Intramedullary Plating of Complex Proximal Humerus Fractures: A Case Series

Document Type : RESEARCH PAPER

Authors

Dept of Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, Scotland

Abstract

Objectives: To assess fracture union rates using novel intramedullary plate technique. Post-operative 
humeral neck-shaft angles, patient range of motion and complication profile were secondary outcomes 
of interest.
Methods: Single surgeon, retrospective case series of surgical technique at major trauma centre in Scotland. A 
2.0mm mini-fragment plate was secured to the humeral head to act as an intramedullary strut during fixation in 
complex proximal humerus fractures. Fracture union and neck-shaft angle were assessed radiologically, whilst 
range of motion and complication profiles were assessed clinically.
Results: Twelve patients were followed up for an average of 10 months post-operatively. All achieved bony union 
with a mean neck-shaft angle of 128°. Mean range of motion values were 100° forward elevation, 83° abduction, 
60° internal rotation and 37° external rotation. Four patients required further surgical intervention- two for hardware 
prominence, one for adhesive capsulitis and one for subsequent rotator cuff failure. There were no cases of 
avascular necrosis or infection.
Conclusion: This novel technique addresses the established biomechanical propensity of proximal humerus 
fractures to fail in varus collapse and screw cut-out. This method provides an alternative to arthroplasty in the most 
severe proximal humerus fractures and is readily adopted via standard orthopaedic kit.
 Level of evidence: IV

Keywords

Main Subjects

References

1. Neer CS 2nd. Displaced proximal humeral fractures. I. 
Classification and evaluation. J Bone Joint Surg Am. 1970; 
52(6):1077-1089.
2. Handoll H, Brealey S, Rangan A, et al. The ProFHER 
(PROximal Fracture of the Humerus: Evaluation by 
Randomisation) trial – a pragmatic multicentre randomised 
controlled trial evaluating the clinical effectiveness and costeffectiveness of surgical compared with non-surgical 
treatment for proximal fracture of the humerus in adults. 
Health Technol Assess (Rockv). 2015; 19(24):1-280. 
doi:10.3310/hta19240
3. Oldrini LM, Feltri P, Albanese J, Marbach F, Filardo G, 
Candrian C. PHILOS Synthesis for Proximal Humerus 
Fractures Has High Complications and Reintervention Rates: 
A Systematic Review and Meta-Analysis. Life (Basel). 2022; 
12(2):311. doi:10.3390/life12020311.
4. McMillan TE, Johnstone AJ. Primary screw perforation or 
subsequent screw cut-out following proximal humerus 
fracture fixation using locking plates: a review of causative 
factors and proposed solutions. Int Orthop. 2018; 
42(8):1935-1942. doi:10.1007/s00264-017-3652-6.
5. Jung WB, Moon ES, Kim SK, Kovacevic D, Kim MS. Does medial support decrease major complications of unstable proximal 
humerus fractures treated with locking plate? BMC 
Musculoskelet Disord. 2013;14(1):102. doi:10.1186/1471-
2474-14-102.
6. Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler 
C, Lill H. Biomechanical effects of calcar screws and bone 
block augmentation on medial support in locked plating of 
proximal humeral fractures. Clinical Biomechanics. 2014; 
29(7):735-741. doi: 10.3390/life12020311.
7. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. 
The Importance of Medial Support in Locked Plating of 
Proximal Humerus Fractures. J Orthop Trauma. 2007; 
21(3):185-191. doi:10.1097/BOT.0b013e3180333094.
8. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect Medial 
Reduction and Strut Support of Proximal Humerus Fractures 
Using an Endosteal Implant. J Orthop Trauma. 2008; 
22(3):195-200. doi:10.1097/BOT.0b013e31815b3922.
9. Doorenbosch CAM, Harlaar J, Veeger DHEJ. The globe system: 
an unambiguous description of shoulder positions in daily life 
movements. J Rehabil Res Dev. 2003; 40(2):147-155.
10. Paavolainen P, Björkenheim JM, Slätis P, Paukku P. Operative 
Treatment of Severe Proximal Humeral Fractures. Acta 
Orthop Scand. 1983; 54(3):374-379. 
doi:10.3109/17453678308996587.
11. Frangen T, Dudda M, Martin D, et al. Operative und klinische 
Erfahrungen mit winkelstabilen Implantaten bei proximalen 
Humerusfrakturen - Wirklich alles besser? Zentralbl Chir. 
2007; 132(1):60-69. doi:10.1055/s-2006-958639.
12. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, 
Szyszkowitz R. A New Locking Plate for Unstable Fractures of
the Proximal Humerus. Clin Orthop Relat Res. 2005; 430:176-
181. doi:10.1097/01.blo.0000137554.91189.a9.
13. Schöbel T, Schleifenbaum S, Nitsch V, Hepp P, Theopold J. 
Primary stability of cement augmentation in locking plate 
fixation for proximal humeral fractures: A comparison of 
absorbable versus non-absorbable cement. Clin Biomech 
(Bristol, Avon). 2022; 91:105516. 
doi:10.1016/j.clinbiomech.2021.105516.
14. Warnhoff M, Jensen G, Dey Hazra RO, Theruvath P, Lill H, 
Ellwein A. Double plating - surgical technique and good 
clinical results in complex and highly unstable proximal 
humeral fractures. Injury. 2021; 52(8):2285-2291. 
doi:10.1016/j.injury.2021.05.047.
15. Park SG, Ko YJ. Medial Buttress Plating for Humerus Fractures 
with Unstable Medial Column. J Orthop Trauma. 2019; 
33(9):e352-e359. doi:10.1097/BOT.0000000000001515.
16. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of 
humeral head ischemia after intracapsular fracture of the 
proximal humerus. J Shoulder Elbow Surg. 2004; 13(4):427-
433. doi:10.1016/j.jse.2004.01.034.
17. Plecko M, Kraus A. Die winkelstabile Plattenosteosynthese bei 
Frakturen am proximalen Humerus mit der LPHP (Locking 
Proximal Humerus Plate). Oper Orthop Traumatol. 2005; 
17(1):25-50. doi:10.1007/s00064-005-1120-8.
18. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical 
Treatment of Three and Four-Part Proximal Humeral 
Fractures. J Bone Joint Surg Am. 2009; 91(7):1689-1697. 
doi:10.2106/JBJS.H.00133.
19. Gerber C, Werner CML, Vienne P. Internal fixation of complex 
fractures of the proximal humerus. J Bone Joint Surg Br. 
2004;86-B(6):848-855. doi:10.1302/0301-620X.86B6.14577.
20. Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of 
hemiarthroplasty for fractures of the proximal humerus. J 
Shoulder Elbow Surg. 2003; 12(6):569-577. 
doi:10.1016/s1058-2746(03)00213-1.
21. Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early 
management of proximal humeral fractures with 
hemiarthroplasty. J Bone Joint Surg Br. 2008; 90-B (11):1407-
1413. doi:10.1302/0301-620X.90B11.21070.
The Archives of Bone and Joint Surgery
Volume 12, Issue 6
June 2024
Pages 407-411

Files

History

  • Receive Date: 13 August 2023
  • Revise Date: 27 March 2024
  • Accept Date: 02 April 2024

Share

How to cite

Statistics