Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate

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Med. J. Cairo Univ., Vol. 85, No. 2, March: 643-650, 2017 www.medicaljournalofcairouniversity.

1 Med. J. Cairo Univ., Vol. 85, No. 2, March: , Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate MOHAMED KADDAH, M.D.*; AHMED MORRAH, M.D.*; HANY R. ANWAR, M.Sc.*,** and KHALED F. EBIDO, M.D.*,** The Department of Orthopaedic Surgery, Faculty of Medicine, Cairo University* and the Department of Orthopeadic Surgery, Al-Helal Hospital** Abstract Regarding treatment of proximal humeral fractures; much controversy and confusion still exist, and no single treatment protocol or algorithm has been proved to be universally effective. In the period between October 2011 to May 2012, a prospective study was conducted involving 15 cases with fracture of the proximal humerus. All patients were operated at El-Halal Hospitals. All cases were surgically managed by fracture fixation procedures, the follow up period of the cases ranged from 3 months to 6 months. The Locking Proximal Humerus Plate is now available for the fixation of these fractures. It is contoured to the anatomy of the lateral aspect of the proximal part of the humerus and ensures stable fixation of the humeral head and its fragments, even in the presence of osteoporosis. Key Words: Locked screws Internal fixator Fracture Humeral head Osteosynthesis. Introduction FRACTURES of the proximal part of the humerus are relatively common injuries, accounting for approximately 4% to 5% of all fractures. Whereas stable fractures are generally and successfully treated nonoperatively, the majority of unstable and displaced fractures may benefit from surgical treatment. Open reduction and internal fixation of proximal humeral fractures is still widely preferred, particularly when recently developed fixed-angle implants and the introduction of reduction techniques accommodating to soft tissue are considered [1]. Fractures of the proximal part of the humerus are most commonly classified with use of the system introduced by Neer in This system is based on the presence of displacement of at least one of the four anatomical parts of the proximal part of the humerus [2]. Correspondence to: Dr. Mohamed Kaddah, The Department of Orthopaedic Surgery, Faculty of Medicine, Cairo University The incidence of proximal humeral fractures increases exponentially after 50 years of age, with approximately 80% of such fractures occurring in women. In the elderly population, most fractures of the proximal humerus are related to osteoporosis [1]. Surgical techniques have included percutaneous fixation, standard plate-and-screw fixation, intramedullary fixation with rods or pins, the use of tension bands with and without plates or rods, standard plate modification into blade plate constructs, and hemiarthroplasty. Many of these alternative open techniques were developed because of the high failure rates noted initially with standard plating. The inherent difficulties with internal fixation have led several authors to recommend hemiarthroplasty for the treatment of most threeand four-part humerus fractures. However, locked plates (Fig. 1) allow for more secure fixation in compromised bone, there by possibly leading to reduced incidence of failure of internal fixation [3]. Fig. (1): The Locking Proximal Humerus Plate is contoured to the anatomy of the lateral aspect of the proximal part of the humerus and works as an internal fixator by securing an anatomical reduction using angular stability. The screw arrangement of the four locking screws in the humeral head is three-dimensional. Additional smaller holes can be used for fixation of sutures or wires, allowing reattachment of the greater or lesser tuberosities in comminuted fractures to neutralize the tension forces of the rotator cuff muscles [3]. 643

2 644 Open Reduction & Internal Fixation of Proximal Humeral Fractures Patients and Methods In the period between October 2011 to May 2012, a prospective study was conducted involving 15 cases with fracture of the proximal humerus. All patients were operated at El-Halal Hospitals. All cases were surgically managed by fracture fixation procedures, the follow-up period of the cases ranged from 3 months to 6 months. Sex distribution: They were 9 females (60%) and 6 males (40%). Table (1): Distribution of Gender in patient group. Gender N % Female Male Total Age distribution: The age ranged from 22 to 74 years, with a mean age of 41 years. Affected side distribution: Eight patients had fractures on the right side, while seven patients on the left side. Table (2): Distribution of Fr. Side in patient group. Fr. Side N % Rt Lt Total Types of fractures: Three patients had two-part fractures, six patients had three-part fractures and six patients had four-part fractures. Table (3): Types of fractures in patient group. Type of fracture N % 2 Part Part Part Total Lag time between trauma and surgery: Lag time ranged from one day to a maximum of 6 days, with a mean of 2 days. Like all other operative procedures in orthopedics, management of fractures of proximal humerus has preoperative, intra-operative and post-operative stages. Pre-operative stage: This includes: Patient counselling. Clinical evaluation (history, general examination and local examination). Radiological evaluation. Operative stage: Asepsis: Patients were operated in conventional operating room. The number of persons in the operative theatre was kept to a minimum, as possible. Traffic in and out of the theater was minimized as possible. The skin edges of the wound were sealed from the rest of the wound with plastic sheets. Surgical approach: Deltopectoral approach has been used for all the patients. Surgical technique: The surgeon should obtain preoperative radiographs, including true anteroposterior shoulder, scapular lateral and axillary views. In tolerant patients, internal and external rotation views of the humerus also may be helpful. Computed tomography is not often necessary, but it can prove beneficial in the more comminuted fracture when tuberosity size and position are difficult to ascertain on standard radiographs [4]. Positioning: Place the patient in the beach-chair position Fig. (2) with the c-arm placed over the shoulder and draped into the sterile field. The c-arm fluoroscopic image intensifier provides an anteroposterior view of the glenohumeral joint, and the humerus can be rotated to obtain radiographs of the shoulder in internal and external rotation [4]. Approach: Incision begins at the lateral third of the clavicle, passes just lateral to the coracoid, and extends to

Mohamed Kaddah, et al. 645 the deltoid insertion. After appropriate haemostasis of the subcutaneous tissue, the deltopectoral interval and the cephalic vein are identified.

3 Mohamed Kaddah, et al. 645 the deltoid insertion. After appropriate haemostasis of the subcutaneous tissue, the deltopectoral interval and the cephalic vein are identified. The cephalic vein is preserved and retracted laterally with the deltoid muscle. The clavipectoral fascia is incised to expose the subscapularis tendon and lesser tuberosity. The conjoint tendon is retracted medially. The coracoid and the coracoacromial ligament are then identified. If needed, the leading edge of the coracoacromial ligament is then partially re- sected using the diathermy to improve superior exposure Fig. (3). The long head of the biceps tendon should be identified to use it as a landmark to identify the fragments of the greater and lesser tuberosities with their attached tendons. The lesser tuberosity and subscapularis tendon lie medial to the biceps tendon, and the greater tuberosity and supraspinatus tendon insertion are lateral to the biceps [1]. Fig. (2): Patient in beach-chair position (case 2). Fig. (3): The deltopectoral grove is opened exposing the clavipectoral fascia (case 9). Results Constant scoring system was used to assess every patient postoperative at 6 months, and at the last follow-up. Table (6) show that there is significant relation between Type of Fracture and pain score where p- value=0.018*. Table (7) and Fig. (5) show that there is significant decrease relation between Final constant score and pain score where p-value=0.003 *. No pain: The range was (76-94) by Mean±SD (87.66±6.62). Mild: The range was (52-72) by Mean ±SD (61 ±8.92). Moderate: The range was (26-86) by Mean ±SD (64.6±20.1). And there was a significant difference Fig. (4): A deltopectoral approach is used. The cephalic vein is retracted laterally to protect its many deltoid branches [1]. between no pain and mild (p-value=<0.003*) and No pain and moderate (p-value=0.029*) but no significant between mild and moderate (p-value =0.884). There was a significant positive correlation between final constant and FWD and abduction but negative correlation with age and from Inj. to operation. Complications: In this study 3 cases (representing 20% of all cases) had 3 complications: One case of varus collapse. One case of secondary screw perforation. One case of postoperative shoulder stiffness. In our study, one of the cases (case no. 14) was a 57 years old male who had four part fracture

4 646 Open Reduction & Internal Fixation of Proximal Humeral Fractures proximal humerus managed by open reduction and internal fixation by proximal humerus locked plate. There was comminution of the inferomedial region of the proximal humerus. At the postoperative routine follow-up, X rays showed varus collapse of the fracture site with pulling out of the two most distal screws. Conservative treatment and close follow-up were attempted. Consecutive serial X-rays showed progressive union with no further progression of the collapse. After achieving full union and completing the rehabilitation program, the patient was satisfied by the final outcome so no further management was needed. Table (4): Data of our patients. No. Gender Age Type of Fracture Fr. Side Chronic disease DM HTN From inj. to operation FWD flexion (º) Abduction (º) Pain Final constant score 1 Female 31 3 part Rt. Negative Negative No 86 2 Female 60 4 part Rt. Positive Positive Moderate 62 3 Male 22 3 part. Lt. Negative Negative Mild 52 Dislocation 4 Female 55 3 part Rt. Negative Positive Mild 70 5 Male 74 4 part Rt. Positive Negative Mild 52 6 Female 38 2 part Lt. Negative Negative No 92 7 Male 46 2 part Lt. Negative Positive No 92 8 Male 58 4 part Lt. Positive Negative Moderate 46 9 Male 24 2 part Lt. Negative Negative No 94 10* Female 54 3 part Rt. Negative Negative No 76 11* Female 54 4 part Lt. Negative Negative Mild Female 69 4 part Rt. Negative Positive Mild Female 44 3 part Lt. Negative Negative No Male 57 4 part Rt. Negative Negative Mild Female 51 3 part Rt. Negative Negative Moderate 86 *Same patient. Table (5): Descriptive Statistics for age, from inj. to operation, FWD flexion, Abduction, Final constant score. Table (7): Relation between pain score and final constant score in patients group. Descriptive statistics Final constant score ANOVA Range Mean ± SD Range Mean ± SD F p-value Age Inj. to operation FWD flexion Abduction Final constant score ± ± ± ± ± Table (6): Relation between Pain score and type of fracture in patients group. Type of Fracture 2 part: N % 3 part: N % 4 part: N % Total: N % Chi-square: X 2 p-value Pain No Mild Moderate Total * No Mild Moderate No & Mild ± ± ± Tukey s test No & Moderate * Mile & Moderate 0.003* 0.029* Table (8): Correlation between Final constant score and Age, from inj. to operation, FWD flexion, Abduction. Age Inj. to operation FWD flexion Abduction Final contant score R p-value Table (9): Distribution of postoperative complications. Complication N % Varus collapse 15 cases Secondary screw perforation Stiffness Total 3 20

$Mohamed Kaddah, et al. 647 internal fixation if at all possible. Osteoporotic fractures in elderly patients are commonly associated with minor trauma.$ $head while other surgeons prefer to go for internal fixation [5]. Comminuted fractures of the proximal humerus are at risk of fixation failure, screw loosening, and fracture displacement [6]. Fig.$ $Percutaneous pinning requires advanced skills, good bone quality, minimal fracture comminution, and a cooperative patient [7]. Fig. (6): Immediate postoperative X-ray AP view.$

5 Mohamed Kaddah, et al. 647 internal fixation if at all possible. Osteoporotic fractures in elderly patients are commonly associated with minor trauma. However, the optimal surgical management of 3 and 4 parts proximal humeral fractures in elderly osteoporotic patients remains controversial, with many advocating prosthetic replacement of the humeral head while other surgeons prefer to go for internal fixation [5]. Comminuted fractures of the proximal humerus are at risk of fixation failure, screw loosening, and fracture displacement [6]. Fig. (5): Preoperative X-ray AP view. (case 14). The technique requires extensive soft tissue stripping, compromising the vascular supply to the humeral head. Minimally invasive methods of plate osteosynthesis may increase the risk of neurovascular structural damage [7]. Percutaneous pinning requires advanced skills, good bone quality, minimal fracture comminution, and a cooperative patient [7]. Fig. (6): Immediate postoperative X-ray AP view. Despite advances in new implant designs, pin fixation with Kirschner wires is still an appropriate option for treatment of some fractures and dislocations around the shoulder. Percutaneous or open pinning techniques are cost-effective and have the potential advantage of preventing additional damage to the blood supply of the humeral head. However, pin fixation can be problematic, especially in osteoporotic elderly patients, in whom loss of fixation and related pin problems are not rare. Because patient compliance, especially during the rehabilitation period, is also very important, pinning is not recommended for patients with mental problems or substance abuse [8]. Close follow-up is necessary, and the pins should be removed at the conclusion of therapy or whenever migration is noted [9]. Fig. (7): Five months postoperative X-ray AP view of case no. 14 showing full union of fracture site. Discussion Optimal surgical management of proximal humeral fractures is still controversial. Fractures in younger patients result from high-energy injuries, and most surgeons attempt open reduction and In our study, the PHILOS plate (Proximal Humeral Internal Locking System) fixation was suitable for 3 and 4 parts proximal humeral fractures. Its complication rate was low, probably because our patients were relatively young, and both the bone quality and the surgical technique were good. During dissection and head fixation with proximal locking screws, care should be taken to avoid damage of the anterior humeral circumflex artery and the axillary nerve. The screw position must be checked intra-operatively with image intensification. In elderly patients with poor bone stock, the humeral head and shaft should be packed with bone grafts or substitutes to prevent fixation failure of the screws.

6 648 Open Reduction & Internal Fixation of Proximal Humeral Fractures Surgical treatment is one of the most commonly accepted forms of management for displaced and unstable proximal humeral fractures and a variety of fixation devices are available [10]. The use of conventional plate fixations through a delto-pectoral approach involves a higher risk of avascular necrosis of the humeral head, as this technique often requires an extensive soft-tissue disruption, which might compromise the vascular supply of the humeral head [10]. The delto-pectoral approach remains the most widely used in the treatment of proximal humeral fractures [10]. Our results are close to that obtained by Gerber et al., in their study that included 15 patients with three part fractures. Those 15 patients were managed by open reduction and internal fixation. The mean age of the patients was 44.9 years and the mean follow-up period was 63 months. The mean final constant score for those patients was 80.4 points [11]. In another study conducted by Martinez et al., 33 patients with three part fractures were treated by open reduction and internal fixation by locked plate. Patients were followed-up for 12 to 18 with a mean of 15 months. The mean Constant score was 80 points.the shoulder range of movement was excellent in22%, moderate in 76%, and poor in 2% [12]. In another study done by Hintermann et al., 34 patients with three part fractures were managed by open reduction and internal fixation plates. The mean age of the patients was 71 years old and the mean follow-up period was 3.5 years. They had a mean final Constant score of 75 points [13]. Fazal et al., conducted a study that included 12 patients with three part fractures. All patients were managed by open reduction and internal fixation by locking plate. Patients were followed up for 6 to 24 (mean, 13) months. The mean final constant score was 73 points (ranged from 26 to 88 points). The score of this study was negatively influenced by one case which developed non-union and avascular necrosis. The screws were removed but she refused further surgery and had a poor Constant score. This may explain why this study had worse results than ours [14]. The study that was done by Björkenheim et al., included 12 patients with four part fractures who were managed by open reduction and internal fixation with locking plates. The mean age of the patients was 67 years. At the twelfths month followup the mean Constant score was 60 points. The higher score of our study than that of Björkenheim et al. s can be explained by the younger mean age of the patients of our study [15]. Summary and Conclusion: Fractures of the proximal humerus can affect both elderly and young individuals causing serious disabilities and handicapping. While most of these fractures are minimally displaced and can be managed conservatively or by minimal interventions, the management of the more complex three and four parts fractures still remains a challenge. The surgical management of displaced three and four part fractures of the proximal humerus in a surgically fit patient includes many options; two of the most commonly used are open reduction and internal fixation and shoulder hemiarthroplasty. The decision to use either of these surgical modalities must depend on certain points. The most important points on which the surgeon can build his decision can be summarized as: The fracture type and pattern, the patient s age, and the bone quality. Conclusion: Locking plates offer more advantages than conventional plates specially when dealing with osteoporotic bone. It is recommended to use locking plate whenever an elderly patient is indicated for internal fixation. Inferomedial comminution of the proximal humerus can lead to failure of locking plate, usage of bone graft is to be considered. Decreasing preoperative lag period is essential to obtain good results. Early passive motion and a well scheduled rehabilitation program have an obvious benefit on the final result. Fixation with Philos plates preserves achieved reduction, and a good functional outcome can be expected. However complication incidence proportions are high, particularly due to primary and secondary screw perforations into the glenohumeral joint. More accurate length measurement and shorter screw selection should prevent primary screw perforation. Awareness of obtaining anatomic reduction of the tubercles and restoring the medial support should reduce the incidence of secondary screw perforations, even in osteopenic bone.

7 Mohamed Kaddah, et al. 649 References 1- KONRAD G., BAYER J. and HEPP P.: Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate. J. Bone Joint Surg Am., 92: 85-95, MICHAEL L. SIDOR and JOSEPH D. ZUCKERMAN: The Neer Classification System for Proximal Humeral Fractures. The Journal of Bone and Joint Surgery, 75.A: , THANASAS C., KONTAKIS G., ANGOULES A., LIMB D. and GIANNOUDIS P.: Treatment of proximal humeral fractures with locking plates: A systematic review. J. Shoulder Elbow Surg., 1-8, MARK MIGHELL BRIAN L. BADMAN: Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures. J. Am. Acad. Orthop. Surg., 16: , SOLBERG B.D., MOON C.N., FRANCO D.P. and PAI- EMENT G.D.: Surgical treatment of three and four-part proximal humeral fractures. J. Bone Joint Surg. Am., 91: , SOLBERG B.D., MOON C.N., FRANCO D.P. and PAI- EMENT G.D.: Surgical treatment of three and four-part proximal humeral fractures. J. Bone Joint Surg. Am., 91: , AGEL J., JONES C.B., SANZONE A.G., CAMUSO M. and HENLEY M.B.: Treatment of proximal humeral fractures with Polarus nail fixation. J. Shoulder Elbow Surg., 13: , LAU T.W., LEUNG F., CHAN C.F. and CHOW S.P.: Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture. Int Orthop., 31: , LYONS F.A. and ROCKWOOD C.A. Jr.: Migration of pins used in operations on the shoulder. J. Bone Joint Surg. Am., 72: , ROULEAU M. and LAFLAMME Y.: Proximal humerus fractures treated by percutaneous locking plate internal fixation. Orthopaedics & traumatology: Surgery & Research, 95: 56-62, GERBER C., WERNER C.M.L. and VIENNE P.: Internal fixation of complex fractures of the proximal humerus. J. Bone Joint Surg. Br., 86-B: , MARTINEZ A.A., CUENCA J. and HERRERA A.: Philos plate fixation for proximal humeral fractures. Journal of Orthopaedic Surgery, 17 (1): 10-14, HINTERMANN B., TROUILLIER H.H. and SCHÄFER D.: Rigid internal fixation of fractures of the proximal humerus in older patients. J. Bone Joint Surg. Br., 82-B: , FAZAL M.A. and HADDAD F.S.: Philos plate fixation for displaced proximal humeral fractures. Journal of Orthopaedic Surgery, 17 (1): 15-18, BJÖRKENHEIM J., PAJARINEN J. and SAVOLAINEN V.: Internal fixation of proximal humeral fractures with a locking compression plate. Acta. Orthop. Scand, 75 (6): , 2004.

8 650 Open Reduction & Internal Fixation of Proximal Humeral Fractures

Index. B Backslap technique depth assessment, 82, 83 diaphysis distal trocar, 82 83

Index. B Backslap technique depth assessment, 82, 83 diaphysis distal trocar, 82 83 Index A Acromial impingement, 75, 76 Aequalis intramedullary locking avascular necrosis, 95 central humeral head, 78, 80 clinical and functional outcomes, 95, 96 design, 77, 79 perioperative complications,