Abstract
The proximal humeral locking plate (PHLP) is a recently developed fixed-angle implant that is an option for open reduction–internal fixation of an unstable displaced proximal humeral fracture. Various articles have reported successful outcomes using the PHLP when compared with other implant designs. However, many complications still occur with use of the PHLP, such as avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. These complications are related to the difficulty in fixation of this particular type of fracture, as well as ineffective surgical technique. We have therefore proposed a step-by-step surgical technique for open reduction–internal fixation of an unstable displaced 3-part proximal humeral fracture using a PHLP. This technique focuses on the precise placement of the PHLP according to the plate design, as well as an effective intraoperative assessment, to improve surgical outcomes and prevent the various complications of proximal humeral fractures.
Open reduction–internal fixation (ORIF) of an unstable displaced proximal humeral fracture is a difficult procedure for general orthopaedic surgeons. The difficulty arises from the fact that it involves fixation of a comminuted fracture in an unfamiliar skeletal area, and the fixation can be particularly difficult when the patient has osteoporosis. Many studies have reported successful outcomes when fixation is performed with a recently developed fixed-angle implant.1, 2, 3, 4 The proximal humeral locking plate (PHLP) is widely preferred for fixation when compared with other implant designs. However, even with the use of the PHLP, many complications still occur after fixation, including avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration.3, 4, 5, 6 To our knowledge, only a few studies in the literature have described the surgical technique in detail, and these studies are still lacking in certain key points that will enable the surgeon to avoid the complications previously described. Therefore, we propose a surgical technique for the fixation of a 3-part proximal humeral fracture using the PHLP. This technique mainly focuses on the precise placement of the plate according to the plate design. This technique is a synergism of anatomic knowledge, traumatology, and sports medicine. It enable the surgeon to achieve adequate surgical fixation as well as adequate intraoperative assessment for avoidance of complications.
Surgical Technique
The key to achieve successful reduction of an unstable displaced 3-part proximal humeral fracture is to attempt to convert a 3-part fracture into a 2-part fracture by converting the 2 parts at the humeral head (the humeral articular part with the attached lesser tuberosity and greater tuberosity) into 1 part, with the humeral shaft as the second part (Fig 1A). After this is completed, the PHLP can assist in further reduction (Fig 1B). In this surgical technique, the type of PHLP used is the Philos plate (Proximal Humeral Internal Locking System; Synthes, Solothurn, Switzerland). Under general anesthesia, the patient is placed in the beach-chair position (at a 60° angle). This position improves shoulder mobilization during surgery. The surgical technique can be described in 4 simple steps as described in the following sections.
Fig 1.
Anteroposterior fluoroscopic images. (A) The proximal humeral locking plate is temporarily placed and fixed with a K-wire after converting the 2 parts at the humeral head (humeral articular part with attached lesser tuberosity and greater tuberosity) into 1 part (H) and leaving the humeral shaft (S) as the second part. (B) The plate assists in reduction of the head and shaft part by insertion of the compression screw (arrow).
Step 1: Surgical Approach and Axillary Nerve Identification
With respect to the fracture configuration, the superolateral approach is generally chosen because it provides greater access to the greater tuberosity and requires minimal soft-tissue dissection when compared with the deltopectoral approach. A 6- to 8-cm incision is made at the anterolateral aspect of the acromion (Fig 2). Superficially, the deltoid is split between the anterior and middle fibers in line with the skin incision (Video 1). The deep part of the deltoid requires careful dissection because the axillary nerve lies in this layer of the deltoid and is located approximately 5 cm below the acromion process. To avoid injury to the axillary nerve, the nerve is identified and looped with a vascular loop (Fig 3).
Fig 2.
Left shoulder in beach-chair position. A 6- to 8-cm incision (arrow) is made at the anterolateral aspect of the acromion (A). (C, tip of coracoid process; D, distal clavicle.)
Fig 3.
Left shoulder in beach-chair position through superolateral approach. The axillary nerve (arrow) lying in the deep layer of the deltoid is identified and looped with a vascular loop. The nerve is usually located 5 cm below the acromion process.
Step 2: Long Head of Biceps Tendon Identification, Rotator Cuff Suture, and Humeral Head Assessment
The long head of the biceps tendon is identified at the bicipital groove along with the lesser tuberosity medially and the greater tuberosity laterally. Heavy sutures (No. 2 Ethibond; Ethicon, Somerville, NJ) are then placed at the lesser and greater tuberosity. These allow mobilization of the fracture fragments, which in turn assists with the reduction. The sutures placed at the lesser tuberosity are pulled laterally to correct the retroversion of the humeral head, whereas the sutures placed at the greater tuberosity are pulled in a downward direction to correct any varus deformity (Fig 4). To avoid avascular necrosis of the articular part, the lesser tuberosity and the subscapularis tendon attached to the lesser tuberosity should be carefully protected; they are the last resort of the blood supply to the articular part of the humerus. A safe assessment of the articular part of the humeral head can be performed by opening the rotator interval with an incision along the biceps tendon and the upper border of the subscapularis tendon. Insertion of a gloved index finger allows us to directly assess the articular part (Fig 5) without violating the blood supply of the articular part (Video 1). The example of the arthroscopic view from the posterior portal of the left shoulder shows the gloved index finger entering through the rotator interval (Fig 6). This step not only helps confirm the correct version of the articular part but also corrects placement of the plate, given that it needs to be placed opposite the articular part to allow maximum purchase of the diverted locking screws (Fig 7). Once the precise plate placement is achieved at both the humeral shaft (5 mm lateral to the bicipital grove) and the humeral head (opposite the articular part), an anatomic reduction is likely. The latter is rarely mentioned in the literature.
Fig 4.
Left shoulder in beach-chair position through superolateral approach. The sutures placed at the lesser tuberosity are pulled laterally to correct the retroversion of the humeral head (black arrow), whereas the sutures placed at the greater tuberosity are pulled in a downward direction to correct any varus deformity (white arrow).
Fig 5.
Left shoulder in beach-chair position through superolateral approach. A gloved index finger is inserted through the rotator interval. (G, greater tuberosity; L, lesser tuberosity.)
Fig 6.
(A, B) Arthroscopic views from the posterior portal of the left shoulder show the gloved index finger (F) entering through the rotator interval. (Bi, long head of biceps tendon; G, glenoid; H, humeral articular part; Ssc, subscapularis tendon.)
Fig 7.
The precise plate (P) placement should be opposite the articular part of the humerus to allow maximum purchase of the diverted locking screws. (B, long head of biceps tendon.)
Step 3: Reduction, Temporary K-Wire Fixation, and Fluoroscopic Assessment
In general, the plate is placed 5 mm lateral to the bicipital groove and 5 to 8 mm below the tip of the greater tuberosity. A K-wire is used for temporary fixation of the reduced 2-part fracture of the head with the aid of suture traction (Figs 1 A and 4). A simple compression screw is placed at the oval hole of the plate. The plate is then used to assist in reduction of the head and shaft part (Fig 1B). The reduction is confirmed by 2 fluoroscopy images, which include the plate view and the screw view. To obtain the plate view, the arm is placed in an internally rotated position. This allows us to see the full profile of the plate. The plate should lie opposite to and be centered over the humeral head, which should have a light-bulb appearance (Fig 8). The screw view is the position in which the articular surface is maximally purchased to the glenoid. The arm is in an externally rotated position of approximately 20° to 30°, corresponding to the degree of retroversion of the humeral head when compared with the humeral shaft (Fig 9).
Fig 8.
A fluoroscopic image of the left shoulder shows the full profile of the plate, which has been referred to as the “plate view.” The arm is placed in an internally rotated position (arrow, inset). The plate should lie opposite to and be centered over the humeral head, which will have a light-bulb appearance.
Fig 9.
A fluoroscopic image of the left shoulder shows the maximum length of the screws, which has been referred to as the “screw view.” The arm is in an externally rotated position of approximately 20° to 30° (arrow, inset).
Step 4: Final Fixation and Suturing of Rotator Cuff to Plate
Once the reduction is confirmed, the remaining screws are placed at the head and shaft, with special attention to the screws supporting the reduced calcar area (Fig 10A). Avoidance of screw penetration should be confirmed by both fluoroscopy and palpation with a gloved index finger. Sutures attached to the rotator cuff are secured to the plate holes for additional stability (Fig 10B).
Fig 10.
(A) The remaining screws are placed at the head and shaft with special attention given to the screws supporting the reduced calcar area (arrow). (B) The sutures attached to the rotator cuff are secured to the plate holes for additional stability.
The 4 simple steps for ORIF of an unstable displaced 3-part proximal humeral fracture using the PHLP are presented in Table 1. A summary of common complications and prevention methods is shown in Table 2.
Table 1.
Four Simple Steps for Open Reduction–Internal Fixation of Unstable Displaced 3-Part Proximal Humeral Fracture Using Proximal Humeral Locking Plate
| Step 1: surgical approach and axillary nerve identification |
| Step 2: long head of biceps tendon identification, rotator cuff suture, and humeral head assessment |
| Step 3: reduction, temporary K-wire fixation, and fluoroscopic assessment |
| Step 4: final fixation and suturing of rotator cuff to plate |
Table 2.
Summary of Common Complications and Methods of Prevention
| Avascular necrosis of articular fragment |
| The lesser tuberosity and the subscapularis tendon attached to the lesser tuberosity should be carefully protected. |
| A safe assessment of the articular part of the humeral head can be performed by opening the rotator interval with direct palpation by a gloved index finger. |
| Malreduction (varus malalignment, incorrect humeral version) |
| The sutures placed at the lesser tuberosity are pulled laterally to correct the retroversion of the humeral head, whereas the sutures placed at the greater tuberosity are pulled in a downward direction to correct any varus deformity. |
| The precise placement of the PHLP at both the humeral shaft and head should be addressed. |
| Screw penetration |
| Gloved index finger assessment should be performed through the rotator interval. |
| Adequate intraoperative fluoroscopic assessment should be performed with the plate view and the screw view. |
PHLP, proximal humeral locking plate.
Discussion
To return to preinjury status, an unstable displaced proximal humeral fracture usually requires ORIF with fracture union in anatomic position for early rehabilitation. The PHLP, a fixed-angle implant, is widely used for anatomic reduction and stable fixation, with various studies reporting successful outcomes. However, there are many common complications associated with this surgical procedure, including avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. In general, the fixation technique for an unstable displaced proximal humeral fracture tends to be problematic because it involves fixation of a comminuted fracture in an unfamiliar skeletal area. Performing the reduction and fixation is particularly difficult in an osteoporotic patient. The intraoperative assessment is also difficult because the proximal humerus connects the upper extremity to the main body trunk, which results in parts of the proximal humerus being obscured by the thoracic cage. Sudkamp et al.6 reported a relatively high postoperative complication rate of 34% in a prospective, multicenter, observational study of proximal humeral fracture fixation with the PHLP. These complications included screw penetration, malreduction, loss of reduction, and avascular necrosis. There were a great number of complications associated with incorrect surgical technique, with 40% of complications already present at the end of the procedure.
Therefore, we propose a step-by-step surgical technique (Table 1) that focuses on the precise placement of the PHLP and how to achieve adequate intraoperative assessment, which will lead to the prevention of common complications listed in Table 2. However, the limitations of this technique should be considered when facing 2 particular situations: The first situation is when there is a 4-part proximal humeral fracture in which the articular fragment is unable to be controlled because of the disruption of the lesser tuberosity (Fig 11). Anatomic reduction is difficult, and a higher risk of avascular necrosis has been reported when compared with a 3-part proximal humeral fracture. Bone autograft or allograft is usually required for reconstruction in this case. The second situation is when there is an impacted fracture in which there is expected bone loss after reduction (Fig 12). In this case, it is also recommended to use bone autograft or allograft to support the fixation. A summary of advantages and disadvantages is presented in Table 3, and tips and tricks are shown in Table 4.
Fig 11.
A 3-dimensional computed tomography scan of the left shoulder shows a 4-part proximal humeral fracture. The articular fragment (H) is difficult to control because of the disruption of the lesser tuberosity (L). (G, greater tuberosity; S, shaft.)
Fig 12.
A computed tomography scan of the right shoulder shows impaction of the humeral shaft into the humeral head (arrow). Bone loss is expected after reduction, and bone grafting is usually indicated.
Table 3.
Summary of Advantages and Disadvantages
| Advantages |
| Our surgical technique is described in 4 simple steps, in a manner that is succinct, is easily understood, and has reproducibility. |
| A superolateral approach gives greater access to the fracture and requires minimal soft-tissue dissection when compared with the deltopectoral approach. |
| Rotator cuff suturing provides secure fracture mobilization when compared with other techniques. |
| Precise placement of the PHLP opposite the articular fragment, confirmed by a gloved index finger, allows maximum purchase of the locking screws. |
| Intraoperative fluoroscopic assessment in the AP and lateral views should be performed in reference to the PHLP position rather than the patient's position. |
| Disadvantages |
| The superolateral approach is not a true internervous approach. The axillary nerve is more at risk of iatrogenic injury when compared with the standard deltopectoral approach. |
| This technique has limitations when used in the following: |
| 4-part fractures (because the articular fragment lacks control) |
| Impacted fractures (because bone loss is usually expected with these types of fractures) |
| Basic shoulder arthroscopy is necessary for assessment of the articular fragment through the rotator interval. |
AP, anteroposterior; PHLP, proximal humeral locking plate.
Table 4.
Tips and Tricks
| Tips | Tricks |
|---|---|
| 1. The superolateral approach gives greater access to the fracture and requires minimal soft-tissue dissection. | 1. After the axillary nerve is identified and looped with a vascular loop, 2 working windows can be accessed either above or below the nerve. |
| 2. The advantages of rotator cuff suturing are as follows: • Secure fracture mobilization is achieved. • Reduction is aided. • The final anchor to the PHLP provides additional stability. |
2. Rotator cuff suturing can be performed with more than 1 suture to each tendon. |
| 3. Placement of the PHLP opposite the articular fragment allows maximum purchase of the locking screws. | 3. Placing a gloved index finger through the rotator interval is a safe way to confirm the correct PHLP position without violating the vascular supply of the articular fragment. |
| 4. Intraoperative fluoroscopic assessment in the AP and lateral views should be performed in reference to the PHLP position rather than the patient's position. | 4. The fluoroscopic plate view and screw view help to detect common complications, particularly varus malalignment and screw penetration. |
AP, anteroposterior; PHLP, proximal humeral locking plate.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
The surgical technique for a 3-part proximal humeral fracture is shown in a 59-year-old male patient who presented with pain after a motorcycle accident caused injury to the left shoulder. Plain radiographs and 3-dimensional computed tomography reconstruction were used to confirm the fracture configuration and orientation. Preoperatively, we decided to operate with the patient in the beach-chair position by use of the superolateral approach and to perform fixation with the proximal humerus interlocking system (Philos plate). The key to achieve successful reduction in a 3-part proximal humeral fracture is to try to convert a 3-part fracture into a 2-part fracture. This is achieved by converting the 2-part fracture at the humeral head into a single part, hence converting a 3-part fracture into a 2-part fracture, after which the Philos plate can be used to further assist reduction. The surgical technique is described in 4 simple steps. Step 1 comprises the surgical approach and axillary nerve identification. The fracture was approached through the superolateral approach, which gives greater access to the greater tuberosity compared with other approaches. After careful soft-tissue dissection, the axillary nerve, which usually lies in the deep layers of the deltoid muscles, is identified and looped with a vascular loop. Step 2 comprises long head of the biceps tendon identification, rotator cuff suturing, and humeral head assessment. The long head of the biceps tendon is identified. The rotator cuff is then sutured, with the subscapularis attached to the lesser tuberosity and the supraspinatus to the greater tuberosity. Pulling the lesser tuberosity helps correct residual retroversion, whereas pulling the greater tuberosity helps correct varus angulation. The rotator interval is cut over and along the biceps tendon and the superior border of the subscapularis to open the rotator interval, giving access to the intra-articular humeral head. The benefit of this step is that it allows assessment of the orientation or version of the humeral head and also helps to assist and confirm fracture reduction. The index finger can be used to help assist reduction and assess version, as shown here in the model, by use of the open approach and in the arthroscopic view. Step 3 comprises fracture reduction and fluoroscopic assessment. This step involves reduction of the fracture fragments with the aid of the sutures that are attached to the greater and lesser tuberosity and conversion of a 3-part fracture into a 2-part fracture. Thereafter, a K-wire is used as temporary fixation for the Philos plate, which further aids in easy and successful reduction of the converted 2-part fracture. The Philos plate ideally should be placed opposite the articular part of the humeral head. The reduction is confirmed in 2 views: the plate view and the screw view. The plate view allows us to see the full profile of the plate. The plate should lie opposite and be centered over the humeral head, which has a light-bulb appearance. The arm is placed in an internally rotated position. The screw view is the position in which the articular surface stays maximally purchased with the glenoid. This corresponds to the arm in 20° of external rotation or 20° of retroversion of the humeral head. Step 4 involves the final fixation of the plate with screws and anchoring of the sutures applied to the rotator cuff to the plate for increased stability. The postoperative plain radiographs show excellent fracture reduction and plate and screw placement. On follow-up at 6 months, an excellent outcome is shown, with the patient able to perform a full range of shoulder movements comparable to the normal shoulder.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The surgical technique for a 3-part proximal humeral fracture is shown in a 59-year-old male patient who presented with pain after a motorcycle accident caused injury to the left shoulder. Plain radiographs and 3-dimensional computed tomography reconstruction were used to confirm the fracture configuration and orientation. Preoperatively, we decided to operate with the patient in the beach-chair position by use of the superolateral approach and to perform fixation with the proximal humerus interlocking system (Philos plate). The key to achieve successful reduction in a 3-part proximal humeral fracture is to try to convert a 3-part fracture into a 2-part fracture. This is achieved by converting the 2-part fracture at the humeral head into a single part, hence converting a 3-part fracture into a 2-part fracture, after which the Philos plate can be used to further assist reduction. The surgical technique is described in 4 simple steps. Step 1 comprises the surgical approach and axillary nerve identification. The fracture was approached through the superolateral approach, which gives greater access to the greater tuberosity compared with other approaches. After careful soft-tissue dissection, the axillary nerve, which usually lies in the deep layers of the deltoid muscles, is identified and looped with a vascular loop. Step 2 comprises long head of the biceps tendon identification, rotator cuff suturing, and humeral head assessment. The long head of the biceps tendon is identified. The rotator cuff is then sutured, with the subscapularis attached to the lesser tuberosity and the supraspinatus to the greater tuberosity. Pulling the lesser tuberosity helps correct residual retroversion, whereas pulling the greater tuberosity helps correct varus angulation. The rotator interval is cut over and along the biceps tendon and the superior border of the subscapularis to open the rotator interval, giving access to the intra-articular humeral head. The benefit of this step is that it allows assessment of the orientation or version of the humeral head and also helps to assist and confirm fracture reduction. The index finger can be used to help assist reduction and assess version, as shown here in the model, by use of the open approach and in the arthroscopic view. Step 3 comprises fracture reduction and fluoroscopic assessment. This step involves reduction of the fracture fragments with the aid of the sutures that are attached to the greater and lesser tuberosity and conversion of a 3-part fracture into a 2-part fracture. Thereafter, a K-wire is used as temporary fixation for the Philos plate, which further aids in easy and successful reduction of the converted 2-part fracture. The Philos plate ideally should be placed opposite the articular part of the humeral head. The reduction is confirmed in 2 views: the plate view and the screw view. The plate view allows us to see the full profile of the plate. The plate should lie opposite and be centered over the humeral head, which has a light-bulb appearance. The arm is placed in an internally rotated position. The screw view is the position in which the articular surface stays maximally purchased with the glenoid. This corresponds to the arm in 20° of external rotation or 20° of retroversion of the humeral head. Step 4 involves the final fixation of the plate with screws and anchoring of the sutures applied to the rotator cuff to the plate for increased stability. The postoperative plain radiographs show excellent fracture reduction and plate and screw placement. On follow-up at 6 months, an excellent outcome is shown, with the patient able to perform a full range of shoulder movements comparable to the normal shoulder.