Proximal Humerus Fractures - Locking
Proximal Humeral Plate, T2 Proximal
Humeral Nail
Dr. T M Chan
Department of Orthopaedics
and Traumatology,
Queen Elizabeth Hospital,
Hong Kong SAR
Epidemiology
Proximal humerus fracture is the third
frequent fracture in elderly patients after
hip fracture and Colle’s fracture. Bengner U, Johnell
O, Redlund-Johnell I. Changes in the incidence of fracture of the upper end of the
humerus during a 30-year period: a study of 2125 fractures. Clin Ortho Relat Res.
1988;231:179-182
There is a trend of increasing incidence of
this fracture over 30 years. Palvanen M, Kannus P, Niemi
S and Parkkari J. Update in the epidemiology of proximal humerus fractures. Clin
Ortho Relat Res. 2006;442:87-92
Increasing incidence
From 1970 to 2002,
incidence of proximal
humeral fractures
– From 32 -> 105
– Per 100,000
– Finland study, CORR
2006
=> 7,000 proximal
humeral fractures in
HK ? each year
Neer’s classification
AO classification
Non-operative treatment
The undisplaced fracture can be
treated conservatively with
satisfactory result.
However, non-operative treatment of
complex, displaced fractures often
results in malunion and stiffness of
the shoulder. Leyshon RL. Closed treatment of
fractures of the proximal humerus. Acta Orthop Scand.
1986;57:320-323. Neer CS. Displaced proximal humeral
fractures. II. Treatment of three-part and four-part displacement.
J Bone Joint Surg. 1970;52A:1090-1103
What is the best treatment for
displaced proximal humerus fracture?
Operative treatment
There are various fixation methods for
treatment of displaced proximal humerus
fractures.
Most authors agree on the importance of
anatomical reduction and stable fixation to
allow early mobilization.
Variable methods of
osteosynthesis- which is the best??
Case example with K
wires fixationsubsequent loss of
fixation, malunion
Method of
percutaneous
screws fixation in a
3 parts fracture
(AO Manual)
?? Stable enough for
aggressive
rehabilitation
Traditional Plating
Traditional plates: T
plate, cloverleaf plate
Impingement due to
bulky implant
Problem of screws
purchase in
osteoporotic bone
Problem of implant
breakage and failure
Problems in fixation
Rigid ORIF : difficult in elderly with
osteoporotic bones
Soft tissue stripping - risk of AVN
Malunion between head & tubercles >
between tubercle & shaft ( rotational
deformity the shaft vs the head are better
tolerated than tuberosities malunion)
Osteoporotic bone
Regular bone
Porotic bone
Avascular Necrosis of Head
Incidence after ORIF :
3-parts : 12-25%
4-parts : 41-59%
Methods to avoid AVN :
meticulous soft tissue handling, avoid
damage to the ascending branch of anterior
humeral circumflex artery - bicipital groove
The new plates
Locking Proximal Humeral Plate
New implant characteristics
The new anatomical locking plate provides angular
stability and works in osteoporotic bone. Helmy N and
Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Ortho Relat Res.
2006;442:100-108
Implant characteristics
Anatomically
contoured
Locking head
screws
Angular stability
Screws in different
directions.
Increases pullout
strength
Western size LPHP (Philos)
Proximal Humeral Internal Locked System plate
Asiatic size LPHP
Material & Method
2002-2006, clinical case series
55 patients, consecutive cases with open
reductions and fixation with locking proximal
humeral plates are included in our study
Minimal follow up 6 months (6-24 months),
mean 12 months
Post-operative standard physiotherapy
Regular follow up radiological assessment of
fracture healing and alignment
ROM assessment, pain score and functional
shoulder scores (ASES,UCLA)
Surgical technique
Supine or beach chair position
with fluoroscan control
Deltopectoral Approach
Reduction
Temporary fixation with K wires
Temporary K wires fixation
Position of the LPHP
Correct position of the plate is very
important
Anatomical reduction, correction
position of the plate. Healing well with
good functional outcome.
Tuberosities repaired with sutures
Case examples
Case examples – 2 parts
Case examples – 3 parts
Case examples – 3 part
Case examples – 4 parts
4 parts fracture
RESULTS
55 patients
Male : female = 19:36
Age 20-96, mean 66 years old
Minimal follow up 6 months (6-24 months),
mean 12 months
Fracture types distribution
2 parts
3 parts
3 parts
dislocation
4 parts
22
27
1
5
3-part D, 2%
4-part, 9%
2-part
3-part
3-part D
4-part
2-part, 40%
3-part, 49%
Results
Fracture union rate – 52/55 (94%)
Mean union time – 3.5 months
Results
No pain / mild pain – 51 (93%)
Average active forward
flexion – 109 deg
Average active ER- 38 deg
Average active IR – T10
Result function scores
Average ASES score : 78 (53-100) – 78%
Average UCLA score : 27 (19-33) – 77%
Complications
3 out of 55 (5.4%)
loss of fixation in 2 patients and avascular
necrosis of humeral head in one patient.
– 78 years old with 4-part facture, the fixation was lost
in 2/52
– 96 years old with 4-part fracture. She was demented
and could not follow rehabilitation instruction. The
fixation was loss in 2/52
– 74 years old who had a 3-part fracture dislocation.
The humeral head was devascularised due to the
severe trauma. Resulted in avascular necrosis
Complication : AVN
AVN
Humeral
head
3 parts fracture
dislocation in a 74 yo
female
Complication
No case of neurovascular injury
No case of superficial or deep infection
Pitfalls and tricks
Pitfall: screws too long
Intra-operative fluoroscope
Intra op fluoroscan in AP,
Lat and oblique views are
necessary
Attempt to have best bone
purchase with using of long screw.
Post operation XR
Correct position of the LPHP
5-10mm
Use intra-operative
fluoroscope
Pitfall: plate too superior
Varus
humeral head
fragment
Impingement on abduction
Varus malunion
Pitfall: plate too low, not enough bone anchorage
at humeral head fragment
Plate too low, bone purchase
at humeral head fragment is
not enough.
Healed in 6 months,
mild varus alignment.
Pitfall: be careful to lock the screws,
use the guiding block
Slight varus alignment
Radiological assessment after
fracture union
Anatomical alignment in 40/52 (77%)
Fair alignment in 12/52 (23%), which is
defined as angulation more than 20 deg or
translation or collapse more than 5mm
from normal anatomy
(excluding 3 complication cases)
Case of anatomical
alignment
135 deg
Case of varus mal-alginment
100 deg
Normal 130-150
degree
Reduction
Anatomical
Fair
Comparison of outcome in 2 groups
Group
Anatomical alignment Fair alignment
(n=12) 23%
(n=40) 77%
2 parts = 19 (45%)
3 parts = 21 (50%)
4 parts = 2 (5%)
Active ROM FF 112 deg
ER 40 deg
IR T10
ASES = 80.3
Scores
UCLA = 27.6 (78%)
Fracture
type
2 parts = 3 (25%)
3 parts = 8 (67%)
4 parts = 1 (8%)
FF 87 deg
ER 35 deg
IR L1
ASES =70
UCLA = 25 (71%)
Discussion
Our series shows encouraging result with lower
complication rate comparing with recent literature about
the use of locking proximal humerus plate
series
Frankhauser
CORR 2005
Koukakis
CORR 2006
Our series
n
complication
Mean score
29
7 (24%)
Constant =
74.6
20
3 (15%)
Constant =
76.1
55
3 (5.4%)
ASES =78
UCLA = 77
Discussion
Perfect anatomical reduction is sometimes
difficult to achieve due to the presence of
unfavorable factors
– Severe osteoporosis
– Bone loss (prone to collapse)
– Anatomical neck fracture (jeopardize the
griping power of the screws)
Surgical principles
Try to achieve best possible anatomical
reduction. It is associated with better final
ROM and function
Meticulous soft tissue handling, avoid
iatrogenic avascular necrosis of humeral
head
In some 4 part fractures especially in old
age, osteosynthesis may not be possible
Non-viable! For
hemiarthroplasty.
The polyaxial locking plate
Numelock
The polyaxial locking plate
The Numelock
Prof Th Begue, Avicenne Hospital, Paris XIII University
The locking screw enjoy a 30 deg
cone of freedom
Prof Th Begue, Avicenne Hospital, Paris XIII University
The locking mechanism
Prof Th Begue, Avicenne Hospital, Paris XIII University
The Nails
The AO Proximal Humeral Nail
Proximal Humeral Nail
PHN
Subcapital fractures
without comminuted
cervical ( A2&3 ) or
tuberosity fragment
( B1&2 ) , including :
–
–
–
–
–
Fresh traumatic fractures
Pathological fractures
Refractures
Delayed unions
pseudarthroses
PHN
The Spiral Blade
consistently prevents
tilting of the humeral
head or migration of
the implant
Especially in
osteoporotic bone
No loss of reduction
PHN
Additional wire loops or
sutures fastened to the
tuberosity can be anchored
in the Spiral Blade
– Neutralise muscle tension
– Maintain reduction
Oblique locking bolt allows
fixing lateral cortex to
humeral head
Case example
PHN
Minimally invasive
Angular stability
Neutralises deforming
force
Even in osteoporotic
bone
Guided distal locking
AO Proximal Nail
Angular Stability
Preserve blood supply
Internal splintage
Counters pulling force
Even osteoporotic bone
A2,A3, B1,B2 #s
T2 Proximal Humeral Nails
Indicated in 2,3 and 4 parts fractures
The T2 proximal humeral nail
The targeting device
Standard 150mm length and long
proximal humeral nail
4 proximal locking
screws, with thread
holes, providing
angular stability
Further holded with
nylon bushing
2 distal locking screwdynamic and static
Surgical technique
Entry point is more medial, into
the humeral head
Prof. V Buhren, Murnau, Germany
Head-anchoring entry point
Prof. V Buhren, Murnau, Germany
Principles of reconstruction
Circular bony support
in the proximal end of
the humeral nail
Adjusting screws
fixed in the thread
within the nail
Angular stability with
nylon bushing
Prof. V Buhren, Murnau, Germany
Skin incision, entry of K-wire
Split deltoid approach
Prof. V Buhren, Murnau, Germany
Locking screws insertion
Prof. V Buhren, Murnau, Germany
Examples
Prof. V Buhren, Murnau, Germany
Examples
Prof. V Buhren, Murnau, Germany
Early result from Prof. V Buhren
2003-2006
34 patients, 28 females, 6 males
Mean age 65
3 parts – 20, 4 parts – 14
Operation time 58 min
Additional fixation in 9 (screws, TBW)
Average Constant score 73.7
Prof. V Buhren, Murnau, Germany
Result- complication
Complication (11 patients)
Impingement nail
3
screws
6
Screw movement distally 1
Secondary dislocation
3
Relevant stiffness
4
AVN partial
5
Infection
1
Nerve injury
0
Long head biceps injury 0
2nd prosthesis
0
Prof. V Buhren, Murnau, Germany
Comparisons of new implants
locked plate vs proximal nails
Deltopectoral or split
deltoid
Open reduction
Indicated in 2,3,4 parts
fractures
Additional sutures
needed for tuberosities
repair
Not interfere with
supraspinatus tendon
Minimal invasive or split
deltoid
Close reduction
sometimes need open
reduction
Depends on nail type, AO
PHN for 2,3 parts or ( A,B
types) where as T2 nail
for 2,3,4 parts fractures
Additional sutures
needed for tuberosity
repair
Entry site may injure the
supraspinatus tendon
Conclusions
Proximal humerus fracture is a challenging
fracture to treat
New implants like locking plates and
proximal nails are both showing
encouraging early results
Surgeon need to know the strength,
limitation and indication of each implant
Thank you!