Original Article Journal of Bone and Joint Diseases| Jan - June 2017 | 32;(1):50-55

Evaluation of Clinical and Radiological Outcome of Fracture Proximal

Humerus by Locking Compression Plate Taking into Consideration of
Biomechanics of the Glenohumeral Joint
D C Srivastava¹, Sachin Yadav¹, Alok Gupta¹
Abstract
Introduction: Although several studies have repeatedly emphasized that PHILOS plating gives better functional
outcomes for fracture proximal humerus and that many studies have speculated and concluded various risk factors for
failure or poor functional outcomes, none of them gives a clear idea about the important parameters of the biomechanics
of the glenohumeral joint and their restoration, while fixation with the PHILOS plate. Our aim of study is to assess and
weigh the functional outcomes when PHILOS plating is done for fracture proximal humerus taking into consideration
biomechanics of the glenohumeral joint.
Material and Methods: This was an open label prospective study of 30 patients of proximal humerus fracture who were
treated with with PHILOS plate in SRN Hospital From Sept 2013 to June 2015. Cases were taken up according to
inclusion and exclusion criteria. All the patients were managed by open reduction and internal fixation by PHILOS plate
and all patients underwent a rehabilitation program. The patients were examined clinically and radiologically, assessed
for range of motion and bony union and complication. Further follow ups were done at 6 weeks,12 weeks, 24 weeks,36
weeks and 1 year.
Results: All the patients were followed up for atleast for 12 months (range 12 to 20 months) with the mean follow up
time was 16.5 months. All the fractures united clinically and radiologically around an average of 8 weeks (range7-
11weeks). Constant scores were excellent to good in 21 patients (70%), fair in 5 patients (16.66%), poor in 4 patients
(13.33%).
Conclusion: Management of proximal humerus fractures with PHILOS plate gives the most satisfactory functional
outcome when fixation is done taking into account following parameters: Corrected neck-shaft angle, maintenance of
retroversion of the humeral head and acromio-humeral head distance.
Keywords: Biomechanics, neck-shaft angle, retroversion of the humeral head, acromio-humeral head distance.

Introduction attachment and paucity of space for fixing implant in

Proximal humerus fractures account for approximately 4 fractures of proximal humerus. While for undisplaced
– 5% of the all fractures [1,2,3]. The incidence of fracture fractures, literature strongly suggests nonoperative
is more common in the elderly because of decreased bone treatment [4,5,6] the treatment of displaced fractures is
density. But it can occur in younger age group following still controversial and challenging. The various methods
high velocity trauma [3]. Because of increasing incidence to treat fractures of the proximal humerus are
of high velocity trauma, the fracture patterns in proximal percutaneous cerclage wiring, k-wire fixation, tension
humerus are becoming complicated. It has been always band wiring, intramedullary nailing, plating, and humeral
enigma of management because of numerous muscles head replacement. Of these methods, recent clinical data
1
Department Of Orthopaedics, M L N have shown favorable results for the treatment of
Medical College Allahabad. fractures with locking plates. Important for a
Address of Correspondence successful stabilization of the fracture are in the order
Dr. Ajai Singh of anatomic reduction, medial cortical support,
Department of Orthopaedics Surgery,
K. G. Medical University, Lucknow, India. Dr Dinesh Chandra
proximal humeral bone density, and patient age[7].
Dr Alok Gupta
Email: [email protected] Srivastava

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50| Journal of Bone and Joint Diseases | Volume 32 | Issue 1 | Jan - June 2017 | Page 50-55
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Although several studies have repeatedly emphasized that humerus was taken and fractures were classified
PHILOS plating gives better functional outcomes for according to Neer’s classification.
fracture proximal humerus and that many studies have Of the contralateral shoulder, True AP view and special
speculated and concluded various risk factors for failure or view as described by Volkan oztuna et al11 were taken. On
poor functional outcomes, none of them gives a clear idea true AP view, Neck-shaft angle and acromio-humeral
about the important parameters of the biomechanics of distance of the contralateral limb could be determined.
the glenohumeral joint and their restoration, while Angle created at intersection of lines that are perpendicular
fixation with the PHILOS plate. Restoration of the normal to anatomic neck and parallel to shaft of humerus
three-dimensional anatomy of the proximal humerus is determines the neck shaft angle. Distance between
desirable. This affects the lever arms of the deltoid and undersurface of acromian and top of humeral head
rotator cuff in the vertical plane and soft-tissue balance in determines the acromio-humeral distance. Special view
the horizontal plane. Changes in this anatomy may were taken as described by Volkan oztuna et al [11].
produce abnormal kinematics by malpositioning the joint Posteroanterior semiaxial radiographs of humerus bones
line and by moving the instant centres of rotation [8,9,10]. was taken. This method was performed while the subject
Our aim of study was to assess and weigh the functional was standing with their shoulder in 90° forward elevation
outcomes when PHILOS plating was done for fracture and 20° abduction. The beam was positioned 1 m away
p ro x i m a l h u m e r u s t a k i n g i n to c o n s i d e r at i o n from the shoulder and centered to the humeral head; and
biomechanics of the glenohumeral joint. the fully supinated forearm was placed on the cassette. On
special view as described by Volkan oztuna et al [11],
Material and Method humeral head retroversion is measured, determining the
From SEPTEMBER 2013 to JUNE 2015, 35 humeral anatomical neck axis, outlining a perpendicular
consecutive patients with proximal humerus fractures line to the humeral head joint surface, and a line tangent to
fulfilling the inclusion criteria were treated with open the trochlea, the humeral head retroversion angle being
reduction and internal fixation with PHILOS plate in SRN the acute angle formed by the intersection of both lines.
Hospital. This was an open label prospective study and the Of the 30 patients, there were 16 males (53%) and 14
sampling technique was consecutive non-probability females (47%). Overall mean age was 53.93 years (range
sampling. A total of 35 patients were included in the study 25 to 92 years). According to Neer’s classification: 12
out of which 5 patients could not be followed up for at least patients (40%) had Neer’s two part fracture, 9 patients
1 year. Patients included in this study were based on the (30%) had Neer’s three part fracture and 9 patients (30%)
following inclusion criteria: all displaced two part, three had Neer’s four part fracture. Mean age of the patients with
part, four part proximal humeral fractures, age above 18, Two-part fractures was 55.17 years (range 27 to 92 years).
patient had fitness and willingness for surgery and Mean age of the patients with Three-part fractures was 49
willingness to undergo physiotherapy and posto-perative years(range 25 to 81 years). Mean age of the patients with
rehabilitation program. Exclusion criteria were: associated Four-part fractures was 57.22 years (range 32 to 89 years).
humerus shaft fracture and associated neurovascular 19 patients (63%) had right upper limb involvement and
injury and acute infection, pathological fractures, old 11 patients (37%) had left upper limb involvement.
fractures ( more than 3 months old), compound fractures, All the patients were managed by open reduction and
undisplaced fractures. On admission of the patient, the internal fixation by PHILOS plate. Postoperatively all
general condition of the patient and the vital signs patients were immobilized in shoulder immobilizer,
were recorded. Methodical examination was done to rule appropriate antibiotics and analgesics were used,
out fractures at other sides. The local examination of immediate postoperative radiographs were taken to
injured shoulder was done for swelling, deformity loss of determine the bone alignment and maintenance of
function and altered attitude. Any nerve injury was also reduction, sutures were removed depending upon the
looked for and noted. Local neurologic deficit of axillary condition of the surgical wound.
nerve was also assessed by looking for anaesthetic patch All patients underwent a rehabilitation program in which
over lateral aspect of shoulder. Radiograph of proximal pendulum exercises were begun immediately depending

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Srivastava D C et al www.jbjdonline.com

developed between deltoid and pectoralis major.

Conjoint tendon was identified and retracted
medially. The long head of biceps is the important
landmark as it signifies rotator interval. Traction
sutures were applied to tuberosity fragments using
Ethibond 5 suture to hold and reduce fragments. K-
wires were used in humeral head as joysticks and
fixed temporarily with the humeral shaft. With the
help of c-arm images displaced proximal humerus
fracture was provisionally fixed with k-wires taking
into consideration biomechanics of glenohumeral
joint with the aim to achieve retroversion, neck shaft
Figure1: Pre-op and immediately postoperative radiographs angle and acromiohumeral distance similar to those
of contralateral limb, so that the head was not fixed in
valgus or varus rotation in coronal plane and repair
on pain, passive range of motion were started at 1st the rotator cuff mechanism so as to restore the length
week. The active range of motion were started at 2-4 between undersurface of acromian and head of the
weeks postoperatively, depending on stability of humerus.
osteosynthesis and bone quality. At 4th to 6th Intra operatively after provisionally fixing two, three
week–immobilization was discontinued. Active and four part fracture proximal humerus by k-wires,
assisted movements were started up to 90° abduction abduct the arm if possible (as more clear images could
with no forced external Rotation. At 6th to 8th week- be obtained) and flex the elbow to 90° such that
full range of movements with active exercises started. horizontal line drawn parallel to the ground overlaps
Th e pat i ent s were e x am i n ed c l i n i c a l l y an d both the condyles of the humerus. In this position by C-
radiologically, assessed for range of motion and bony ARM machine take an AP view of the shoulder. Now
union and complication. Further follow ups were done rotate the forearm externally or internally everytime by
at 6 weeks and 12 weeks and 24 weeks and 36 weeks and 10° and take subsequent C-ARM images. At that
1 year depending upon the condition of the patient. At rotation of the forearm externally or internally where
1 year, True AP view and special view of the operated maximum diameter of the head of the humerus is visible
limb as described by Volkan oztuna et al11 were taken to will be the version angle of the head of the humerus. If
measure neck-shaft angle, acromiohumeral head the provisional fixation achieved by k-wires intra-
distance and retroversion angle of the humeral head of operatively was satisfactory ensuring maximum
the operated limb. The final result were evaluated using correction of the various biomechanics parameters of
the following score at 1 year follow up : CONSTANT the glenohumeral joint by c-arm images, rigid fixation
AND MURLEY SCORING SYSTEM. with PHILOS plate was done and k-wires were
Surgical technique: General anesthesia was used in all removed. PHILOS plate was placed about 5 to 10 mm
patients. Patients were placed in supine position on distal to the tip of greater tuberosity (confirmed under
operating table with wedge or a sandbag under the image intensifier) and just lateral to bicipital groove.
spine and medial border of scapula to push the affected First a standard 3.5 mm cortical screw was placed in oval
side forward while allowing the arm to fall backward. hole and tightened lightly. Fracture reduction and plate
Arm was draped free, because it had to be moved during position were reconfirmed under image before placing
the approach. A deltopectoral approach was used. Skin other screws. Locking screws were placed in humeral
was infiltrated with local anaesthetic. The incision was head using drill guide. Drilling was done under
started midway between coracoid and clavicle, and sequent ial f luoroscop ic imag ing to prevent
extended distally up to deltoid insertion. Cephalic vein intraarticular penetration. Subchondral screw position
was identified and retracted laterally. Plane was was confirmed under two image views. Finally screws

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Srivastava D C et al www.jbjdonline.com
Table 4: Various sub-scores of Constant Murley Score
Table 1: Functional outcome Two part fracture
Three part
Four part fracture Over All
fracture

NO. OF PATIENTS 12 9 9 30
Two part Three part Four part
Over all
fracture fracture fracture MEAN PAIN 12.91 ± 2.57 11.11 ± 2.20 7.78 ± 2.64 10.83± 3.24
NO. OF PATIENTS 12 9 9 30 13.27 ±
MEAN ADL 15.67 ± 3.89 14.00 ± 2.45 9.33± 3.60
4.28
MEAN CONSTANT MEAN STRENGTH 21.25 ± 2.00 19.67 ± 2.35 16.00 ± 3.67
19.20 ±
83.33 ± 11.51 75.67 ± 8.94 56.89 ± 15.67 73.10 ± 16.34 3.43
SCORE
29.80 ±
MEAN ROM 33.50 ± 3.92 30.89 ± 4.70 23.78 ± 6.74
6.46

Table 3: Grading of results Table 5: Comparison between sub-scores of Constant Murley

Score in various fracture types.
Two part Three part Four part
Over all PAIN ADL STRENGTH ROM
fracture fracture fracture FRACTURES
NO. OF PATIENTS 12 9 9 30 (p value) (p value) (p value) (p value)
3 PART 0.335 0.843 0.582 0.774
MEAN CONSTANT 2 PART
83.33 ± 11.51 75.67 ± 8.94 56.89 ± 15.67 73.10 ± 16.34 4 PART 0 0.001 0 0.001
SCORE
2 PART 0.335 0.843 0.582 0.774
3 PART
4 PART 0.025 0.023 0.023 0.02
2 PART 0 0.001 0 0.001
Table 2: Functional outcome in various fracture types 4 PART
3 PART 0.025 0.023 0.023 0.02

CONSTANT SCORE
FRACTURES
(p value) Table 6: Radiological parameters compared with opposite limb
3 PART 0.503 UNINJURED
2 PART LIMB
OPERATED LIMB p-value
4 PART 0
MEAN ACROMIO-
HUMERAL HEAD 10.43 ± 0.93 10.30 ± 0.53 0.92
2 PART 0.503
3 PART DISTANCE
4 PART 0.009 MEAN NECK
133.33 ± 3.59 133.23 ± 4.33 0.42
SHAFT ANGLE
2 PART 0 MEAN
4 PART RETROVERSION 31.10 ± 1.98 32.06 ± 2.27 0.08
3 PART 0.009 ANGLE

were placed in humeral shaft. Tuberosity sutures were tied necrosis of the humerus head in 1 patient (3.33%),
to the plate. The wound was closed over a suction drain, superficial infection in 2 patient (6.66%), anterior deltoid
which was removed after 24 to 48 hours -postoperatively. muscle atrophy in 3 patients (10%), transiently decreased
Arm was supported with a sling. radial nerve sensations in 3 patients (10%), subacromial
Statistical analysis: All data were collected on a form with impingement in 2 patients (6.66%).
the patient’s details. Afterwards these data were filled into In our study overall mean Constant Murley score (Table
a Microsoft Excel-2010 sheet for simple calculations. 1) was 73.1 (Range 35-96) with standard deviation of
Statistical analysis was performed over the data using the 16.34. Mean Constant Murley score for Two- part fracture
software SPSS 20.0 for Windows. Test used was the One- was 83.33 with standard deviation of 11.51. Mean
way ANOVA test and Post Hoc Bonferroni test for Constant Murley score for Three- part fracture was 75.67
comparison and analysis of mean Constant score and with standard deviation of 8.94. Mean Constant Murley
mean Neer score between two part, three part and four score for Four- part fracture was 56.89 with standard
part fractures which was considered significant at P <0.05. deviation of 15.67.
RESULTS Pearson correlation coefficient between Constant Murley
All the patients were follow up for 12 to 20 months with Score and Neer Score is 0.98 .
the mean follow up time was 16.5 months. All the fractures Difference in mean Constant Murley scores (Table 2) of
united clinically and radiologically at 8 weeks (range7- Two-part fracture and Three part fracture was not
11weeks). Complications observed were avascular significant (p value 0.503). Difference in mean Constant

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Srivastava D C et al www.jbjdonline.com

Murley scores of Two-part fracture and Four-part fracture proximal humerus fracture by PHILOS is done taking into
was significant (p value 0.000). Difference in mean consideration various biomechanical parameters of the
Constant Murley scores of Three-part fracture and Four- glenohumeral joints, most important being acromio-
part fracture was significant (p value 0.009). Thus two- humeral head distance, neck-shaft angle of the humerus
part fractures and three-part fractures are amenable to give and retroversion angle of the humeral head. It is observed
better functional results than four part results even with that there is no significant difference in these
the best technique and methods of fixation and post biomechanical parameters at one year follow up between
operative rehabilitation. the operated limb and uninjured contralateral limb. Thus,
we have achieved the various important biomechanical
Grading Of Results (Table 3):In our study at one year parameters of the injured limb with fracture proximal
follow up, constant scores were excellent to good in 21 humerus after fixation with PHILOS plate at one year
patients (70%), fair in 5 patients (16.66%), poor in 4 follow up nearly similar to those of contralateral
patients (13.33%) uninjured limb. Overall mean Constant Murley score is
73.1 (Range 35-96) with standard deviation of 16.3398.
Comparison between various sub-scores of constant- Average age and sex adjusted Constant Murley score was
murley score: (Table 4)There was no significant 80.934. The functional outcome based on Constant
difference in pain, activities of daily living, strength and Murley score at one year follow up, is excellent to good in
range of motion between Two-part fractures and Three- 21 patients (70%), fair in 5 patients (16.66%), poor in 4
part fractures ( p value 0.335, 0.843, 0.582, 0.774 patients (13.33%).
respectively). There was significant difference in pain, It is observed that in young patients, internal fixation using
activities of daily living, strength and range of motion the proximal humeral internal locking system (PHILOS)
between Two-part fractures and Four- part fractures ( p plate has yielded better functional outcome than in older
value 0.000, 0.001, 0.000, 0.001 respectively). There was patients. We speculate the role of osteoporosis in older
significant difference in pain, activities of daily living, patients that has lead to above finding. Functional
strength and range of motion between Three-part outcome of two part and three part fracture promixal
fractures and Four- part fractures ( p value 0.025, 0.023, humerus fixed with PHILOS plate are significantly better
0.023, 0.020 respectively)(Table 5). when compared with four part fracture promixal humerus
There is no significant difference between mean acromio- fixed with PHILOS plate. It is observed that there is no
humeral head distance in the uninjured limb and operated significant difference in pain, activities of daily living,
limb at one year follow up ( p value 0.92). There is no strength and range of motion between Two-part fractures
significant difference between mean neck-shaft angle in and Three- part fractures (p value 0.335, 0.843, 0.582,
the uninjured limb and operated limb at one year follow up 0.774 respectively). While there is significant difference in
( p value 0.42). There is no significant difference between pain, activities of daily living, strength and range of motion
mean retroversion angle of the humeral head in the between Two-part fractures and Four- part fractures ( p
uninjured limb and operated limb at one year follow up ( p value 0.000, 0.001, 0.000, 0.001 respectively) & between
value 0.08) (Table 6). Thus we have achieved fixation of Three-part fractures and Four- part fractures ( p value
the proximal humerus fracture with the PHILOS plate 0.025, 0.023, 0.023, 0.020 respectively).
and restored the impor tant three dimensional
biomechanical parameters nearly as that of the CONCLUSION
contralateral normal limb. Proximal humerus fractures demands careful evaluation
of type of fracture and higher surgical skills to restore
DISCUSSION three-dimensional anatomy of the gleno-humeral joint.
The treatment of proximal humerus fractures with Management of proximal humerus fractures with
PHILOS plate gives a satisfactory outcome when fixation PHILOS plate gives the most satisfactory functional
is done taking into consideration biomechanics of outcome when fixation is done taking into account
glenohumeral joint. In our study the fixation of the following parameters:

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Srivastava D C et al www.jbjdonline.com

A) Corrected neck-shaft angle has been associated with range of motion especially in horizontal plane.
better functional outcome as it prevents lengthening of C) Acromio-humeral head distance if maintained is
lever arm of the deltoid and supraspinatus muscles, associated with better functional outcome as it facilitates
abductor muscle dysf unction and subsequent rotator cuff mechanism and prevents impingement of the
subacromial impingement. Thereby associated with early supraglenoid structures.
restoration of range of motion especially abduction. Adequate biomechanical stability is achieved by bone
B) Maintenance of retroversion of the humeral head is grafts in fractures of the base of the neck of humerus
associated with better functional outcome as it prevents having gross metaphyseal communition and bone gap.
shoulder subluxation and maintains the stability and

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How to Cite this Article

Conflict of Interest: NIL
Source of Support: NIL Srivastava D C, Yadav S, Gupta A. Evaluation of Clinical and Radiological Outcome of
Fracture Proximal Humerus by Locking Compression Plate Taking into Consideration of
Biomechanics of the Glenohumeral Joint. Journal of Bone and Joint Diseases Jan - June
2017;32(1):50-55 .

55| Journal of Bone and Joint Diseases | Volume 32 | Issue 1 | Jan - June 2017 | Page 50-55