ACTA

ORTHOPAEDICA
et
TRAUMATOLOGICA Acta Orthop Traumatol Turc 2010;44(2):97-104
TURCICA doi:10.3944/AOTT.2010.2275

Locking plate fixation of three- and four-part

proximal humeral fractures

Atilla Sancar PARMAKSIZOĞLU, Sami SÖKÜCÜ, Ufuk ÖZKAYA, Yavuz KABUKÇUOĞLU, Murat GÜL

Department of Orthopedics and Traumatology, Taksim Training and Research Hospital, İstanbul

Objectives: We evaluated the functional results of open reduction and internal fixation with a
locking plate in patients with three- or four-part fractures of the proximal humerus.
Methods: We reviewed 32 consecutive patients (22 women, 10 men; mean age 63 years; range 29
to 82 years) who were treated with open reduction and internal fixation using the PHILOS locking
plate for comminuted proximal humeral fractures. According to the Neer classification, 12 patients
(mean age 56 years) had three-part fractures, 19 patients (mean age 67 years) had four-part fractures,
and one patient had a four-part fracture dislocation. Ten patients were in the age group of <60 years,
22 patients were in the age group of 60≥years. All the patients were evaluated with plain radiographs
preoperatively; in addition, computed tomography was used in 14 patients in whom articular surface
and tuberculum displacement could not be assessed adequately. The operation was performed through
a standard deltopectoral approach, and minimal soft tissue dissection was used aiming not to impair
vascularization of the fracture fragments. A cerclage wire was used to help reduction in 12 patients. An
oblique screw was inserted to stabilize the medial colon in cases in which medial cortical contact was
insufficient. Bone grafting was not used in any of the patients. Active-assisted and passive exercises
of the shoulder were initiated on the second postoperative day. Active abduction to 90 degrees was
allowed two weeks after surgery. During follow-up, implant failure, loss of reduction, malunion, and
bone healing were assessed on plain radiographs. Bone scintigraphy was performed after 12 postop-
erative months for the detection of avascular necrosis. The results were assessed using the Constant
shoulder score. The mean follow-up period was 25 months (range 18 to 36 months).
Results: An anatomic or near-anatomic reduction was obtained in 29 patients (90.6%). In two
patients, the fractures were fixed in a varus position, and in one patient, the greater tubercle was
displaced proximally. All fractures united in a mean of three months (range 2 to 5 months). The
mean Constant score of the patients was 79.5 (range 50 to 100). The results were excellent in 13
patients (40.6%), good in nine patients (28.1%), fair in eight patients (25%), and poor in two pa-
tients (6.3%). The mean Constant scores were 88.3 (range 69 to 100) and 74.2 (range 50 to 100) in
three-part and four-part fractures, and 88.3 (range 71 to 100) and 75.5 (range 50 to 100) in the age
groups of <60 years and ≥60 years, respectively. Constant scores showed significant differences
with respect to the number of comminution and age groups (p=0.03). Avascular necrosis was
observed in two patients. None of the patients had reduction loss, implant failure, deep infection,
or neurovascular injury, and none required implant removal.
Conclusion: Preservation of humeral head vascularity through minimal soft tissue dissection,
fixation with a locking plate, and early postoperative motion were effective in decreasing potential
complications following surgical treatment of three- and four-part proximal humeral fractures.
The degree of fracture comminution and age of the patients affect functional results significantly.
Key words: Bone plates; fracture fixation, internal/methods; humeral fractures/surgery; shoulder fractures.

Correspondence: Ufuk Özkaya, MD. Taksim Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, 34433 Beyoğlu, İstanbul, Turkey.
Tel: +90 212 - 252 43 00 / 1409 e-mail: [email protected]
Submitted: May 26, 2009 Accepted: December 27, 2009
© 2010 Turkish Association of Orthopaedics and Traumatology
98 Acta Orthop Traumatol Turc

Three- and four-part fractures represent 13% to 16% dislocation. All the patients were evaluated with plain
of all proximal humeral fractures.[1] Although one or radiographs (anteroposterior, lateral, and axillary
more fragments may be totally displaced in 15% of views); in addition, computed tomography was used
the patients, fragments may still keep their attach- in 14 patients in whom articular surface and tuber-
ments through preserved soft-tissue composed of culum displacement could not be assessed on plain
the intact rotator cuff, capsule, and uninjured perios- radiographs.
teum.[2] Preservation of this intact soft tissue envelope Ten patients were in the age group of <60 years,
during surgery is of utmost importance in all frac- 22 patients were in the age group of 60≥years. The
tures, particularly high energy and/or comminuted mean ages of the patients with three-part and four-
fractures, to achieve reduction without endangering part fractures were 56 years (range 29 to 75 years)
vascularity of the fragments and restore revascular- and 67 years (range 57 to 82 years), respectively. The
ization of the humeral head.[3,4] most common mechanism of injury was fall in 21
Many different techniques have been described patients. None of the patients had neurologic impair-
for the treatment of comminuted fractures of the ment on admission. All patients received prophylactic
proximal humerus, including closed reduction and 1 g of first-generation cephalosporin preoperatively.
percutaneous K-wire fixation, open reduction fol- Operative technique
lowed by fixation with bone sutures, tension band,
The operation was performed in the beach-chair
cerclage wire, T-plate, intramedullary nails, or lock-
position through a standard deltopectoral approach.
ing plate, and prosthetic replacement.[5-26] Complica-
Meticulous care was taken during minimal soft tis-
tions have been reported including implant failure,
sue dissection in order not to impair vascularization
avascular necrosis, nonunion, malunion, nail migra-
of the fracture fragments. Bone fragments were not
tion, rotator cuff impairment, and impingement syn-
exposed. A Schanz screw was used as a joystick
drome.[2,10,11,14,15] The incidence of these complications
under fluoroscopic guidance for indirect reduction
has been reported to be higher in elderly patients
of the humeral head into the glenoid. A cerclage
compared to younger age groups.[10]
wire was placed around the tendinous insertions of
The purpose of this study was to evaluate the re- the greater and lesser tuberosities and was used as
sults of open reduction and internal fixation with a a reduction clamp to reduce the fracture. Kirsch-
locking plate in patients with three- or four-part frac- ner wires were used to temporarily fix the fracture
tures of the proximal humerus. fragments. Using the image intensifier, the height
and position of the PHILOS locking plate were
Patients and methods checked and the plate was placed 5-10 mm distal
We reviewed 35 patients who were treated with open to the greater tubercle and 2-3 mm posterior to the
reduction and internal fixation using the PHILOS bicipital groove, leaving adequate space between the
locking plate (Proximal Humeral Internal Locking plate and the long head of the biceps tendon. First,
System, Synthes, Stratec Medical, Mezzovico, Swit- the proximal locking screws were inserted into the
zerland) for comminuted proximal humerus fractures humerus head. Then, the distal screws were inserted
during 2005 and 2007. Inclusion criteria were as fol- into the humeral metaphysis or diaphysis. Tendinous
lows: (i) three-part or four-part fractures according to insertions of both tubercles were fixed to the plate
the Neer classification system;[27] (ii) valgus impacted using 5/0 nonabsorbable sutures (polyethylene tere-
fractures described by Stableforth;[28] (iii) presenta- phthalate). Care was taken to obtain sufficient corti-
tion within 10 days after fracture occurrence; and cal contact medially; in cases in which this was not
(iv) patients older than 18 years of age. Three patients possible, an oblique screw was inserted inferomedi-
were excluded; two due to presentation beyond 10 ally to stabilize the medial colon, as described by
days of injury, and one due to a history of metastatic Gardner et al. (Fig. 1).[29]
tumor. Of the remaining 32 patients (22 women, 10 Bone grafting was not used in any of the patients.
men; mean age 63 years; range 29 to 82 years), 12 A broad arm sling was used postoperatively and the
patients had three-part fractures, 19 patients had four- patients were discharged on the fourth postoperative
part fractures, and one patient had a four-part fracture day (range 2 to 7 days). Active-assisted and passive
Parmaksızoğlu et al. Locking plate fixation of three- and four-part proximal humeral fractures 99

(a) (b) (e)

(f) (g)

(c)

(h)
(d)

Fig. 1. (a) The anteroposterior radiograph of a 66-year-old woman sustaining a four-part fracture of the left humerus
after a fall. (b) Computed tomography clearly demonstrates the comminution of the fracture. (c) Intraoperative
views of the fracture showing preservation of soft-tissue attachments to avoid further devascularization of the
bone. (d) Intraoperative fluoroscopic views of the fracture showing a Schanz screw used as a joystick to ana-
tomically reduce the humeral head into the glenoid and Kirschner wires to temporarily keep the reduction of the
fragments. (e) Intraoperative view showing fixation of the fracture using a locking plate. (f) Immediate postopera-
tive radiograph shows reduction and internal fixation of the fracture using a locking plate and cerclage wire and
an oblique screw inserted inferomedially to provide medial support. (g) Postoperative radiograph obtained at 12
months shows solid union of the fracture with no loss of reduction. (h) Bone scintigraphy performed at postopera-
tive 12 months shows no sign of avascular necrosis.

exercises of the shoulder were initiated on the second shoulder score.[30] The mean follow-up period was 25
postoperative day under the supervision of a physical months (range 18 to 36 months).
therapist. Active abduction to 90 degrees was allowed For comparison of functional results with respect
two weeks after surgery. to age groups of patients (<60 years vs. ≥60 years)
Follow-up was designed at monthly intervals for and the type of fractures (3-part vs. 4-part), the Mann-
the first six months, and yearly thereafter. Implant Whitney U-test was used. P values of less than 0.05
failure, loss of reduction, malunion, progress of bone were considered significant.
healing were assessed on plain radiographs (antero-
posterior, lateral, and axillary views). Bone scintig- Results
raphy was performed after 12 postoperative months Of 32 patients, an anatomic or near-anatomic reduc-
for the detection of avascular necrosis. At final fol- tion was obtained in 29 patients (90.6%) (Fig. 2). Two
low-ups, the results were assessed using the Constant patients whose fractures were fixed in a varus position
100 Acta Orthop Traumatol Turc

(a) (b) (e)

Fig. 2. (a) The anteroposterior radiograph of a 71-year-

old man sustaining a four-part fracture of the
left humerus after a road traffic accident. (b)
Computed tomography clearly demonstrates
(c) (d)
the comminution of the fracture. (c) Immediate
postoperative radiograph shows anatomical
reduction and fixation of the fracture using a
locking plate and cerclage wire placed around
the subscapularis tendon. Osseous continuity
and a stable medial colon were obtained. (d)
Postoperative radiograph obtained at 12 months
shows solid union of the fracture with no loss
of reduction. (e) Bone scintigraphy performed
at postoperative 12 months shows no sign of
avascular necrosis.

had a fair functional result. In another patient, early (74.2, range 50 to 100) fractures (p=0.03), and be-
postoperative examination showed that fixation of the tween patients younger than 60 years of age (88.3,
greater tubercle had been made while proximally dis- range 71 to 100) and ≥60 years of age (75.5, range 50
placed. The patient refused revision surgery and later to 100) (p=0.03).
developed subacromial impingement and limitation in
It was observed that computed tomography was
abduction, and finally was considered to have a poor
helpful in patients in whom articular surface and tu-
functional outcome. No reduction loss was observed
berculum displacement could not be assessed satis-
during the follow-up of these three patients. Despite
factorily on plain radiographs.
the presence of radiographic and clinical bony union,
the patient with a four-part fracture dislocation devel- Discussion
oped partial collapse of the humeral head, avascular
necrosis, and penetration of the screw into the joint There is controversy concerning both the surgical in-
(Fig. 3). However, the patient whose Constant score dications and treatment algorithms for proximal hu-
was fair was satisfied with the functional outcome, so meral fractures.[3,6,7,9-11,31] The management of three-
no further treatment was planned. Avascular necrosis and four-part fractures is even more complicated; open
was also observed in a patient with a four-part frac- reduction and internal fixation using conventional or
ture, who ended up with a poor result. locking plates have been recommended.[4,14,17,19,20,32]
Meticulous care must be taken to preserve the over-
All fractures united in a mean of three months lying soft tissues during open reduction and internal
(range 2 to 5 months). None of the patients had deep fixation since damage to these soft tissues may dis-
infection, implant failure, or neurovascular injury. turb the vascularity of fracture fragments.[4,29,32] Thus,
None of the patients required implant removal. the ideal incision to be chosen is also controversial;
At final assessments, the results were excellent in some authors favor the standard deltopectoral inci-
13 patients (40.6%), good in nine patients (28.1%), sion,[4,19,20,23-25] while some recommend the anterolat-
fair in eight patients (25%), and poor in two patients eral acromial incision on the grounds that the former
(6.3%). The mean Constant score of the patients was may cause injury to the anterior circumflex artery,
79.5 (range 50 to 100). The mean Constant scores which has an important role in vascularization of the
showed significant differences between patients hav- humeral head.[17,21] In our study, we used the standard
ing three-part (88.3, range 69 to 100) and four-part deltopectoral incision in all the patients.
Parmaksızoğlu et al. Locking plate fixation of three- and four-part proximal humeral fractures 101

(a) (b) (c)

Fig. 3. (a) The anteroposterior radiograph of a 69-year-old man with a four-part fracture dislocation of the left humerus
occurring after a fall. (b) Immediate postoperative radiograph shows anatomical reduction, internal fixation of the
fracture, and a stable medial colon. (c) Radiograph of the fracture at postoperative 12 months shows partial collapse
of the humeral head and penetration of the screws into the joint.

Conventional radiographs are usually adequate to Nonunion is another potential complication of

evaluate the comminution of the fracture, displace- three- or four-part fractures of the proximal hu-
ment of the fragments, and congruity of the articu- merus. Wijgman et al.[32] reported union in all their
lar surface in proximal humeral fractures. However, patients treated with open reduction and internal
computed tomography has been recommended in fixation using either cerclage wires or butress plates.
fractures where plain radiographs fail to provide ad- Jaberg et al.[7] encountered nonunion in 4% of pa-
equate information to assess articular surfaces and tients following closed reduction and percutaneous
tuberculum displacement.[17,19] Computed tomography K-wire fixation of unstable proximal humeral frac-
was used in 14 patients in whom the articular surface tures. The incidence of nonunion following open
was not clearly seen on plain radiographs. reduction and internal fixation using locking plates
Complications may have an adverse effect on func- has been reported as 2.7% to 8%.[19,20,23-25] Nonunion
tional results. The most important complications en- was not observed in our study, being mainly attrib-
countered in the treatment of three- or four-part frac- utable to our attentive surgical approach to handle
tures are nonunion and avascular necrosis.[32-35] The soft tissues.
incidence of avascular necrosis has been reported in The incidence of infection is low following open
a wide range of 4% to 75%.[7,32-36] Wijgman et al.[32] reduction and internal fixation using locking plates.
pointed out the importance of obtaining a stable osteo- Egol et al.[20] observed only one case of acute infec-
synthesis and preservation of vascularity of the frag- tion in their series of 51 patients who mainly had
ments through meticulous surgical handling of soft tis- three- or four-part fractures. Gardner et al.[29] report-
sues. The main advantage of the locking plate system ed superficial wound dehiscence in one patient, and
is that early and stable fixation can be obtained even
Moonot et al.[24] reported one superficial infection
in elderly osteoporotic patients.[4,22] However, avascu-
that healed with oral antibiotic treatment. No super-
lar necrosis may occur even with the use of locking
ficial or deep wound infection was observed in our
plates in the management of proximal humeral frac-
study. This may be related to appropriate antibiotic
tures.[4,15,20] Gerber et al.[35] found a direct relationship
prophylaxis as well as to good preservation of soft
between avascular necrosis and poor functional results.
tissues during surgery.
In our study, avascular necrosis developed in only two
patients (6.3%), one with a four-part fracture, and the Implant failure and loss of primary fixation of
other with a four-part fracture dislocation. Minimal the implants occur in 2.7% to 13.7% following open
soft tissue dissection without disturbing the vascular- reduction and fixation with a locking plate in proxi-
ity of the humeral head was thought to be effective in mal humeral fractures.[15,20,24,25] During radiographic
decreasing the risk for avascular necrosis. follow-up, Owsley and Gorczyca[19] observed pen-
102 Acta Orthop Traumatol Turc

etration of the screws to the joint in 23% of their score as 77 at the end of 12 months. The authors
patients and a tendency to varus displacement. In emphasized the role of increased stability provided
a series of 29 patients treated with a locking plate, by the PHILOS plate in starting early motion and
Fankhauser et al.[16] reported implant failure in one obtaining good functional results. Using a similar
patient and loss of reduction in four patients. Agude- postoperative rehabilitation program, Egol et al.[20]
lo et al.[25] found a statistically significant correla- and Papadopoulos et al.[4] achieved good functional
tion between a primary varus malreduction defined results. Moonot et al.[24] allowed active exercises af-
as the head-shaft angle of <120 degrees and loss of ter three postoperative weeks in three- and four-part
reduction. Gardner et al.[29] noted that the presence fractures. In our study, the mean Constant scores
or absence of medial support had a significant ef- were 88.3 and 74.2 in patients having three-part
fect on the degree of postoperative reduction loss. and four-part fractures, respectively, showing a sig-
In our study, excluding the two patients whose frac- nificant difference in favor of three-part fractures.
tures were initially fixed in a varus position of 90 Despite some studies reporting no significant differ-
degrees, no reduction loss or implant failure were ences between functional results of patients in the
seen following fixation of the fractures. Partial col- age groups of <60 years and ≥60 years,[20,24] func-
lapse of the humeral head due to avascular necrosis tional results in our study were significantly better
and screw penetration into the joint were observed in patients younger than 60 years of age.
in the patient with a four-part fracture dislocation. This study has some limitations. First, there was
Malunion is another potential complication in the no other treatment or control group to compare our
treatment of proximal humeral fractures. Moonot et results. Second, as in most series on proximal hu-
al.[24] reported the incidence of malunion as 6% fol- meral fractures, the number of patients was relative-
lowing open reduction and internal fixation with a ly small. Finally, its retrospective design is another
locking plate of three- and four-part fractures of the limitation of this study. On the other hand, two main
proximal humerus. Björkenheim et al.[15] reported strengths of this study merit mention. First, the data
that 26.3% of the fractures having two, three, or four pertain to a specific type of injury, three-part or four-
parts united in a slightly varus position after open part fractures of the proximal humerus which are
reduction and internal fixation with a locking plate. quite challenging even for experienced shoulder sur-
Agudelo et al.[25] considered primary varus reduc- geons. Second, despite different surgeons performing
tion to be an important risk factor for poor results. the operations, the results were found similar indicat-
Gerber et al.[35] who achieved an anatomic reduction ing the feasibility of the technique.
in 88.2% of the patients concluded that this was the In conclusion, preservation of the vascularity of
major factor to obtain a good functional outcome. the humeral head through minimal soft tissue dissec-
In our study, anatomic reduction was observed in tion and fixation with a locking plate were effective in
90.6% of the patients and good functional results decreasing potential complications following surgical
were attributed to both anatomic reduction and rigid treatment of three- and four-part proximal humeral
fracture fixation. fractures. The degree of fracture comminution, age
Atalar et al.[8] used tricortical bone graft to sup- of the patients, and the role of early postoperative
port the impacted humeral head in patients with val- motion must be considered to obtain good functional
gus impacted fractures. We did not use bone graft in results.
our patients and none developed loss of reduction.
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