bone. Osteoporosis Int 2005;16:65-72.
25. Micic ID, Kim KC, Shin DJ, et al. Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures. J Orthop Sci 2009;14:596 601.
26. Tan J, Lee HJ, Aminata I, et al. Radiographic landmark for humeral head rotation: A new radiographic landmark for humeral fracture fixation. Injury 2015;46(4):666-70.