The Journal of TRAUMA威 Injury, Infection, and Critical Care

Case Report

Percutaneous Plating of the Humerus With Locked Plating:

Technique and Case Report
Bruce H. Ziran, MD, William Belangero, MD, Bruno Livani, MD, and Rodrigo Pesantez, MD

J Trauma. 2007;63:205–210.

H
umerus fractures are treated in a variety of different fracture is reduced and screws are placed to provide balanced
ways. Closed treatment is most common with isolated fixation. With screws near and remote to the fracture site, a
injuries, whereas intramedullary nailing and plating are relatively stiff and stable construct is created. In the second
the most commonly used methods for surgical treatment. mode, the plate is placed with remote stabilization (screws
Although there are polarized views on which method is bet- further from the zone of injury) and a relatively long working
ter, each has its distinct advantages and disadvantages. Plat- length. With this method, the resulting construct is flexible
ing incurs a more invasive approach, may be less desirable because of the long working length and stable because of the
cosmetically (especially in women), and may incur more locking mechanism. With the first method of application, an
elbow issues, but it is reliable and has a good success rate. environment of absolute stability is sought, whereas with the
Nailing is known to incur more shoulder complaints, has a second method relative stability is sought. Use of the locked
slightly lower success rate than plating has, but it does not plate with remote fixation makes the application of the plate
impose on the biology of the fracture and is minimally from remote window possible, which avoids opening of the
invasive.1– 4 A recent analysis of the literature found that both fracture site and preserves the biologic envelope. Thus, the
methods are acceptable methods of treatment with the differ- plate can be placed with a minimally invasive approach.
ences noted above.1– 4 Recent reports in a cadaveric study and one clinical
Traditional plating is associated with the need for ana- series have demonstrated that it is feasible to perform mini-
tomic alignment and reduction with respect to the biology. mally invasive plating using two small incisions.5–7 In the
When bone-to-bone contact is achievable, compression and clinical series by Livani and Belangero,6 the plate was placed
load sharing is possible and desirable. When load sharing is anteriorly using standard plating techniques with nonlocking
not possible, standard plates are subject to failure either by plates, and good results were reported. Yet, if standard plates
loosening between the implant bone interface or by fatigue are used, there remains a possibility that construct loosening
failure of the metal. Furthermore, in osteoporotic bone, the could occur, especially with unstable fracture patterns. Al-
purchase of standard bone screws can be difficult and prone though this could be minimized with load sharing or more
to early loosening. anatomic reductions, it would be difficult with minimally
Recently, locked plating has been introduced as a new invasive methods and would necessitate some exposure of the
paradigm in plating technique. The screws do not toggle in fracture zone. Using a long locking plate, indirect reduction
the plate and resistance to axial loading is improved, thus, the methods could be used and the plate could be placed from
plate can function as an internal fixator. In this mode, two remote windows, which would provide a flexible yet stable
methods of application are possible. In the first, the plate can construct. As long as alignment was acceptable, the fracture
be used with traditional goals of more rigid fixation. The would be allowed to heal in an environment of relative stability
with minimal biologic insult. This would be because of the
use of long plate spans with stable locked constructs. In the
Submitted for publication March 10, 2006. present report, we describe the technique of minimally inva-
Accepted for publication May 26, 2006. sive (semi-percutaneous) placement of an anterior humeral
Copyright © 2007 by Lippincott Williams & Wilkins, Inc.
plate using locked plating technique and concepts.
From Orthopaedic Trauma (B.H.Z.), St. Elizabeth Health Center,
Northeastern Ohio Universities College of Medicine, Youngstown, Ohio;
Department of Orthopaedics and Traumatology (W.B., B.L.), Sao Paulo, TECHNIQUES
Brazil; Department of Orthopaedics (R.P.), Fundacion Santa Fe, Bogota The patient is supine with use of a radiolucent armboard.
Colombia.
Address for reprints: Bruce H. Ziran MD, Director of Orthopaedic An assistant provides gentle in-line traction to achieve length,
Trauma, St. Elizabeth Health Center, Associate Professor of Orthopaedic and a roll of towels acts as a fulcrum to overcome gravita-
Surgery, Northeastern Ohio Universities College of Medicine, 1044 Belmont tional sag. A long plate narrow 4.5-mm locking plate with
Ave., Youngstown, OH 44501; email: Bruce_Ziran@[Link]. combi-holes (Synthes, Paoli PA), usually 10 to 14 holes, is
DOI: 10.1097/[Link].0000231870.11908.3e chosen and centered anteriorly over the fracture zone. A

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Fig. 1. Plate is centered anteriorly over the fracture site, which is

determined with fluoroscopic guidance. Incisions are centered over
the second hole from each end.

marker is used to mark the ends of the plate (Fig. 1). From
these ends, a small 3- to 4-cm incision is made and carried to
the fascial layer. Proximally, the cephalic vein might course
in the field. The deltopectoral fascia is opened and, with blunt
dissection, the deep anatomy is exposed. The pectoralis in-
sertion, as well as the deltoid insertion on the humerus, is
palpable with the fingertip. Proximally, the pectoralis is taken
down and the biceps tendon is identified. It is generally
retracted medially and a finger is used to feel for any fascial
obstruction to plate placement. Distally, another 3- to 4-cm
incision is made and taken to the fascial layer. Using the
concept of a “mobile-operating window”, the skin incision is
moved laterally to identify the interval between the brachi-
oradialis and brachialis. In this interval, the radial nerve is
identified by direct vision to ensure its safety (Fig. 2A–C).
Then the skin incision is moved medially and blunt dissection
of the brachialis is performed. Usually the tip of the plate
is easily found. Once the bone under each end of the plate is
identified, the plate is oriented anteriorly and the arm is
aligned clinically. We use the recommendations of Livani
and Belangero,6 which are to position the arm with approx-
imately 60 degrees of shoulder abduction, the elbow is flexed,
and a small bump is placed under the apex of the fracture
(Fig. 3). Fluoroscopy is used to determine any adjustments
that are needed. Once satisfactory alignment is achieved, the
plate is centered over the bone in each window. We find it
useful to carefully place on each side of the bone two small
Fig. 2. (A) Distal operating window showing the antebrachial cu-
Hohmann retractors to assist with the centering of the plate.
taneous nerve. (B) Moving to the interval between the brachialis and
The locking handles can be used in the end holes to facilitate
the brachioradialis, the radial nerve is identified. After the nerves
alignment and positioning of the plate (Fig. 4A–B).
are identified, the interval through the lateral third of the brachialis
A unicortical screw is place in the second hole from one
is used to expose the humerus. (C) Retractors on each side of the
end and gently tightened to pull the bone to the plate (Fig.
bone protect the nerves. Retraction is only performed during
5A–B). Then the bump under the fracture apex is used to
screw placement to avoid any inadvertent traction injury during
maintain reduction in the sagittal plane and fluoroscopy is
manipulation.
used to verify appropriate alignment before placing the sec-
ond unicortical 4.5-mm screw on the opposite end of the plate
(again in the second hole from the end). Rotational alignment

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 Plating of Humerus With Locked Plating

Fig. 3. A bump is placed under the arm as a fulcrum and a towel

is used for traction. The arm is place at approximately 60 degrees
of abduction and the elbow is flexed to determine rotation.

Fig. 5. (A–B) The second to last hole is used to place a unicortical

standard screw to help pull the plate and bone together. This allows
provisional alignment and fixation and in case repositioning is
needed, the far cortex is not sacrificed. Thereafter, the final fixation
is performed. (C) Bicortical locking screws are placed in holes 1
and 3 for stability. The initial standard unicortical screw can be
Fig. 4. (A) Plate is slid under the muscle and alignment is facil- exchanged for either a bicortical screw or a locking screw; we have
itated with the locking handles. (B) A standard screw is placed not found this to be necessary.
into the second hole on each end once the plate is centered over
the bone and satisfactory fracture alignment is verified.

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 The Journal of TRAUMA威 Injury, Infection, and Critical Care

was determined using the landmarks of the biceps tendon and

flexed elbow forearm. If the fracture is stable, it is possible to
provide some manual compression via proprioceptive feed-
back. As these screws are further tightened, the bone and
plate construct have some provisional stability. The sagittal
reduction can usually be verified with rotation of the shoulder
at this point.
If at this point, alignment of the fracture and orientation
of the plate is acceptable, then bicortical-locking screws are
placed in holes one and three at each end of the plate. Now,
the unicortical 4.5-mm locking screw can be converted to a
bicortical 4.5-mm standard screw or exchanged for a bicor-
tical locking screw. The unicortical 4.5 mm is used so that
adjustments can be made without jeopardizing the far cortex
of the bone. The 4.5-mm screw can be loosened and the plate
and bone can then be adjusted. If needed, another unicortical
4.5-mm screw could be placed into holes one or three but
would need to be exchanged to a bicortical locking screw at
the end of the case. The final desired configuration is at least
two locking screws in holes one and three at each end, with
either a standard 4.5-mm screw or a locked 5-mm locking
screw in between (in hole two) (Fig. 5C). The incisions are
cleansed and closed in standard fashion. Bracing is provided
for comfort and active and passive motion with weight bear-
ing as tolerated is allowed. Figure 6A–C shows initial post-
operative and healed radiographs.

CASE REPORT
Table 1 summarizes the patient data; eight patients were
treated with this technique and went on to heal uneventfully.
In the following text, a brief summary of each patient’s
course is presented. Patients were allowed unrestricted activ-
ity with weight bearing as tolerated using a standard humeral
fracture brace for comfort. All patients went on to radio-
graphic and clinical healing. There were no cases of antebra-
chial radial nerve injury. The radial nerve was identified in
each case in the distal window and protected during plate and
screw insertion. As seen in the table, the incision size pro-
gressively decreased between 2.5 and 3.5 cm, as experience
grew. Also, a 12-hole plate became the standard plate size. At
first, the initial standard screws in the second to last holes
were replaced with locking screws. With experience, the
initial unicortical standard screw was not exchanged and only
two bicortical locked screws were used.
In two cases, the fracture involved either the surgical
neck or the proximal quarter of the humerus; so long 3.5 Fig. 6. Serial radiographs of healing. (A) Initial lateral demon-
Proximal Humeral Locking Plates were used in the same strating construct. (B–C) Radiographs at 3 months.
fashion. In some of the earlier cases a 10-hole plate was used,
but we realized that it would be more advantageous to use a to enhance the construct strength. Flexible fixation was used
12-hole plate. A 12-hole not only allows for windows of when anatomic reduction with lag screws was not possible.
insertion further from the zone of injury, but it also increases Two patients (numbers 3 and 4) had slight loss of motion
the working length and the flexibility of the construct. In a of the shoulder but each had an ipsilateral clavicle fracture.
few segmental cases, the plate ends were relatively close to We think that these associated conditions may have influ-
the fracture. If there were fracture patterns amenable to enced the resultant motion. One patient (number 5) with a
closed reduction and lag screw fixation, this was performed head injury was transferred out of the area with only short-

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Volume 63 • Number 1
Table 1 Patient Data
F/U Shoulder Elbow Shoulder Elbow
Patient Age Sex L/R AO/OTA Plate Holes Assoc. Inj. Complications Healed Incision (cm)
Months Pain Pain ROM ROM

1 14 23 M L C2.1 12 hole 1,2,3,9,10, None No No None Abd-160 0–130 Yes Prox 4.0
11,12 Flex-150 Dist 4.0
IR-L2
ER-30
2 12 43 M L A3.2 10 hole 1,2,3,8,9, None No No None Abd-160 0–135 Yes Prox 3.5
10 Flex-160 Dist 4.0
IR-L2
ER-30
3 12 35 M R B1.2 10 hole 1,2,3,8,9, R clavicle No No None Abd-150 5–130 Yes Prox 2.5
10 Flex-150 Dist 3.5
IR-L3
ER-25
4 lost 48 M R B2.2 12 hole 1,2,3,10, Clavicle, N/A N/A N/A Abd-150 0–125 Yes Prox 2.5
11,12 CHI Flex-150 Dist 2.5
IR-L4
ER-20
5 9 21 M R B2.2 12 hole 1,2,3,10, CHI, L No No None Abd-140 0–135 Yes Prox 2.5
11,12 BBFA, L Flex-140 Dist 2.5
tibia/fibula ER-30
IR-L3
6 6 64 F L A3.2 12 hole 1,2,3,10, L tibial No No Preoperative radial Abd-160 5–125 Yes Prox 2.5
11,12 plateau, L nerve palsy Flex-160 Dist 3.0
MC neck IR-L3
ER-25
8 4 22 F L A3 12 hole 1,2,3,9,10, R acet. No No Radial nerve. Abd-180 0–135 Yes Prox. 3.5
11 Improved Flex-150 Dist 3.5
IR-L3
ER-30
F/U, follow up; L/R, left/right; ROM, range of motion; Pvox, proximal; Dist, distal; CHI, closed head injury; BBFA, both bone forearm fracture; MC, metacarpal; IR, internal rotation;
ER, external rotation; Abd, abduction; Flex, flexion; Prox, proximal; Dist, distal; Assoc. Inj., associated injury; Acet., acetabulum.

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Plating of Humerus With Locked Plating
 The Journal of TRAUMA威 Injury, Infection, and Critical Care

term clinical (1 month) follow-up, but radiographs obtained The technique described in the current report uses a plate
remotely demonstrated good healing. The last patient had in a combined method. After percutaneous placement, initial
preoperative radial nerve palsy. Because she also had a closed reduction and provisional stabilization is performed with
manipulation and reduction during plate placement, she had a standard screws that allow minor adjustments. The placement
small incision made laterally to ensure that the nerve was not of standard screws helps pull the bone to the plate (effect a
accidentally entrapped in the fracture site because of inter- reduction) and uses the plate in a “standard” mode. A uni-
vention. In fact, the nerve crossed the septum at the level of cortical screw is used if placement of the plate has to be
the fracture but was free from tenting and entrapment. At the changed. The far cortex is not violated and does not compro-
time of this writing, the nerve had recovered function. mise placement of screws placed later. The second screw
from each end was used, because it allows the locked screws
DISCUSSION to be placed into holes one and three and thus increases the
The theory behind the present technique rests on the spread of the locked screws. The unicortical screw can be
concept of relative stability. If such a methodology were to be replaced with either a bicortical standard screw or a locking
used with standard plates and screws, the construct would screw. In this aspect, the plate is applied with a similar
undoubtedly fail because of the high stresses experienced at philosophy to external fixation. In fact, locked plates have
the plate bone interface. The frictional interface would be been termed internal fixators because of the similarities of
easily overcome from the long moment arms. If a standard their mechanical function to external fixators.
plate were used, it would be highly recommended to have We acknowledge that the present technique is unproven
greater separation between screws and to have screws closer and requires further study and that follow-up is short. Yet, we
to the fracture zone. This would require more exposure and think that it is important to first establish the safety and
would be very difficult to perform percutaneously. When feasibility of any new technique and then assess its efficacy.
locking screws are used remotely from the fracture zone, For the purposes of the present report, we think that the
there is load transfer to the plate more directly and motion at technique is feasible and appears safe. It is too early to
the fracture site is reflected by the flexibility of the construct. comment on efficacy without a larger series with longer
Thus, there is a stable and controlled micromotion present in follow-up and ultimately a comparative series. However, we
the fracture zone, consistent with relative stability. Also with also note that locked plating itself has little evidence-based
remote screw placement, the motion is distributed over a clinical validation and also requires further evaluation. Stan-
longer span, and the effects of Perren’s interfragmentary dard plates and open plating technique remain the standard by
strain theory are invoked. In fact, if the locking screws are which newer methods and implants must be judged. Further-
placed too close to the fracture zone with the presence of a more, the costs of new technology must be weighed against
fracture gap, Perren’s strain theory would imply that this potential benefits, and we have not identified any studies that
would potentially amplify the effects of gap instability and make any valid comparisons. As such, new products and
potentially reduce healing. techniques, as described in the present report, must be inter-
However, there is one theoretical caution that exists with preted in this context. The intention of the present report is
locked plating theory. If bone contact is not achieved during not to purport this technique as a replacement to standard
reduction and gaps exist, a construct that is too stiff may not techniques but to describe a potential application of such
allow the stimulus of micromotion that is involved with plates in a manner that uses the theories behind its design.
secondary healing (endochondral). In this scenario, gaps be-
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