2279

Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
MARK W. PAGNANO
EDITOR, VOL. 62

COMMITTEE
MARK W. PAGNANO
CHAIR
CRAIG J. DELLA VALLE
KENNETH A. EGOL
ROBERT A. HART
PAUL TORNETTA III

EX-OFFICIO
DEMPSEY S. SPRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of Orthopaedic

Surgeons. This article, as well as other lectures presented at the
Academys Annual Meeting, will be available in March 2013 in
Instructional Course Lectures, Volume 62. The complete volume can be
ordered online at [Link], or by calling 800-626-6726 (8 A.M.-5
P.M., Central time).
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2280
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

Proximal Humeral Fractures:

Internal Fixation
Daniel Aaron, MD, Joshua Shatsky, MD, Juan Carlos Paredes, MD, Chunyun Jiang, MD
Bradford O. Parsons, MD, and Evan L. Flatow, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Fractures of the proximal part of the recently because of advances in tech- Anatomy
humerus represent 4% to 5% of all nology and improved understanding of To understand the pathophysiology of
fractures1,2. Older individuals are more pathophysiology. Unless contraindica-tions fractures of the proximal part of the
likely to sustain these injuries: 71% of exist, the recommended general strategy for humerus, knowledge of the osseous,
proximal humeral fractures occur in the management of displaced proximal muscular, and vascular anatomy is
patients over the age of sixty years3,4. As humeral fractures is operative, with use of imperative. The commonly used clas-
the population ages, such data suggest a various forms of internal fix-ation. These sification schemes rely on this
potential increase in the total number of include pins, screws, tension-band wires, anatomy as do the deforming forces
proximal humeral fractures. Some plate and screw constructs, heavy sutures, that must be overcome by reduction
authors have estimated a threefold in- and intramedullary devices. Arthroplasty, maneuvers and fixation. Furthermore,
crease in the upcoming thirty years5. which has also undergone dramatic prognostic in-formation is a direct
Neer asserted that most proximal hu- advances in recent years, is an additional correlate of the specific sites of
meral fractures are minimally displaced option. Each technique has particular anatomic disruption. The proximal part
or nondisplaced, allowing nonoperative indications, and each is subject to its own of the humerus initially had a primary
treatment to yield high rates of union and set of potential complications. Therefore, ossification center and two secondary
functional restoration6; however, a recent familiarity with all of these techniques is ossification centers (greater and lesser
multicenter study noted that 64% were essential for the practitioner caring for tuberosities) that fuse, but as Codman
displaced7. Management strategies for fractures of the proximal part of the first recog-nized, fractures tend to
displaced fractures have evolved humerus. occur along these physeal lines, even
with skeletal maturity6.
 The supraspinatus, infraspina-
Look for this and other related articles in Instructional Course Lectures, tus, and teres minor muscles attach to
Volume 62, which will be published by the American Academy of the greater tuberosity and exert ab-
Orthopaedic Surgeons in March 2013: duction and external rotation forces.
The subscapularis tendon attaches
Proximal Humeral Fractures: Prosthetic Replacement, by Daniel Aaron, MD,
to the lesser tuberosity and exerts a
Bradford O. Parsons, MD, Francois Sirveaux, MD, and Evan L. Flatow, MD medial and internal rotation vector.
The deltoid, pectoralis major, and
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of
this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity
in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships,
or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of
Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2012;94:2280-8

Downloaded From: [Link] by a HINARI User on 03/15/2014
 2281
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

latissimus dorsi muscles all insert dis- importance of anatomic reductions, as Evaluation
tal to the tuberosities. The pectoralis well as to appropriately counsel the Evaluation of the patient with a fracture of
major muscle is a strong deforming patient. the proximal part of the humerus begins
force, and it is important to recognize with a history and physical examination.
this during reduction maneuvers and Classification Relevant medical comor-bidities must be
when fracture fixation is selected and The most widely used classification identified. A social history should be
placed8. scheme for proximal humeral fractures is obtained to assess the patients level of
The vascular anatomy of the the Neer classification system6,16,17. In activity and demand on the shoulder, as
proximal part of the humerus is this system, the humeral articular sur- well as his or her expectations after
complex, and has implications for the face, greater tuberosity, lesser tuberos- intervention. Physical examination should
risk of the development of osteone- ity, and humeral shaft are considered the begin with assessment of the skin condition
crosis of the humeral head after a parts of the proximal aspect of the and the neurovascular status. Motor
fracture. The principal vascular sup-ply humerus. A part is considered to be function of the deltoid muscle should
to the humeral head is via the displaced if it is angulated 45L or include voluntary isometric con-traction of
anterolateral branch of the anterior displaced 1 cm. Recently, a valgus- all three heads. Palpation of the distal
humeral circumflex artery, which arises impacted subset of four-part fractures pulses and careful inspection for signs of
from the axillary artery9,10. The anterior was added18. This is an important arterial injury should be performed acutely.
circumflex system courses at the addition because valgus-impacted Any question about vascular com-promise
inferior border of the subscapu-laris fractures retain an intact medial calcar should prompt Doppler exami-nation and,
tendon near its insertion to the lesser hinge, which makes them biomechan- if necessary, angiography.
tuberosity, and then underneath the ically relatively stable and likely to have Imaging assessment begins with a
biceps tendon to penetrate bone at the a preserved blood supply to the hu-meral standard series of radiographs, including
superomedial border of the greater head. Therefore, percutaneous fixation is anteroposterior, true anteroposterior,
tuberosity9,11,12. A relatively minor a viable option and the prognosis is axillary lateral, and scapular-Y radio-
segment of the posteromedial aspect of good8. Head-splitting fractures and large graphs of the proximal humeral fracture.
the humeral head is directly sup-plied (>40%) humeral impression fractures Anteroposterior radiographs with the arm
by the posterior circumflex ar-tery9. compose a sepa-rate category, for which in internal and external rotation may better
There is a rich network of other arthroplasty is considered. characterize tuberosity fractures or occult
arteries, including the profunda bra- fractures of the surgical neck. Computed
chii, thoracoacromial, subscapular, and The AO classification system is tomography (CT) can pro-vide additional
suprascapular arteries10, that can based on the vascular supply to the information for both classification and
sustain the humeral head even in the humeral head19. It consists of three preoperative planning21, particularly with a
event of injury to both circumflex main types: extra-articular unifocal, fracture of the lesser tuberosity22. CT is also
systems or axillary artery disrup- extra-articular bifocal, and intra- helpful in fractures with articular surface
tion13,14. An injury in which both articular. Each type contains three involvement and for enumeration of
tuberosities are fractured with a con- subtypes based on the severity of the fracture fragments (Figs. 1-A, 1-B, and 1-
comitant metaphyseal fracture places injury as indicated by displacement, C). The number of fragments in the setting
the patient at high risk for osteone- comminution, or glenohumeral joint of severe com-minution is underestimated
crosis of the humeral head15. The dislocation. This scheme is more by standard radiography in >60% of
operating surgeon must be aware of complex than the Neer classification cases23.
this risk to make educated decisions system, yet there is no evidence that it Magnetic resonance imaging
about fixation or arthroplasty, the is more reliable17,20. (MRI) is not part of the routine
Fig. 1
Anteroposterior radiograph (Fig. 1-A), axial CT scan (Fig. 1-B), and coronal CT scan (Fig. 1-C) of a comminuted head-split fracture.
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2282
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d
 shoulder and arm off the edge of the bed. It
must be ensured that a good anteroposte-
rior and axillary radiograph can be made
prior to skin preparation. Once the c-arm
fluoroscopic image intensifier is properly
positioned, sterile preparation and draping
of the shoulder is performed.
Careful pin placement is essential to
avoid neurovascular injury. Lateral pins
should be distal to the anterior branch of
the axillary nerve27 but proximal to the
deltoid insertion to avoid the radial nerve.
The musculocutaneous nerve, cephalic
vein, and biceps tendon are at risk from
placement of the anterior pins.
Reduction of the humeral shaft
under the humeral head is done by
applying longitudinal traction with a
posterolateral force to the arm. If this
does not reduce the fracture, a 2.5-mm
Fig. 2 terminally threaded pin inserted through
Anteroposterior radiograph of a valgus-impacted four-part fracture.
the greater tuberosity into the humeral
head can be used as a so-called joystick.
evaluation of proximal humeral frac- Percutaneous Fixation Another reduction technique is to use a
tures. While traumatic rotator cuff tear- Indications small so-called reduction portal to ma-
ing at the time of a proximal humeral Percutaneous fixation with pins is a nipulate the fragments with
fracture is rare, some authors have minimally invasive strategy with a theo- instruments such as elevators, tamps,
recommended consideration of the use retically lower rate of osteonecrosis than or hooks28 (Figs. 3-A and 3-B).
of MRI24. Rutten et al. recently that with open fixation. However, it offers Once adequate reduction is
described an ultrasonographic sign that less stability than other forms of fixation, achieved, a 2.5-mm terminally threaded
reliably detected occult proximal and is technically demanding. It is pin is driven from the lateral metaphysis
humeral frac-tures25. The so-called advocated for unstable two-part sur-gical into the humeral head. As the pin nears
double-line sign was present in 93% of neck fractures, but also has a role in more the articular surface of the humeral head,
patients with occult fractures. complex three-part and valgus-impacted driving it in by hand with use of a T-
four-part fractures8 (Fig. 2). This form of handled chuck rather than a power driver
Surgical Indications fixation is generally reserved for patients provides better tactile feedback and
Many proximal humeral fractures with with good bone quality; minimal minimizes the risk of penetrating the
minimal displacement are amenable to comminution, particularly in-volving the articular cartilage. Insertion should also
nonoperative treatment. Displaced two, tuberosity; and an intact medial calcar. It is be done under image guidance to further
three, and four-part fractures are also essential that patients are compliant minimize the risk of pin penetration.
indications for surgical management to with postoperative follow-up and If penetration occurs, the pin must be
optimize anatomic healing and im-prove immobilization8. removed and a completely new track
functional outcome. Displace-ment of the createdif the pin is simply withdrawn,
tuberosities above the humeral head, as Technique it may migrate and penetrate over time.
in three or four-part fractures or in varus A detailed description of the When inserting the pin, the surgeon must
two-part fractures, often yields a poor percutane-ous pinning technique has recognize that the humeral head is
functional outcome, even if healing been previ-ously published26. Pearls of retroverted 20L to 40L. Two or three
occurs nonoperatively. Surgery is aimed management are discussed below. antegrade pins in a parallel configuration
at restoring the proximal humeral Percutaneous techniques should be are usually adequate for fixation of the
anatomy, including the neck-shaft angle, performed within five to seven days of humeral head to the shaft29, although a
version, and tuberosity-to-head and injury to avoid difficulties associated retrograde pin from the greater tuberos-
tuberosity-to-tuberosity relationships, with early callous and scarring. ity to the humeral shaft is sometimes
and bone-preserving options include Proper setup and timing of surgery is used to augment stability30. Fixation of
percutaneous tech-niques, intramedullary critical to outcome. The patient is placed in the tuberosities in displaced three and
nailing, and locked plating. a supine or modified beach-chair posi-tion four-part fractures is achieved with 3.5 or
on a radiolucent table with the 4.0-mm cannulated screws placed
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2283
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

Fig. 3-A Fig. 3-B Fig. 3-C

Use of an elevator (Fig. 3-A) and a hook (Fig. 3-B) in fracture reduction during percutaneous pinning. Fig. 3-C Final construct after percutaneous pinning.

antegrade from the tuberosity either Pin-Track Infection Intramedullary Nailing

bicortically into the calcar (for the greater Superficial infections are treated with Indications
tuberosity) or unicortically into the head local wound care, antibiotics, and pin Intramedullary nails are accepted as an
(for the lesser tuberosity). Pins and removal. Ensuring that the pins remain effective method to treat two-part sur-
screws are buried underneath the skin below the skin lessens the chance of gical neck fractures, although their use
(Fig. 3-C). The arm is immobilized for infection. One must be-ware of a in more complex proximal humeral
three to four weeks, and the pins are deeper infection including fractures has varied37-39. Small
removed after four to six weeks. osteomyelitis. incisions, closed reduction, and
excellent nail-bone purchase in
Prognosis and Outcomes Osteonecrosis osteoporotic bone are advantages.
Functional outcome is correlated with the Osteonecrosis of the humeral head is Gradl et al. treated displaced
adequacy of reduction and the residual most likely related to the magnitude of proximal humeral fractures with an
deformity. Union rates are high, and good the injury, with four-part fractures antegrade nail (Targon PH; Aesculap,
results should be expected with two-part associated with a prevalence of osteo- Tuttlingen, Germany) and had better
and three-part frac-tures28,31,32. If necrosis of up to 28%28,31,33. Kralinger et functional results in patients with two-
acceptable alignment can-not be obtained al. found a significantly lower rate of part and three-part fractures than in those
at the time of surgery, open reduction is osteonecrosis after percutaneous pin- with four-part fractures40. The published
recommended. ning compared with open reduction results have varied41-45. The
and internal fixation34. intramedullary nail may be rigid and
Complications We followed a series of twenty- locked or flexible and unlocked. Locked
Malunion seven patients treated with percutaneous intramedullary nails are axially and
Malunion rates have been reported to pin fixation for a minimum of three years rotationally stable, whereas flexible in-
be as high as 28%31. Patients with after surgery. Osteonecrosis was noted in tramedullary nails are not. Shoulder
osteopo-rotic bone and those who have 26% at an average fifty months (range, impairment and iatrogenic fractures are
fracture comminution have the highest eleven to 101 months), including half of risks with locked intramedullary nails46-
risk. Varus angulation of the humeral the four-part fractures, two of the twelve 48
. Advantages of the flexible
head with posterosuperior three-part fractures, and none of the two- intramedullary nails are relatively little
displacement of the greater tuberosity part fractures. The mean American blood loss, no soft-tissue stripping at the
is the most common deformity8. Shoulder and Elbow Surgeons (ASES) fracture site, minimal muscular trauma,
score was 65 for patients with and low risk of radial nerve injury. A
Pin Migration and/or Loosening osteonecrosis and 84 for patients with- disadvantage of flexible intramedullary
Despite the use of terminally threaded out osteonecrosis26. nails, particularly among patients with
pins, the migration of pins occurs in up to osteoporotic bone, is restricted early
a third of patients28,31. Migration into the Neurovascular Injury motion and delayed physiotherapy due to
chest and other vital structures has been Despite cadaveric studies demonstrating relatively low con-struct stability49.
described8. Weekly evaluation and potential neurovascular injury with
radiographs are performed to monitor percutaneous fixation, clinical rates are Technique
fracture reduction and pin alignment. low27,35,36. A good knowledge of anatomy Rigid Intramedullary Nail
Pins that become loose or migrate should and normal variants is essential to The patient is placed supine in the
be removed prior to four weeks. prevent complications. beach-chair position, and the image
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2284
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

intensifier device is positioned to Flexible Intramedullary Nails Complications

ensure that anteroposterior and axillary Retrograde flexible intramedullary nailing Nonunion
radio-graphs of the affected shoulder utilizes more than one 2-mm-diameter, In a systematic review by Lanting et al.
can be obtained intraoperatively. curved, flexible nail to achieve multiple- (sixty-six articles with results on 2653
A 4-cm longitudinal incision is point intramedullary fixation. The frac-ture fractures), nonunion was as high as 4%
made anterolateral to the acromion. The pattern and the diameter of the medullary in two and three-part fractures39.
deltoid is split from the anterolateral canal dictate the number of nails that are
corner of the acromion distally for 4 cm. inserted. Usually, three, four, or five nails Nail Migration
The humeral head fragment is exposed, are necessary to ob-tain sufficient stability. Verbruggen and Stapert stated that
and the head fragment is reduced, with Once closed re-duction has been achieved, rates of flexible nail migration as high
use of a 2.5-mm Kirschner wire or the nails are advanced from distal to as 29% and rates of fracture distraction
Steinmann pin, under fluoroscopic proximal from an entry point 3 cm of up to 41% have been reported48.
guidance. For displaced four-part frac- proximal to the olecra-non tip under
tures, 1.25-mm Kirschner wires can be fluoroscopic guidance to the medial half of Malunion
used for temporary fragment reduction. A the humeral head, di-verging in the Malunion is one of the commonly
1-cm incision is made in the supra- subchondral region37. reported complications, and the rate of
spinatus tendon in line with its fibers. An Pendulum movements of the postoperative varus deformity of the
awl or a guide pin is used to enter the shoulder are started on the first post- humeral neck has been reported to be
medullary canal. For the straight 150-mm operative day, with mobilization of the as high as 7.7% to 37%39,54,57.
Targon PH nail (Aesculap), the elbow joint. Passive movement
recommended entry point is about exercises may be initiated on the third Nerve Injury
8 mm medial to the cartilage-bone week, and active exercises may be The locking screws that are used with
transitional zone at the sulcus between started on the fourth week onward. the nails may pose a danger to the
the humeral head and the greater tu- axillary nerve51. Closed reduction and
berosity50. For the 6L angled Stryker T2 Prognosis and Outcomes implant insertion place the radial nerve
Proximal Humerus nail (Stryker, Kiel, When appropriate patients are chosen, at risk. Blunt dissection and use of
Germany), the recommended entry point careful placement of the nail entry point protection sleeves during drilling and
is 10 mm posterior to the anterior edge of and effective postoperative rehabilita- screw insertion can prevent this injury.
the supraspinatus and at the junction of tion lead to a successful result38,40,50.
the greater tuberosity and the articular
cartilage50. The entry point for the Rigid Intramedullary Nail Rotator Cuff Injury
proximal humeral nail (Synthes, West Several recent cohort studies have dem- Insertion of the nail through the rotator
Chester, Pennsylvania) is just lat-eral to onstrated 100% union rates, low com- cuff tendon causes different degrees of
the articular margin in the sulcus between plication rates, and favorable subjective injury to the supraspinatus tendon that
the greater tuberosity and the articular outcomes with rigid intramedullary can lead to shoulder pain38,46,52. Care
margin38. The entry point of the nailing38,52,53. Three recent comparisons should be taken in the dissection of the
intramedullary nail is important; of rigid intramedullary nailing and supraspinatus tendon and in its metic-
however, cortical apposition may be lost locked plate fixation did not reveal a ulous repair.
following the insertion of the nail as a significant difference in objective or
result of the specific humeral pathology subjective outcomes54-56. One study did Open Reduction and
and anatomic characteristics50. The show a trend of more complications and Locked Plate Fixation
medullary canal is reamed. The nail is lower relative Constant scores with nail Background
inserted manually with its targeting fixation, but this did not reach signifi- Prior to the advent of locked plating,
device. The depth of nail insertion may cance55. Another showed a higher rate of hemiarthroplasty had been advocated
vary according to manufacturer and complications but better outcome scores for most three and four-part fractures.
design. Precise orientation of the tar- with locked plate fixation at one year; Anatomic proximal humeral locking
geting device is necessary to avoid injury however, no difference was detected plates represent an advance in
to the long head of the biceps and between the locked plate group and the construct stability58,59 and have a lower
neurovascular structures51. Fixation nail fixation group at three years56. rate of implant failure compared with
screws are inserted. We recommend Matziolis et al. found no signifi- unlocked plating. However, the
placement of all of the proximal screws, cant difference in absolute Constant complication rate remains substantial.
particularly if the tuberosities are frac- scores between Zifko nailing and fixed- Continued inno-vation in technology
tured. The rotator cuff tendon and deltoid angle plating for two-part fractures. The (i.e., polyaxial systems and suture
are repaired, and active-assisted to active score for the subitem activity of daily eyelets) and tech-nique (i.e., structural
shoulder motion is begun on the third life was significantly higher in the plate allograft and rotator cuff sutures) are
postoperative day. group than in the Zifko group37. aimed at improving current outcomes.
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2285
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

Fig. 4
Anteroposterior radiographs of a comminuted proximal humeral fracture with a head split made preoperatively (Figs. 4-A and 4-B) and immediately after
open reduction and locked-plate fixation (Fig. 4-C).

The importance of medial cor- plates are biomechanically more stable improved preservation of the blood
tical support has been demonstrated than the tested constructs under these supply. However, these approaches may
with the locking construct, as the circumstances, the added stability may place the axillary nerve at risk72-77. Con-
screw buttressing the inferomedial reduce the fracture failure rate. versely, the classic deltopectoral ap-
portion of the proximal segment aids in proach is the only truly internervous
medial column support60. Restora-tion Indications approach and is the most widely utilized
of medial calcar and medial sup-port Most displaced two, three, or four-part exposure. Controversy exists as to what
plays an important role in maintaining fractures of the proximal part of the approach to use for locking plate fixa-
reduction61. This screw functions as a humerus can be treated with locked tion9,71-74. We use the deltopectoral ap-
so-called kickstand and is beneficial in plates. Fracture dislocations and head- proach because of its extensile nature
maintaining the stabil-ity and ultimate splitting fractures in patients older than and long track record of safety.
reduction of the construct. forty years are relative contraindications
Additionally, anatomic or slightly to plate fixation. Both are higher-energy Deltopectoral Approach
impacted reductions aid in construct injuries associated with risk of osteo- The deltopectoral approach utilizes the
stability61. necrosis of the humeral head; however, internervous plane between the deltoid
Other constructs have attempted in younger patients in whom joint- (axillary nerve) and the pectoralis major
to utilize pegs as alternatives to screws preserving strategies are most appro- (medial and lateral pectoral nerves)70.
to prevent articular perforation. priate, head-splitting and high-energy The patient can be positioned in the
Schumer et al. found no significant fractures may be fixed with a locked beach-chair position or supine, de-
difference in joint perforation between plate (Figs. 4-A, 4-B, and 4-C). Few pending on the available equipment and
the two constructs62. Newer locking other contraindications exist, except the surgeon preference. The skin inci-
constructs offer polyaxial locking prohibitive medical comorbidities, pe- sion is approximately 10 to 15 cm long,
mechanisms. In a comparison of diatric fractures, or patterns of injury beginning at the coracoid and angled
monoaxial and polyaxial constructs, amenable to less invasive techniques68,69. distally to the deltoid tuberosity.
the polyaxial system had equal biome- The cephalic vein is identified in
chanical performance with the advan- Proximal Humeral Exposures70 the deltopectoral interval and is usually
tage of more head fixation63. Multiple exposures for the proximal part mobilized laterally to protect the many
In a comparison of a locked plate of the humerus, including the classic deltoid branches78; however, it may be
and locked nail, plates were found to deltopectoral, anterolateral deltoid- taken medially as well. The
be stronger in torsion, equivalent in splitting approach, and two-incision clavipectoral fascia is opened, and the
axial stiffness64, and superior in varus techniques9,71-73, have been described. conjoint ten-don is retracted medially.
bend-ing65. In comparison with There are advantages and disadvantages Deltoid or pectoralis major detachment
proximal humeral blade plates, locking of each. The anterolateral and two- is not needed, and no more than one-
plates provided better torsional fatigue incision approaches were developed with fifth of each should be released79.
resis-tance and stiffness66. the primary purposes of improving Continuity of the axillary nerve
Proximal humeral fracture fixa- visualization, minimizing soft-tissue can be tested with the so-called tug test80
tion fails because of bending and rota- dissection, and allowing more direct at the inferior border of the subscapu-
tional moments60-67. Because locking plate application, which may permit laris and beneath the deltoid. The
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2286
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

distance from the coracoid to the point head). If the plate is placed too high, being developed. Improved results and
of entrance of the main musculocuta- there is a risk of impingement. If it is decreased complications were detailed
neous nerve trunk into the coracobra- placed too low, head fixation can be in a series by Ricchetti et al., in which
chialis averages 5.6 cm (range, 3 to 8 compromised. Proximal screws should the authors supplemented plate-and-
cm)81. remain short of the subchondral bone to screw fixation with suturing of the
The rotator cuff interval may be reduce the risk of perforation with rotator cuff tendons to the plate69.
incised at the level of penetration of the humeral head collapse. Rotator cuff su- Hettrich et al. used endosteal fibular
biceps tendon to mobilize the tuberos- tures are then tied to the plate to neu- strut allografts or medial semitubular
ities and to allow visualization and tralize the displacing force of the cuff plates and noted only one substantial
palpation of the articular surfaces. The muscles and offload the proximal screws. loss of reduction and no implant
long head of the biceps tendon is Screw penetration into the joint is a risk, failures or screw cut-out96. Egol et al.
uncovered in its groove and is followed and rotator cuff sutures add additional used calcium phosphate cement to
proximally to its insertion on the supe- stability and are believed to stabilize the prevent settling and screw cutout, and
rior aspect of the glenoid. The tendon fracture enough to allow early motion less humeral settling was seen97.
may be tenotomized and tenodesed to and decrease fixation failure86-88. After In conclusion, locked plating has
the pectoralis major, removing a source completion of fixation, fluoroscopy been a major advance in the treatment
of postoperative pain82. It is important should be utilized and the humeral of displaced proximal humeral frac-
to avoid excessive dissection and articular surface should be palpated to tures, and has allowed many more
cauteri-zation in the bicipital groove to ensure that no screws violate the joint. fractures to be successfully treated
preserve the ascending branch of the with a joint-preserving method in-stead
anterior humeral circumflex artery. Rehabilitation of arthroplasty. Complications remain
Postoperative rehabilitation is a bal- substantial, but the techniques and
Reduction ance between early motion and not technology of proximal humeral
Control of the rotator cuff is the most disrupting the fixation89. Initially, the locked plating are areas of active
important step to reduce and control arm is placed in a sling. Active range research.
the multiple fracture fragments. Non- of motion of elbow, wrist, and hand, as
absorbable sutures are placed in the well as pendulum exercises may begin Overview
subscapularis to control the lesser tu- on the first postoperative day. Gentle Percutaneous, intramedullary, and
berosity, and in the supraspinatus and passive range of motion of the locked-plate fixation can be reliable
infraspinatus to control the greater shoulder is started as soon as the fixation strategies for proximal humeral
tuberosity and humeral head. Eleva- patient is comfortable. Active shoul- fractures with the correct indications and
tors, if necessary, are placed in the der motion should begin at four to six careful patient selection, which are based
fracture planes to disimpact the frag- weeks, and strengthening exercises on an understanding of the anat-omy and
ments and to correct varus or valgus should not be started until twelve biomechanics of the injury. Each method
positioning of the head. The tuberosi- weeks. has advantages and dis-advantages that
ties are reduced to their anatomic the surgeon must con-sider and
position with respect to the head and Results and Complications individualize for a particular patient.
the metaphysis and shaft. Tuberosity The results of locked plate fixation are Regardless of the technique selected,
reduction is a key predictor of func- evolving, but the overall complication meticulous surgical technique and
tional outcome83,84. If there is insuffi- rate remains high86,90-94. The most com- anatomic reduction are essential. Careful
cient metaphyseal bone, the surgeon mon complications are screw joint postoperative rehabilitation is essential.
may place a fibular strut allograft perforation (13.7% to 23%) and osteo- Each method also has specific
within the intramedullary canal and necrosis (3.1% to 16.4%). The rate of complications, which may be mitigated
impact the head onto it to provide revision surgery has been reported to as techniques and technology continue to
control and structural support85. range from 13% to 26.7%. However, in a evolve.
study comparing the functional out-
Fixation comes of patients with three and four-
Locking plates have a low profile, a part proximal humeral fractures treated
hole for a kickstand screw to buttress with locked plating or with a hemiar- Daniel Aaron, MD
the medial calcar, divergent proximal throplasty, the University of California at Joshua Shatsky, MD
locking screws, and eyelets to allow Los Angeles shoulder score, the Constant Bradford O. Parsons, MD
score, patient satisfaction, and motion Evan L. Flatow, MD
passage of rotator cuff sutures through
Department of Orthopaedic Surgery,
the plate68. The plate should be placed were superior in the locked-plate group95.
Mount Sinai Hospital, 5 East 98th Street,
lateral to the bicipital groove, 1.5 to 2 Strategies to augment locked plate Box 1188, New York, NY 10029.
cm distal to the greater tuberosity (2 to fixation and minimize complications are E-mail address for E.L. Flatow:
3 cm from the superior aspect of the [Link]@[Link]
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2287
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

Juan Carlos Paredes, MD Beijing Ji Shui Tan Hospital, No. 31 article, as well as other lectures presented at the
St. Lukes Medical Center, Xinjiekoudonggjie Street, Academys Annual Meeting, will be available
279 East Rodriguez Sr. Boulevard, Xicheng District, in March 2013 in Instructional Course
Quezon City, 1102 Philippines 100035 Beijing, China Lectures, Volume 62. The complete volume
can be ordered online at [Link], or by
Chunyun Jiang, MD Printed with permission of the American calling 800-626-6726 (8 a.m.-5 p.m., Central
Department of Orthopaedic Surgery, Academy of Orthopaedic Surgeons. This time).

References

1. Buhr AJ, Cooke AM. Fracture patterns. 19. Mueller ME. The principle of classification. In: 33. Hertel R, Hempfing A, Stiehler M, Leunig M.
Lancet. 1959 Mar 14;1(7072):531-6. Mueller ME, Allgower M, Schneider R, Willenegger Predictors of humeral head ischemia after intracap-
2. Court-Brown CM, Garg A, McQueen MM. The H. Manual of internal fixation: techniques sular fracture of the proximal humerus. J Shoulder
epidemiology of proximal humeral fractures. Acta recommended by the AO-ASIF group. 2nd ed. New Elbow Surg. 2004 Jul-Aug;13(4):427-33.
Orthop Scand. 2001 Aug;72(4):365-71. York: Springer-Verlag; 1995. p 118-25. 34. Kralinger F, Irenberger A, Lechner C, Wambacher
3. Lind T, Krner K, Jensen J. The epidemiology of 20. Sjoden GO, Movin T, Guntner P, Aspelin P, M, Golser K, Sperner G. [Comparison of open versus
fractures of the proximal humerus. Arch Orthop Ahrengart L, Ersmark H, Sperber A. Poor percutaneous treatment for humeral head fracture].
Trauma Surg. 1989;108(5):285-7. reproducibil-ity of classification of proximal Unfallchirurg. 2006 May;109(5):406-10. German.
4. Horak J, Nilsson BE. Epidemiology of fracture humeral fractures. Additional CT of minor value. 35. Kamineni S, Ankem H, Sanghavi S. Anatomical
of the upper end of the humerus. Clin Orthop Relat Acta Orthop Scand. 1997 Jun;68(3):239-42. considerations for percutaneous proximal humeral
Res. 1975 Oct;(112):250-3. 21. Edelson G, Kelly I, Vigder F, Reis ND. A fracture fixation. Injury. 2004 Nov;35(11):1133-6.
5. Kannus P, Palvanen M, Niemi S, Parkkari J, three-dimensional classification for fractures of 36. Rowles DJ, McGrory JE. Percutaneous pinning of
Jarvinen M, Vuori I. Increasing number and incidence the proxi-mal humerus. J Bone Joint Surg Br. the proximal part of the humerus. An anatomic study. J
of oste-oporotic fractures of the proximal humerus in 2004 Apr;86(3):413-25. Bone Joint Surg Am. 2001 Nov;83-A(11):1695-9.
elderly people. BMJ. 1996 Oct 26;313(7064):1051-2. 22. Mora Guix JM, Gonzalez AS, Brugalla JV, 37. Matziolis D, Kaeaeb M, Zandi SS, Perka C,
6. Neer CS 2nd. Displaced proximal humeral Carril EC, Banos FG. Proposed protocol for Greiner S. Surgical treatment of two-part
frac-tures. I. Classification and evaluation. J reading images of humeral head fractures. Clin fractures of the proximal humerus: comparison of
Bone Joint Surg Am. 1970 Sep;52(6):1077-89. Orthop Relat Res. 2006 Jul;448:225-33. fixed-angle plate osteosynthesis and Zifko nails.
7. Tamai K, Ishige N, Kuroda S, Ohno W, Itoh H, 23. Haapamaki VV, Kiuru MJ, Koskinen SK. Multi- Injury. 2010 Oct;41(10):1041-46.
Hashiguchi H, Iizawa N, Mikasa M. Four-segment detector CT in shoulder fractures. Emerg Radiol. 38. Zhu Y, Lu Y, Wang M, Jiang C. Treatment of
classification of proximal humeral fractures revisited: a 2004 Dec;11(2):89-94. proximal humeral fracture with a proximal humeral
multicenter study on 509 cases. J Shoulder Elbow 24. Gallo RA, Altman DT, Altman GT. Assessment nail. J Shoulder Elbow Surg. 2010 Mar;19(2):297-
Surg. 2009 Nov-Dec;18(6):845-50. Epub 2009 Mar of rotator cuff tendons after proximal humerus 302. Epub 2009 Aug 6.
17. fractures: is preoperative imaging necessary? J 39. Lanting B, MacDermid J, Drosdowech D,
8. Magovern B, Ramsey ML. Percutaneous Trauma. 2009 Mar;66(3):951-3. Faber KJ. Proximal humeral fractures: a
fixation of proximal humerus fractures. Orthop Clin 25. Rutten MJ, Jager GJ, de Waal Malefijt MC, systematic review of treatment modalities. J
North Am. 2008 Oct;39(4):405-16, v. Blickman JG. Double line sign: a helpful sonographic Shoulder Elbow Surg. 2008 Jan-Feb;17(1):42-54.
9. Gerber C, Schneeberger AG, Vinh TS. The arterial sign to detect occult fractures of the proximal humerus. 40. Gradl G, Dietze A, Arndt D, Beck M, Gierer P,
vascularization of the humeral head. An anatomical Eur Radiol. 2007 Mar;17(3):762-7. Epub 2006 Jun 7. Borsch T, Mittlmeier T. Angular and sliding stable
study. J Bone Joint Surg Am. 1990 Dec;72(10): 26. Harrison AK, Gruson KI, Zmistowski B, Keener J, antegrade nailing (Targon PH) for the treatment of
1486-94. Galatz L, Williams G, Parsons BO, Flatow EL. Inter- proximal humeral fractures. Arch Orthop Trauma
10. Laing PG. The arterial supply of the mediate outcomes following percutaneous fixation of Surg. 2007 Dec;127(10):937-44.
adult humerus. J Bone Joint Surg Am. 1956 proximal humeral fractures. J Bone Joint Surg Am. 41. Koike Y, Komatsuda T, Sato K. Internal fixation
Oct;38-A(5):1105-16. 2012 Jul 3;94(13):1223-8. of proximal humeral fractures with a Polarus
11. Brooks CH, Revell WJ, Heatley FW. 27. Liu KY, Chen TH, Shyu JF, Wang ST, Liu JY, humeral nail. J Orthop Traumatol. 2008
Vascularity of the humeral head after proximal Chou PH. Anatomic study of the axillary nerve in a Sep;9(3):135-9. Epub 2008 Jul 16.
humeral fractures. An anatomical cadaver study. J Chinese cadaveric population: correlation of the 42. Lin J. Effectiveness of locked nailing for
Bone Joint Surg Br. 1993 Jan;75(1):132-6. course of the nerve with proximal humeral fixation
displaced three-part proximal humeral fractures. J
12. Netter FH. Upper limb. In: The CIBA collection with intra-medullary nail or external skeletal
Trauma. 2006 Aug;61(2):363-74.
of medical illustrations. Vol 8. Summit, NJ: CIBA- fixation. Arch Orthop Trauma Surg. 2011
May;131(5):669-74. Epub 2010 Sep 2. 43. Park JY, An JW, Oh JH. Open intramedullary
GEIGY; 1987. p 20-74.
nailing with tension band and locking sutures for
13. Fitzgerald JF, Keates J. False aneurysm as a 28. Keener JD, Parsons BO, Flatow EL, Rogers
proximal humeral fracture: hot air balloon technique. J
late complication of anterior dislocation of the K, Williams GR, Galatz LM. Outcomes after
Shoulder Elbow Surg. 2006 Sep-Oct;15(5):594-601.
shoulder. Ann Surg. 1975 Jun;181(6):785-6. percutane-ous reduction and fixation of proximal
humeral frac-tures. J Shoulder Elbow Surg. 2007 44. Agel J, Jones CB, Sanzone AG, Camuso M,
14. Gerber C, Lambert SM, Hoogewoud HM. Absence
May-Jun;16(3):330-8. Epub 2007 Feb 22. Henley MB. Treatment of proximal humeral
of avascular necrosis of the humeral head after post-
fractures with Polarus nail fixation. J Shoulder
traumatic rupture of the anterior and posterior hu-meral 29. Jiang C, Zhu Y, Wang M, Rong G. Biomechanical
Elbow Surg. 2004 Mar-Apr;13(2):191-5.
circumflex arteries. A case report. J Bone Joint Surg comparison of different pin configurations during
percutaneous pinning for the treatment of proximal 45. Bernard J, Charalambides C, Aderinto J, Mok D.
Am. 1996 Aug;78(8):1256-9.
humeral fractures. J Shoulder Elbow Surg. 2007 Mar- Early failure of intramedullary nailing for proximal
15. Neer CS 2nd. Displaced proximal humeral
Apr;16(2):235-9. Epub 2007 Jan 31. humeral fractures. Injury. 2000 Dec;31(10):789-92.
frac-tures. II. Treatment of three-part and four-
part dis-placement. J Bone Joint Surg Am. 1970 30. Durigan A Jr, Barbieri CH, Mazzer N, Shimano 46. Lin J, Inoue N, Valdevit A, Hang YS, Hou SM,
Sep;52(6):1090-103. AC. Two-part surgical neck fractures of the humerus: Chao EY. Biomechanical comparison of antegrade
16. Sidor ML, Zuckerman JD, Lyon T, Koval K, Cuomo F, mechanical analysis of the fixation with four Shanz- and retrograde nailing of humeral shaft fracture.
Schoenberg N. The Neer classification system for proximal type threaded pins in four different assemblies. J Clin Orthop Relat Res. 1998 Jun;(351):203-13.
humeral fractures. An assessment of inter-observer Shoulder Elbow Surg. 2005 Jan-Feb;14(1):96-102. 47. Chao TC, Chou WY, Chung JC, Hsu CJ. Humeral
reliability and intraobserver reproducibility. 31. Calvo E, de Miguel I, de la Cruz JJ, Lopez- shaft fractures treated by dynamic compression
J Bone Joint Surg Am. 1993 Dec;75(12):1745-50. Martn N. Percutaneous fixation of displaced plates, Ender nails and interlocking nails. Int Orthop.
17. Siebenrock KA, Gerber C. The reproducibility proximal humeral fractures: indications based on 2005 Apr;29(2):88-91. Epub 2005 Feb 16.
of classification of fractures of the proximal end of the correlation be-tween clinical and radiographic 48. Verbruggen JP, Stapert JW. Humeral fractures
the humerus. J Bone Joint Surg Am. 1993 results. J Shoulder Elbow Surg. 2007 Nov- in the elderly: treatment with a reamed
Dec;75(12):1751-5. Dec;16(6):774-81. Epub 2007 Oct 26. intramedullary locking nail. Injury. 2007
18. Neer CS 2nd. Four-segment classification of 32. Jaberg H, Warner JJ, Jakob RP. Percutaneous Aug;38(8):945-53. Epub 2007 Jun 19.
proximal humeral fractures: purpose and reliable use. J stabilization of unstable fractures of the humerus. J 49. Durbin RA, Gottesman MJ, Saunders KC. Hacke-
Shoulder Elbow Surg. 2002 Jul-Aug;11(4):389-400. Bone Joint Surg Am. 1992 Apr;74(4):508-15. thal stacked nailing of humeral shaft fractures.
Downloaded From: [Link] by a HINARI User on 03/15/2014
 2288
TH E J O U R N A L O F B O N E & JO I N T SU R G E R Y d
JBJS . ORG PR O X I M A L HU M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N
VO L U M E 9 4 - A NU M B E R 2 4 D E C E M B E R 1 9 , 2 0 1 2
d d

Experience with 30 patients. Clin Orthop Relat fixed-angle locked nail: the role of implant 82. Tosounidis T, Hadjileontis C, Georgiadis M,
Res. 1983 Oct;(179):168-74. stiffness. Clin Biomech (Bristol, Avon). 2010 Kafanas A, Kontakis G. The tendon of the long
50. Noda M, Saegusa Y, Maeda T. Does the May;25(4):307-11. Epub 2010 Feb 13. head of the biceps in complex proximal humerus
location of the entry point affect the reduction of 65. Edwards SL, Wilson NA, Zhang LQ, Flores S, fractures: a histological perspective. Injury. 2010
proximal humeral fractures? A cadaveric study. Merk BR. Two-part surgical neck fractures of the Mar;41(3): 273-8.
Injury. 2011 Sep;42 Suppl 4:S35-8. proximal part of the humerus. A biomechanical 83. Gerber C, Hersche O, Berberat C. The clinical
51. Nijs S, Sermon A, Broos P. Intramedullary fixation evaluation of two fixation techniques. J Bone Joint relevance of posttraumatic avascular necrosis of
of proximal humerus fractures: do locking bolts Surg Am. 2006 Oct;88(10):2258-64. the humeral head. J Shoulder Elbow Surg. 1998
endanger the axillary nerve or the ascending branch of 66. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Nov-Dec;7(6):586-90.
the anterior circumflex artery? A cadaveric study. Locking plates improve torsional resistance in the 84. Hintermann B, Trouillier HH, Schafer D. Rigid
Patient Saf Surg. 2008 Dec 16;2(1):33. stabilization of three-part proximal humeral fractures. J internal fixation of fractures of the proximal
52. Hatzidakis AM, Shevlin MJ, Fenton DL, Curran- Shoulder Elbow Surg. 2006 Mar-Apr;15(2):239-43. humerus in older patients. J Bone Joint Surg Br.
Everett D, Nowinski RJ, Fehringer EV. Angular-stable 67. Wheeler DL, Colville MR. Biomechanical 2000 Nov;82(8):1107-12.
locked intramedullary nailing of two-part surgical neck com-parison of intramedullary and percutaneous 85. Gardner MJ, Boraiah S, Helfet DL, Lorich DG.
fractures of the proximal part of the humerus. A pin fixa-tion for proximal humeral fracture fixation. Indirect medial reduction and strut support of proximal
multicenter retrospective observational study. J Bone J Orthop Trauma. 1997 Jul;11(5):363-7. humerus fractures using an endosteal implant. J
Joint Surg Am. 2011 Dec 7;93(23):2172-9. 68. Badman BL, Mighell M. Fixed-angle locked Orthop Trauma. 2008 Mar;22(3):195-200.
53. Georgousis M, Kontogeorgakos V, plat-ing of two-, three-, and four-part proximal 86. Brunner F, Sommer C, Bahrs C, Heuwinkel R,
Kourkouvelas S, Badras S, Georgaklis V, Badras L. humerus fractures. J Am Acad Orthop Surg. 2008 Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M,
Internal fixation of proximal humerus fractures with May;16(5):294-302. Audige L, Babst R. Open reduction and internal
the polarus intramedullary nail. Acta Orthop Belg. 69. Ricchetti ET, Warrender WJ, Abboud JA. Use fixation of proximal humerus fractures using a
2010 Aug;76(4):462-7. of locking plates in the treatment of proximal proximal humeral locked plate: a prospective
54. Gradl G, Dietze A, Kaab M, Hopfenmuller W, humerus fractures. J Shoulder Elbow Surg. 2010 multi-center analysis. J Orthop Trauma. 2009
Mittlmeier T. Is locking nailing of humeral head Mar;19(2 Suppl):66-75. Mar;23(3):163-72.
fractures superior to locking plate fixation? Clin 70. Hoppenfeld S, deBoer P. Surgical exposures 87. Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani
Orthop Relat Res. 2009 Nov;467(11):2986-93. NC, Zuckerman JD. Early complications in proximal
in orthopaedics: the anatomic approach. 2nd ed.
Epub 2009 Jun 13. humerus fractures (OTA Types 11) treated with locked
Phila-delphia: Lippincott Williams & Wilkins; 1994.
55. Krivohlavek M, Lukas R, Taller S, Sram J. plates. J Orthop Trauma. 2008 Mar;22(3):159-64.
71. Gardner MJ, Griffith MH, Dines JS, Briggs SM,
[Use of angle-stable implants for proximal humeral 88. Vallier HA. Treatment of proximal humerus frac-
Weiland AJ, Lorich DG. The extended anterolateral
fractures: prospective study]. Acta Chir Orthop tures. J Orthop Trauma. 2007 Aug;21(7):469-76.
acromial approach allows minimally invasive
Traumatol Cech. 2008 Jun;75(3):212-20. Czech. access to the proximal humerus. Clin Orthop Relat 89. Hawkins RJ, Kiefer GN. Internal fixation
56. Zhu Y, Lu Y, Shen J, Zhang J, Jiang C. Res. 2005 May;(434):123-9. tech-niques for proximal humeral fractures. Clin
Locking intramedullary nails and locking plates in Orthop Relat Res. 1987 Oct;(223):77-85.
72. Gardner MJ, Boraiah S, Helfet DL, Lorich DG.
the treat-ment of two-part proximal humeral
The anterolateral acromial approach for fractures 90. Sudkamp N, Bayer J, Hepp P, Voigt C,
surgical neck fractures: a prospective randomized
of the proximal humerus. J Orthop Trauma. 2008 Oestern H, Kaab M, Luo C, Plecko M, Wendt K,
trial with a minimum of three years of follow-up. J
Feb;22(2):132-7. Kostler W, Konrad G. Open reduction and internal
Bone Joint Surg Am. 2011 Jan 19;93(2):159-68.
73. Gallo RA, Zeiders GJ, Altman GT. Two- fixation of proximal humeral fractures with use of
57. van den Broek CM, van den Besselaar M,
incision technique for treatment of complex the locking proximal humerus plate. Results of a
Coenen JM, Vegt PA. Displaced proximal humeral prospective, multicenter, observational study. J
proximal humerus fractures. J Orthop Trauma.
fractures: intramedullary nailing versus Bone Joint Surg Am. 2009 Jun;91(6):1320-8.
2005 Nov-Dec;19(10): 734-40.
conservative treatment. Arch Orthop Trauma Surg.
2007 Aug;127(6):459-63. Epub 2006 Nov 15. 74. Wu CH, Ma CH, Yeh JJ, Yen CY, Yu SW, Tu 91. Owsley KC, Gorczyca JT. Fracture displacement
YK. Locked plating for proximal humeral and screw cutout after open reduction and locked
58. Seide K, Triebe J, Faschingbauer M, Schulz AP,
fractures: dif-ferences between the deltopectoral plate fixation of proximal humeral fractures [cor-
Puschel K, Mehrtens G, Ch Jurgens. Locked vs. un-
and deltoid-splitting approaches. J Trauma. 2011 rected]. J Bone Joint Surg Am. 2008 Feb;90(2):233-
locked plate osteosynthesis of the proximal humerus -
Nov;71(5): 1364-70. 40. Erratum in: J Bone Joint Surg Am.
a biomechanical study. Clin Biomech (Bristol, Avon).
75. Gardner MJ, Voos JE, Wanich T, Helfet DL, 2008 Apr;90(4):862.
2007 Feb;22(2):176-82. Epub 2006 Nov 28.
Lorich DG. Vascular implications of minimally 92. Yang H, Li Z, Zhou F, Wang D, Zhong B. A
59. Strauss EJ, Schwarzkopf R, Kummer F, Egol
KA. The current status of locked plating: the good, invasive plat-ing of proximal humerus fractures. J prospective clinical study of proximal humerus
the bad, and the ugly. J Orthop Trauma. 2008 Orthop Trauma. 2006 Oct;20(9):602-7. frac-tures treated with a locking proximal humerus
Aug;22(7):479-86. 76. Neviaser AS, Hettrich CM, Dines JS, Lorich DG. plate. J Orthop Trauma. 2011 Jan;25(1):11-7.
60. Lescheid J, Zdero R, Shah S, Kuzyk PR, Rate of avascular necrosis following proximal hu- 93. Clavert P, Adam P, Bevort A, Bonnomet F, Kempf
Schemitsch EH. The biomechanics of locked merus fractures treated with a lateral locking plate JF. Pitfalls and complications with locking plate for
plating for repairing proximal humerus fractures and endosteal implant. Arch Orthop Trauma Surg. proximal humerus fracture. J Shoulder Elbow Surg.
with or without medial cortical support. J Trauma. 2011 Dec;131(12):1617-22. Epub 2011 Aug 4. 2010 Jun;19(4):489-94. Epub 2009 Dec 7.
2010 Nov;69(5):1235-42. 77. Cetik O, Uslu M, Acar HI, Comert A, Tekdemir 94. Roderer G, Erhardt J, Kuster M, Vegt P, Bahrs C,
61. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet I, Cift H. Is there a safe area for the axillary nerve Kinzl L, Gebhard F. Second generation locked plating
DL, Lorich DG. The importance of medial support in in the deltoid muscle? A cadaveric study. J Bone of proximal humerus fracturesa prospective multi-
locked plating of proximal humerus fractures. J Orthop Joint Surg Am. 2006 Nov;88(11):2395-9. centre observational study. Int Orthop. 2011
Trauma. 2007 Mar;21(3):185-91. 78. Radkowski CA, Richards RS, Pietrobon R, Mar;35(3):425-32. Epub 2010 Apr 25.
62. Schumer RA, Muckley KL, Markert RJ, Moorman CT 3rd. An anatomic study of the cephalic 95. Wild JR, DeMers A, French R, Shipps MR, Bergin
Prayson MJ, Heflin J, Konstantakos EK, Goswami vein in the deltopectoral shoulder approach. Clin PF, Musapatika D, Jelen BA. Functional outcomes for
T. Biome-chanical comparison of a proximal Orthop Relat Res. 2006 Jan;442:139-42. surgically treated 3- and 4-part proximal humerus
humeral locking plate using two methods of head 79. Klepps S, Auerbach J, Calhon O, Lin J, Cleeman fractures. Orthopedics. 2011 Oct 5;34(10):e629-33.
fixation. J Shoulder Elbow Surg. 2010 E, Flatow E. A cadaveric study on the anatomy of the doi: 10.3928/01477447-20110826-14.
Jun;19(4):495-501. Epub 2010 Mar 1. deltoid insertion and its relationship to the deltopec- 96. Hettrich CM, Neviaser A, Beamer BS, Paul
63. Zettl R, Muller T, Topp T, Lewan U, Kruger A, toral approach to the proximal humerus. J Shoulder O, Helfet DL, Lorich DG. Locked plating of the
Kuhne C, Ruchholtz S. Monoaxial versus polyaxial Elbow Surg. 2004 May-Jun;13(3):322-7. proximal humerus using an endosteal implant. J
locking systems: a biomechanical analysis of 80. Flatow EL, Bigliani LU. Tips of the trade. Locating Orthop Trauma. 2012 Apr;26(4):212-5.
different locking systems for the fixation of proximal and protecting the axillary nerve in shoulder surgery: 97. Egol KA, Sugi MT, Ong CC, Montero N,
humeral fractures. Int Orthop. 2011 the tug test. Orthop Rev. 1992 Apr;21(4):503-5. Davidovitch R, Zuckerman JD. Fracture site augmen-
Aug;35(8):1245-50. Epub 2011 Feb 8. 81. Flatow EL, Bigliani LU, April EW. An tation with calcium phosphate cement reduces screw
64. Foruria AM, Carrascal MT, Revilla C, Munuera L, anatomic study of the musculocutaneous nerve penetration after open reduction-internal fixation of
Sanchez-Sotelo J. Proximal humerus fracture rota- and its rela-tionship to the coracoid process. Clin proximal humeral fractures. J Shoulder Elbow Surg.
tional stability after fixation using a locking plate or a Orthop Relat Res. 1989 Jul;(244):166-71. 2012 Jun;21(6):741-8. Epub 2011 Dec 21.
Downloaded From: [Link] by a HINARI User on 03/15/2014