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 Table of Contents  
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 35-38

Long angular stable plates: A solution for complex fractures of humerus

1 Department of Bone and Soft Tissue, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Paediatrics, DRPGMCH, Tanda, Himachal Pradesh, India
3 Department of Orthopaedics, DRPGMCH, Tanda, Himachal Pradesh, India

Date of Web Publication13-Jun-2016

Correspondence Address:
Vipin Sharma
Department of Bone and Soft Tissue, Tata Memorial Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-7341.183950

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Segmental fractures of humerus are difficult to treat. Various options exist for treating ipsilateral metadiaphyseal fractures of humerus but have their own set of complications. Management of these fractures with long angular stable plates gives us an advantage of treating these two level fractures simultaneously thereby reducing complications and postoperative morbidity. Applying minimally invasive plate osteosynthesis (MIPO) principles helps in the biological healing of fracture by being minimally invasive and preserving blood supply to the soft tissues. We are presenting a small series of ipsilateral metadiaphyseal fractures humerus using long angular stable plates in an MIPO fashion.

Keywords: Angular stable plate, minimally invasive percutaneous plate osteosynthesis, radial nerve

How to cite this article:
Sharma V, Sharma S, Awasthi B. Long angular stable plates: A solution for complex fractures of humerus. J Orthop Traumatol Rehabil 2015;8:35-8

How to cite this URL:
Sharma V, Sharma S, Awasthi B. Long angular stable plates: A solution for complex fractures of humerus. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2021 Jan 21];8:35-8. Available from: https://www.jotr.in/text.asp?2015/8/1/35/183950

  Introduction Top

Ipsilateral metadiaphyseal humeral fractures are problem fractures for an orthopedic surgeon. This fracture combination is rare and is difficult to treat. Traditionally, for treating this fracture pattern, open reduction, and more than one implant options are required to manage this fracture combination. However, an extensive soft tissue dissection in a surgery of this magnitude can result in vascular insult to periosteum, delayed fracture healing, and can lead to iatrogenic neurovascular injury. By minimally invasive percutaneous plate osteosynthesis (MIPO) technique, such complications can be minimized to a large extent.[1] We present our experience with the long angular stable plate, a locking plate device, in the management of this fracture combination.

  Case Reports Top

Case 1

A 55-year-old homemaker presented with pain, inability to use the right upper limb following fall from stairs. On radiography, she was found to have undisplaced fracture right neck of the humerus with a displaced spiral fracture of the shaft.

Case 2

This was a 50-year-old female who had a fall on outstretched hand with the whole of the body weight coming on her left upper limb. The baseline investigation and radiographs were done which revealed an undisplaced fracture neck left humerus and spiral fracture shaft of the upper 3rd humerus.

Case 3

Another middle-aged female presented to us with a history of having motor vehicle accident. On investigations, she was found to be having ipsilateral proximal humeral and shaft humerus fractures left side with diabetes mellitus. It was an ipsilateral closed Neer type 2 fracture neck humerus with shaft fracture. After achieving a normal blood sugar level, the patient was taken for surgery.

All the three patients were operated with a long angular stable plate using MIPO techniques. No complications were noted in the postoperative period.

Operative technique

After appropriate anesthesia and beach chair position, patients were operated by anterior extended deltopectoral approach in Case 1 and lateral deltoid splitting approach in case 2 and 3 [Figure 1]. With manual traction under C-arm control reduction of proximal and distal fractures was achieved. In lateral deltoid splitting approach, an incision was limited to 5 cm. distal to acromion to avoid injury to axillary nerve. Axillary nerve was carefully palpated running on the under surface of the deltoid. Here, ever required the anterior one-third of deltoid insertion was subperiosteally elevated from the insertion to prepare the bed for the long angular stable plate. A probe was passed carefully under the axillary nerve and circumflex humeral vessels, gently to elevate them, and create a plane deep to them. The probe was advanced deep to brachialis as far as a distal entry site. The angular stable plate was slid in the submuscular plane downward. While the proximal end of the plate was fixed temporarily at the anterolateral side of the greater tuberosity using a Kirschner wire, the distal end was fixed with a screw. The location and alignment of the plate humerus construct were confirmed under the C-arm. Distal access was gained through the brachialis muscle, splitting apart its medial and lateral portions for approximately 5 cm to reveal the anterior humeral surface. By placing the plate deep to brachialis, radial nerve was protected by the lateral portion of brachialis. In general, the nerve was not exposed, and the lateral retraction was performed gently. Postoperatively, a sling was given, and gentle physiotherapy started on the 2nd postoperative day. Patients were followed up at 4 weeks, 3 months, and 6 months or until full radiological healing of the fracture [Figure 2]. No deep wound infections, nerve or vascular injuries were noted. All the fractures reported healing by a mean follow-up of 3 months. At 1-year follow-up, all patients had full range of shoulder and elbow movement.
Figure 1: Patient position, outline of surgical approaches, and nerves at risk

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Figure 2 (A-E): Position of incision, preoperative, immediate postoperative, and 3 months follow-up X-rays showing union

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  Discussion Top

Operative management of ipsilateral metadiaphyseal fracture humerus has been a constant challenge to operating surgeon because multiple implant options have been used in the past to address these two level fractures simultaneously. These include closed reduction, percutaneous pinning and plating, intramedullary devices with cerclage augmentation, T-buttress plate and shaft plating, tension band wiring and shaft plating, fixed-angle plate fixation, humeral interlocking nail, and primary arthroplasty used in varying combinations.[2],[3] Using multiple implant options for these fractures is difficult for the surgeon and patient alike as it involves multiple incisions, chances of complications, blood loss, delayed mobilization and is definitely more expensive. Delayed mobilization of the limb leads to complications such as periarthritis shoulder and prolonged rehabilitation. Studies have shown that percutaneous methods for proximal humerus fracture component, although theoretically advantageous because of the preservation of the blood supply, are inferior in stability compared with intramedullary devices and conventional plating.[4] Humeral head necrosis was seen in 15.9% of the patients with a T-plate fixation and 9.1% of the patients with minimal invasive techniques in one such study.[4] Complications such as backing out of screws, humeral head necrosis, and pseudarthrosis have been reported by some authors while managing this fracture combination with proximal humeral interlocking nails.[5] Long plates have been used in the past after manually contouring them to the proximal neck and shaft area. However, extensive soft tissue dissection needed for the application of long plates and the uneven contour of the bony surfaces has deterred surgeons from using long plates in the humerus.[6],[7] However, precontoured locking plates with their angular stability and nonintimate biological fixation have circumvented these limitations of conventional plating.[8] This study highlights the ability to achieve simultaneous fixation of ipsilateral metadiaphyseal humerus fractures by the long angular stable plate. Precontoured angular stable locking plates have useful design features that make them near ideal implant for managing this fracture combination. These can be applied easily without any additional bending thereby maintaining its metal strength. An indigenous proximal humerus angular stable plate utilizing the AO principles and made from AISI 316 L steel was used in this study. Multiple and multidirectional locking holes in the proximal part of the plate make it capable of dealing with proximal humeral fractures with varying geometry and providing better purchase in proximal fragment without compromising its vascularity. The option of combi holes in the stem portion of plate gives the choice to apply it in a compression or locking mode. Using this implant in MIPO fashion permits indirect fracture reduction thus lowering tissue dissection and preserving blood supply to fracture fragments. Due to better fixation provided by the plate, early mobilization of the limb is started which avoids complications such as frozen shoulder. The angular stable plate has proven to be a versatile implant for fractures extending into the proximal humeral shaft.[9] Placing the plate laterally in MIPO enables the reduction of the proximal humeral fracture component which is usually in abduction due to contraction of the deltoid muscle.[10] Although the angular stable plate has been extensively used and studied in proximal humeral fractures, limited evidence-based literature exists regarding the use of long angular stable plate in complex metadiaphyseal humeral fractures.[11] Aiming for MIPO with this plate can put axillary and radial nerves at risk. Lau et al. treated 17 patients with proximal humerus fractures using a metaphyseal locking compression plate, which was put on the lateral side of the humerus. Using this implant, they achieved stable fixation of the proximal fragment, even in osteoporotic bone, with three to four 3.5-mm locking screws. Three cases of radial nerve neurapraxia were reported postoperatively who subsequently improved. They suggested that this problem was very likely because of the traction to the nerve during fixation of the plate distally. Some other complications such as delayed union and subacromial impingement were also noted.[10] With the deltopectoral approach, there are less chances of injury to axillary nerve as compared to deltoid splitting approach;[12] although we did not encounter any axillary or radial nerve injury in our patients using both the approaches. Another study documented 29 metadiaphyseal proximal humerus fractures that were managed by PHILOS ® plates (AO Synthes) using MIPO. The axillary nerve was not exposed proximally, but the radial nerve was laid out distally. Subacromial impingement syndrome was noted in one patient while another patient had to be reoperated following the implant failure distally.[13]

In our patients using long angular stable plates in MIPO fashion in these complex fractures had no complications at all. MIPO leading to preservation of the biological environment of fracture, and rapid fracture healing gave us the advantage of achieving an early range of shoulder, elbow motion, and rapid rehabilitation.

  Conclusion Top

Long angular stable plate is a versatile option for management of ipsilateral metadiaphyseal humerus fractures as we can achieve early union with minimal complications and rapid mobilization.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Brunner A, Thormann S, Babst R. Minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS). J Shoulder Elbow Surg 2012;21:1056-63.  Back to cited text no. 1
Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-6.  Back to cited text no. 2
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;430:176-81.  Back to cited text no. 3
Bäthis H, Tingart M, Bouillon B, Tiling T. Surgical treatment of proximal humeral fractures. Is the T-plate still adequate osteosynthesis procedure? Zentralbl Chir 2001;126:211-6.  Back to cited text no. 4
Mittlmeier TW, Stedtfeld HW, Ewert A, Beck M, Frosch B, Gradl G. Stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail (Targon PH). J Bone Joint Surg Am 2003;85 Suppl 4:136-46.  Back to cited text no. 5
Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84-A:1919-25.  Back to cited text no. 6
Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma 2006;20:253-60.  Back to cited text no. 7
Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking plates: Tips and tricks. J Bone Joint Surg Am 2007;89:2298-307.  Back to cited text no. 8
Schwarz N, Windisch M, Mayr B. Minimally invasive anterior plate osteosynthesis in humeral shaft fractures. Eur J Trauma Emerg Surg 2009;35:271-6.  Back to cited text no. 9
Lau TW, Leung F, Chan CF, Chow SP. Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture. Int Orthop 2007;31:657-64.  Back to cited text no. 10
Zhang H, Ni W, Gao S, Liang X, Zhou A. Long PHILOS locking compression plate for treatment of proximal humerus and humeral shaft fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23:419-22.  Back to cited text no. 11
Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754-65.  Back to cited text no. 12
Rancan M, Dietrich M, Lamdark T, Can U, Platz A. Minimal invasive long PHILOS ®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus. Injury 2010;41:1277-83.  Back to cited text no. 13


  [Figure 1], [Figure 2]

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