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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 10-15

Functional outcome after management of displaced proximal humerus fractures using angle-stable plates: A prospective study

1 Department of Orthopedics, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
2 Department of Pediatrics, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Vipin Sharma
H. No 21, Type 5, Block B, Dr. Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_3_19

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Background: Management of three- and four-part fractures proximal humerus is a surgical challenge. Plate and screw fixation of these fractures is a viable treatment option. The aim of the present study is to analyze the clinical results after proximal humerus fracture fixation using angle-stable implants. Materials and Methods: Forty-eight patients (48 fractures) of the proximal humerus (three and four part, Neer classification) were treated at our institute by proximal angle-stable plates. Patients between 27 and 85 years presented to us during the study (Mean = 51.104 years, range = 27–85 years) over a 1-year and were operated by open reduction and internal fixation with angle-stable plates. Patients were followed up at 3, 6, and 9 months and evaluated using the Constant-Murley and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Results: The mean follow-up period was 24 months (8–60 months). Fractures united at an average of 12 weeks (range 8–16 weeks) with a mean follow-up of 1.5 years (10–18 months). The mean Constant-Murley and mean DASH scores at final follow-up visit were 67.438 and 17.154, respectively. Conclusion: Despite some complications, the locking plate system is quite efficient in the management of three- and four-part fractures proximal humerus.

Keywords: Angle-stable plates, proximal humeral fractures, union

How to cite this article:
Sharma V, Kohli N, Sharma S. Functional outcome after management of displaced proximal humerus fractures using angle-stable plates: A prospective study. J Orthop Traumatol Rehabil 2019;11:10-5

How to cite this URL:
Sharma V, Kohli N, Sharma S. Functional outcome after management of displaced proximal humerus fractures using angle-stable plates: A prospective study. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2020 Sep 21];11:10-5. Available from: http://www.jotr.in/text.asp?2019/11/1/10/264728

  Introduction Top

Proximal humerus fractures (PHFs) account for almost 4%–5% of all fractures[1],[2] and 45% of all humerus fractures and are secondary only to hip fractures and distal radius fractures. These fractures have a dual age distribution occurring either in young people following high-energy trauma or in those older than age >50 years with low-velocity injuries.[3] The incidence is approximately 3/1000 persons a year and is rapidly increasing with age. Women are affected twice as often as men.[3],[4] About 85% of these fractures are minimally displaced and are effectively treated with immobilization followed by early motion. The remaining 15% of these are either displaced or unstable. These fare poorly with nonoperative treatment and are better treated with surgical intervention. Surgical treatment is necessary, especially in young patients and active elderly people. The quality of bone seems to be crucial factor both for posttraumatic intervention and functional outcome. Because of osteoporosis and comminution, both reduction and fixation are difficult. The aim of treatment in PHFs is to achieve a painless and simultaneously functional shoulder. The result depends on the age, medical condition, bone quality, and expectations of the patient as well as a good evaluation of the current fixation techniques. While for undisplaced fractures, the literature suggests nonoperative treatment,[5],[6],[7] treatment of displaced PHFs is challenging and controversial and various operative modalities have been used in the past which include transosseous suture fixation, tension band wiring, standard plate, and screw fixation, hemireplacement arthroplasty, and percutaneous wire.[8],[9],[10] Complications of these fracture fixations such as reduction loss, malunion of fracture, avascular necrosis (AVN) of the humeral head, and impingement syndrome, may compromise shoulder function.[11],[12],[13],[14] To overcome these complications during the past decade, locking plate devices have been developed for the treatment of displaced PHFs. Locking plate technology after open reduction can achieve anatomic reduction and rigid fixation of multiple fragmented fractures. In particular, the technique improves the stability of the osteoporotic bone. These advantages make the locking plate the preferred choice for the treatment of proximal humeral fractures. Precontoured locking plates work on the principle of angle stability, less disruption of vascularity, and less chances of plate failure.[15] Improved fixation of locking plates is attributed to the angular stability of the screws locking in the plate and their three-dimensional distribution in the proximal head. The key to this technology is fixed angle relationship between the screws and plate. The threaded screw heads are locked into the threaded plate holes to prevent screw toggle, slide and pull-out, thus diminishing the possibility of primary or secondary loss of reduction. However, their use for the treatment of PHFs demands an accurate surgical technique, the long learning curve to avoid plate impingement, and screw perforation of the articular surface.[16],[17],[18] Furthermore, like with all locking plates, fracture reduction must be achieved before plate application which can be challenging. However, till now, very limited prospective studies have been done describing the functional outcome and complications following locking plate fixation of the proximal humeral fractures.[9],[18],[19] Thus, the aim of the present study was to determine the functional outcome after the management of Type 3 and Type 4 PHFs with angle-stable plates.

  Materials and Methods Top

This hospital-based prospective study was performed at a tertiary care institute over a period of 1 year (2015–2016) after due ethical clearance. All patients who visited our department during above period with displaced posttraumatic proximal humeral fractures were included; while patients who refused consent, pathological fractures, with distal neurovascular deficit, concomitant ipsilateral fracture of distal humerus or elbow joint, polytrauma patients with an injury severity score >16, previous fracture at the ipsilateral humerus or glenoid and patients lost to follow-up were excluded from the study. Patients with displaced PHFs who consented to participate in the study were evaluated by history taking, clinical examination. Preoperative true anteroposterior, lateral, and axillary X-rays were reviewed along with computed tomography scans to define fracture type and classify fractures (Neer's classification). After baseline investigations, anesthetic clearance and informed explained consent, patients with displaced PHFs were taken up for osteosynthesis using angle-stable plates (locking plates). Postoperatively, arm sling was applied and continued till fracture union [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Passive-guarded physiotherapy was started in the first postoperative week and continued till fracture union. Active range of motion exercises and passive stretching exercises were started after fracture union. Postoperative follow-ups involving clinico-radiological assessment and functional evaluation with Constant and Murley[20] and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores[21] were conducted at 3, 6, and 9 months follow-up.
Figure 1: Preoperative images of 28-year-old male showing 3-part fracture of proximal humerus (right side)

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Figure 2: Postoperative images after open reduction and internal fixation with proximal humeral angle-stable plates (14th postoperative delirium)

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Figure 3: Three-month postoperative images showing fracture union

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Figure 4: Twelve months postoperative radiographs-fracture postoperative radiographs-fracture healing

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Surgical method

After preoperative evaluation, patient was positioned on the radiolucent table in beach chair position with waist flexed approximately 45° and the knees placed in 30° of flexion. A rolled up towel under the medial border of the scapula was placed to help with exposure. The landmarks of the shoulder were carefully palpated and marked. Deltopectoral was used for surgical exposure. The incision was made just above the coracoid process. Pectoralis major was retracted medially and deltoid laterally. The cephalic vein was retracted medially. The short head of biceps and the coracobrachialis was displaced medially. By applying external rotation to the arm, the subscapularis muscle was stretched. Small vessels underneath were either ligated or cauterized. A blunt instrument was passed between the capsule and the subscapularis, moving upward. Rotating the shoulder internally, the insertion of the subscapularis onto the humerus was identified. Muscle belly was tagged with stay sutures to prevent it from disappearing medially when it was cut and also to allow easy reattachment of the muscle to its new insertion onto the humerus. Subscapularis was divided one inch from its insertion onto the lesser tuberosity of the humerus.

Fracture fragments were reduced without stripping periosteum to best possible anatomical position and reduction was provisionally held with Kirschner wires. Fracture was reduced by manual traction and abduction to neutralize the pull of the deltoid muscle. After fracture was reduced, the plate was applied on the lateral aspect of the proximal humerus and locking screws inserted first into the head fragment. The reduction was assessed under image intensifier. Definitive fixation with proximal angle-stable locking plate was done with plate positioned at least 5–8 mm distal to the upper end of the greater tuberosity and at least 2 mm posterior to the bicipital groove, thus sparing the tendon of the long head of biceps.

Outcome assessment

Functional outcome of the patients was assessed at 3 mo, 6 mo, and 9 mo follow-ups using the Constant-Murley and DASH scores.

Statistical analysis

Data were collected and entered into MS Excel 2007 and statistically analyzed using Epi-info version 7.2, (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, US). The qualitative variables were expressed in proportion, and quantitative variables were summarized by the mean and standard deviation. Data were expressed as frequency, percentages, or mean/standard deviation. Pearson correlation and two-tailed t-test were used for studying the correlation between the Constant-Murley and DASH scores. A value of P < 0.05 was considered statistically significant.

  Results Top

Forty-eight patients with Neer 3- and 4-part fractures, who underwent surgery with proximal humeral locking plate at our institute over a 1-year period, were analyzed. Age of patients was 27–85 years (mean = 51.104 years, range = 27–85 years); 32 were male and 16 were female (male:female ratio of 2:1). Thirty-six patients (75%) had fall, and 12 patients (25%) had roadside accidents. Thirty-eight patients (79.6%) had 3-part fracture and 9 patients (20.4%) had 4-part fractures (Neer's classification). Nineteen patients (39.6%) had fracture on the left side, whereas 29 patients (60.4%) had right side fractures.

All fractures united at an average of 12 weeks postoperative (range 8–16 weeks) with a mean follow-up of 1.5 years (10–18 months).

Six patients had plate impingement which improved following plate removal. The fractures united at the time of implant removal. One patient developed late wound infection (deep infection) which was managed by wound debridement and implant removal at 3 months postoperative. Other complications such as screw penetration were observed in three patients for which the involved screw removal was done at 6 months follow-up. Constant-Murley and DASH scores of the patients were calculated at 3, 6, and 9 mo follow-up visits. Overall the functional outcome was found to be fair to good in 77% of our patients. However, almost 2% of patients had a poor outcome. The mean Constant-Murley and mean DASH scores at final follow-up visit achieved were 67.438 and 17.154, respectively. Correlation between DASH score and the Constant-Murley score was found to be significant [Table 1], [Table 2], [Table 3] and [Figure 5], [Figure 6].
Table 1: Correlation between Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score at final follow-up visit (n=48)

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Table 2: Functional outcome on the basis of Constant-Murley score at the last follow-up visit

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Table 3: Functional outcome on the basis of Disabilities of the Arm, Shoulder and Hand score at the last follow-up visit

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Figure 5: Mean disabilities of the arm, shoulder, and hand score in prospective group at 3, 6, and 9 months (n = 48)

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Figure 6: Mean Constant-Murleyscore in prospective group at 3, 6 and 9 months (n = 48)

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  Discussion Top

Management of three- and four-part proximal humeral fractures is controversial and is a surgical challenge for many. Various operative modalities and techniques have been described in the literature. Varying outcomes have been reported with plate osteosynthesis for PHFs.[11],[12],[22],[23] Whereas such fractures in the young have uniformly good results with plate and screw fixation, results in osteoporotic fractures in elderly patients are often poor.

The study focuses on the treatment of PHFs (three- and four-part) with proximal locking angle stabilizing plate and functional evaluation by DASH score and the Constant-Murley score. It allows early mobilization as the fixation is usually stable. In addition, treatment of these fractures is challenging, especially in the elderly. The proximal humerus angle-stable plate is locked compression plate that can also be used with minimally invasive technique. It permits indirect fracture reduction thus lowering the possibility of AVN and by reducing the need of immobilization time helps diminishing the possibility of frozen shoulder. Furthermore, it is a low-profile plate with the proximal-fixed angled screws thus making it a fixating device with high stability in osteoporotic bones.

In this study, men suffered more complex fractures because they were exposed more to high-energy trauma. Dominant side was involved in the majority of cases.

The mean age in this series was 58 years (range 19–92 years), and fractures were Neer's 3-part and 4-part fractures.

We could achieve a mean Constant-Murley score of 67.438. The results of our study showed good-to-excellent outcomes in 66.67% of our patients. Our results were somehow inferior to those reported in the western literature. Various studies had reported varying results. The results were inferior in patients >60 years. Nevertheless, our results in older age group patients are better than those of traditional plates used in such osteoporotic fractures. Thyagarajan et al.,[15] in their study, on 30 patients showed an overall average Constant score of 57.5. We, thus, believe that a locking plate device for PHFs gives a satisfactory outcome in most of the patients including those with the old age and poor bone density.

Within our patient population, screw penetration occurred in three patients. The perforating screw was removed at 6 mo follow-up which lead to fair to good outcome later on. Yang et al.[23] found an overall complication rate of 35.9% with a screw cut-out rate of 7.6%. These previous studies agree that screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening as the main implant-related complication of nonfixed-angle implants. All our cases with screw penetration and backouts were those from the early cases when we started using this implant.

AVN is one of the most dramatic complications requiring re-operation. As per the published literature, the chances of AVN of the shoulder are directly proportional to the severity of the injury. The risk of osteonecrosis increases if the anterolateral branch of the anterior humeral circumflex artery is damaged. Utmost care should be taken while exposing the biceps tendon in the bicipital groove. Although no patient with vascular nacrosis was reported in our study, Wijgman et al.[24] reported 37% of cases of AVN of the humeral head in 3- and 4-part fractures of proximal humerus treated with proximal humerus plates.

Subacromial impingement of plate leading to limitation of overhead abduction associated with pain was seen in six patients (12.5%) which was thought to be a result of too far cranial positioning of the plate. Plate removal was done after fracture union at 6 months follow-up following which range of motion improved. Leonard et al. reported 22.5% of cases of subacromial impingement (in 7 of 31 cases) treated by proximal humerus locking plates.[25]

Deep delayed wound infection was seen in one patient which was managed by wound debridement and implant removal at 3 months postoperative.

In the present study, mean Constant-Murley and DASH scores at final follow-up visit were 67.438 and 17.154, respectively. Correlation between DASH score and Constant-Murley score was found to be significant. Kettler et al.[26] reported a Constant-Murley score between 52 and 72 points after open reduction and internal fixation with the proximal humerus angle-stable plate. Hente et al.[27] reached a mean Constant-Murley score of 55 points in these specific fracture types, which was lower than for fractures without dislocation. In one study by Aggarwal et al., mean Constant-Murley score was 68.31 in 19 patients.[28] These results are near identical to those achieved in our study. In the present study, proximal humerus locking plate has shown promising results in displaced and comminuted PHFs.

  Conclusion Top

Fractures of the proximal humerus especially three- and four-part fractures have been a difficult group to treat. In the present study, good functional outcome was achieved in these group of patients using proximal locking plates. Familiarity with surgical technique and biomechanical principles can go a long way in the management of part three and four fractures with locking humeral plate group. The Constant-Murley and DASH scores showed a significant correlation in our study, so either of them could be used for functional assessment of patients with PHFs operated by angle-stable proximal locking plates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3]


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