|Year : 2021 | Volume
| Issue : 2 | Page : 51-57
Locking plate fixation for unstable proximal humerus fracture: A prospective study
Prem Regis, Victor Moirangthem
Department of Orthopaedics, Chettinad Hospital and Research Institute, Kanchipuram, Tamil Nadu, India
|Date of Submission||02-Dec-2020|
|Date of Acceptance||17-Jul-2021|
|Date of Web Publication||27-Nov-2021|
Department of Orthopaedics, Chettinad Hospital and Research Institute, Kelambakkam, Kanchipuram, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Unstable fractures of the proximal humerus represent a surgical challenge despite the wide range of treatment options available. The proximal humerus locking plate is a good surgical option in the management of unstable proximal humerus fractures.
Aim: The purpose of this study is to determine whether locking plate fixation in the treatment of displaced and unstable proximal humerus fractures leads to a good functional outcome.
Settings and Design: Medical school hospital, observational study.
Subjects and Methods: Thirty-two patients with unstable proximal humerus fractures treated with proximal humerus locking plate between November 2017 and March 2019 were included in the study. The fractures were classified based on the Neer's classification into two-, three-, and four-part fractures. The minimum follow-up was 1 year. The Constant–Murley scoring system was used for functional assessment. Constant scores for two-, three-, and four-part fractures were determined and compared with respect to the age, gender, handedness, and occupation of the study participants.
Statistical Analysis Used: Chi-square test was applied for discrete variables and one-way ANOVA was used to compare between the three fracture types. P ≤ 0.05 was taken as significant.
Results: Fourteen patients had two-part fractures, 13 patients had three-part fractures, and 3 patients had four-part fractures. The mean follow-up period was 17.5 months (range: 12–24 months). About 65.6% (n = 21) patients had good result, 31.3% (n = 10) had fair, and 3.1% (n = 1) had poor result. Constant scores for 2-part (84.14 ± 2.98) and 3-part fractures (82.15 ± 3.78) were significantly superior to those of 4-part fractures (72.80 ± 3.63) (P = 0.000 and 0.000, respectively). Difference between 2-part and 3-part fractures was not significant (P = 0.142). There was no significant difference in the functional outcome between patients who were employed and unemployed, right and left handed. Complications include stiffness in 6.3% (n = 2) and infection in 3.1% (n = 1) of cases.
Conclusion: Proximal humerus locking plate gives stable fixation for 2-part and 3-part fractures. However, in case of Neer's 4 part-fractures, the functional outcome is relatively poor.
Keywords: Proximal humerus fracture, proximal humerus locking plate, unstable fracture
|How to cite this article:|
Regis P, Moirangthem V. Locking plate fixation for unstable proximal humerus fracture: A prospective study. J Med Soc 2021;35:51-7
| Introduction|| |
Proximal humerus fractures represent approximately 5% of all fractures with a preponderance of women above the age of 65 years following a low velocity fall, usually a fall from standing height. These fractures are also reported in young adults who were involved in high-velocity motor vehicular accidents. The fracture pattern therefore differs depending on the mechanism of injury., Due to the multitude of fracture morphology, the choice of treatment is equally varied. Minimally displaced and stable fractures are best treated nonoperatively, especially in the elderly patient who usually presents with comorbid medical conditions that keep surgery as a second option. However in the case of displaced and unstable fractures, open reduction and internal fixation with a locking plate can give a predictable outcome irrespective of age of the patient.,
The proximal humerus locking plate is a fixed-angle construct that can mitigate the deforming forces trying to separate the fracture fragments exerted by weight of the arm, pull of the rotator and pectoralis muscles, even in the presence of osteoporosis. Unlike conventional plates, periosteal blood supply is maximally preserved with the use of locking plates.,,
This study aims to determine whether locking plate fixation in the treatment of displaced and unstable proximal humerus fractures leads to a good functional outcome. It is hypothesized that the proximal humerus locking plate would provide sufficient mechanical stability to facilitate rehabilitation and recovery in the management of displaced and unstable proximal humerus fractures.
| Subjects and Methods|| |
This prospective study was conducted in a tertiary hospital on 32 consecutive patients who were diagnosed and treated with locking plate for displaced and unstable proximal humerus fracture. The duration of the study was from November 2017 to March 2019.
All consenting patients with displaced fractures (more than 1 cm of separation between the major fragments) of the proximal humerus, angulation more than 45° with respect to the other fragments, and medial metaphyseal comminutions were included in the study group [Figure 1]. Skeletally immature patients, those patients with open fractures, multiple fractures, pathological fractures, and associated neurovascular injuries were excluded. This study was approved by the institute's human ethical committee.
|Figure 1: Preoperative clinical photograph of a patient with right proximal humerus fracture showing diffuse swelling around the shoulder and ecchymosis on the medial aspect|
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A true anterior–posterior radiograph (Grashey's view) of the shoulder, scapular Y view, and axillary lateral view were routinely ordered for a patient with a clinical suspicion of proximal humerus fracture. All radiographs were reviewed and categorized according to Neer's classification of proximal humerus fractures. Three-dimensional computed tomography imaging was routinely used for the preoperative assessment of the fracture pattern and in determining the correct choice of the implant.
Demographic data, mode of violence, side of the injury, fracture type according to the Neer's classification, date of surgery, and complications were recorded.
All the surgeries were performed through the deltopectoral approach with the patient in beach-chair position under general anesthesia [Figure 2]. The cephalic vein is identified proximally and retracted along with the deltoid laterally. The tuberosity fragments are identified, and tag sutures passed through the rotator cuff muscles near their insertion to assist in getting the reduction with the lateral humeral shaft. Medial calcar alignment and neck-shaft angle were checked under an image intensifier and manipulated if necessary, to achieve acceptable levels. The fracture reduction is then secured with multiple 1.5 mm K-wires and an appropriate size locking plate placed lateral to the bicipital groove. The position of the plate is checked under the image intensifier to avoid too high or too low placement after anchoring it with a nonlocking screw passed through the oblong hole in the middle. A minimum of five cancellous screws including the lowermost calcar screw were placed in the head fragment. The polyester braided sutures used to tag the cuff muscles were then tied through the small holes in the plate. The final construct was checked under fluoroscopy before closure to identify any screw that had breached the subchondral bone [Figure 3] and [Figure 4].
|Figure 2: Beach-chair positioning of the patient with complete prepping and draping|
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|Figure 3: Intraoperative C-Arm images showing preliminary K-wire fixation to secure reduction and subsequent plate fixation|
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|Figure 4: Plate fixation completed through standard deltopectoral approach|
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From the 1st postoperative day, all patients were encouraged to start pendulum exercise, isometric exercises of the deltoid, biceps, and triceps muscles under adequate analgesia. The passive range of movement exercises was progressively increased for 4–6 weeks after the surgery. This was then followed by active range of movement exercise as soon as there were visible radiological signs of healing [Figure 5] and [Figure 6].
|Figure 6: Immediate postoperative radiographs showing satisfactory reduction and implant position|
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The patients were followed up at intervals of 6 weeks, 3 months, 6 months, and 1 year. The Constant score was measured and documented in the patient information sheet from the 3rd-month follow-up onward. Anteroposterior, axillary lateral, and scapular Y views were reviewed for hardware loosening, loss of reduction, screw protrusion, malunion, nonunion, or avascular changes in the head fragment [Figure 7] and [Figure 8].
|Figure 7: Preoperative and 4-month postoperative radiograph of a patient showing sustained reduction with no sign (s) of hardware-related problems|
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|Figure 8: Clinical photographs of the same patient showing satisfactory recovery of shoulder movements|
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The collected data were entered and analyzed using an appropriate tool. Chi-square test was applied for discrete variables and one-way ANOVA was used to compare the three fracture types. P ≤ 0.05 was taken as significant.
| Results|| |
Thirty-two patients were enrolled for the study of which 62.5% were males and 37.5% were females. The mean age was 52.50 years (range: 18–77 years). Majority (50%) of the study participants belonged to the age group of 40–60 years. Motor vehicular accidents accounted for most of the fractures (62.5%) predominantly in young male individuals, whereas the remaining (37.5%) were due to low energy falls especially in elderly women. Seventeen patients had fractures on the right side and the remaining patients presented with left-sided fractures [Table 1] and [Table 2]. Among the 32 patients, 14 (43.75%) had sustained a two-part fracture, 13 (40.625%) had a three-part fracture, and 5 (15.625%) had a four-part fracture based on Neer's classification for proximal humerus fracture.
The interval between the time of injury and surgical treatment was 3.44 days in most (81.3%) of the cases and there was a delay in surgery in remaining participants due to native treatment and presurgery treatment requirements like control of uncontrolled diabetes and hypertension.
The mean neck-shaft angle measured 128.9° at final follow-up (range: 115°–135°). Late collapse was noted in an elderly female patient. The average duration of follow-up 17.5 months (range: 12–24 months). The time to union to radiological union was 3.9 months (range: 3–5 months).
There is a negative correlation between the final Constant score and age of the patients (P = 0.00). A similar correlation is also observed between the age of the patient and the neck-shaft angle (P = 001). There is a good correlation between the Neer's type and the final Constant value, two- and three-part fractures scores better than four-part fracture (P = 0.000 in both pairs), whereas no significant difference exists between the final Constant scores of two- and three-part fractures (P = 0.142). The Constant scores at the latest follow-up did not show any significant difference between the two genders (P = 0.822) [Table 3] and [Table 4].
The handedness and occupation of the patient have no significant correlation with the final functional outcome (P = 0.143 and P = 0.207, respectively). The mean active range of movement was abduction of 138.91° (range: 90°–160°), flexion of 94.22° (range: 70°–110°) external rotation at the side of 44.69° (range: 30°–50°), and internal rotation to T8 (range: L4–T5). At the final follow-up, 21 patients had good, ten patients had moderate, and one patient had poor Constant score.
There were three complications in our series. Two patients had stiffness and the third patient had surgical site infection noted on the 2nd postoperative day. The patient with surgical site infection was managed with debridement and intravenous antibiotics. The other patients were able to perform most activities of daily living after an extended course of physiotherapy.
| Discussion|| |
The principles of management of unstable and displaced proximal humerus fracture as outlined by the AO are anatomic reduction, stable fixation, preservation of blood supply, and early restoration of movement. The presence of co-existing osteoporosis in elderly patients increases the incidence of fixation failure with conventional plates. However, the unique design of the proximal humerus locking plate prevents toggling and pull-out at the screw-plate interface and at the same time, anchors the surrounding rotator cuff muscles through its peripheral holes. These two features provide a mechanical as well as biological advantage to the proximal humerus locking plate.,
The mean age of the participants was 52.50 years (range: 18–77 years) with the majority (50%) of the study participants belonging to the age group of 40–60 years, which conformed with most reported values. Out of the 32 patients who were enrolled for the study, 62.5% were males. The increased predominance of male patients in our study may be explained due to the higher number of patients who were involved in motor vehicular accidents (62.5%) and most reported fractures in elderly female patients were due to low-velocity injuries. Few studies have reported a higher incidence in the male populations.
Earlier studies have shown that the functional outcome does not depend on the handedness of the patients or their occupational status but on the mode of injury, the force of impact, and method of management.
In this study, most of the patients had sustained Neer Type 2 and Ttype 3 fractures which were 43.8% and 40.6%, respectively, which is like other studies., The strong relationship exists between the Neer type and functional outcome. In addition, the age of the patients negatively influences the functional outcome of the fracture and the neck-shaft angle, and we observed a similar finding in our study.
Most of the participants in our study were taken immediately for the surgical fixation of the fracture using a locking compression plate. However, surgical fixation was delayed in 24% of participants due to poor clinical status either due to native treatment and/or preexisting medical ailments. The relation between the delay in surgical fixation and the postoperative stiffness measured by the Constant score was found statistically significant which showed these patients achieving only a moderate Constant score postoperatively. These results were comparable with those of Menendez and Ring who showed that delayed surgical intervention after 3 days has been associated with unfavorable events such as prolonged postoperative stay, increased nonroutine discharge, poor rehabilitation, and therefore increased chances of postoperative stiffness. It was suggested that even when comorbidities and poor clinical condition of patients were controlled, delay in surgical intervention for proximal humeral fractures is likely to increase patient morbidity in relation to postoperative stiffness.
In our study, the average range of movement was 44.69° of external rotation, abduction was 138.91°, 94.22° of flexion postoperatively after 6 months and comparable with other studies. An increase in active range of movement directly reflects on the Constant score of the participants in our study. Almost 84.4% of our patients showed a good Constant score after 6months of follow-up. The mean score was 82.13 which is rated as good according to the Constant score scale.,, Many studies,, have shown the association between the Neer type and the Constant score, suggesting whether the severity of the fracture type is related to the poorer the Constant score and the same is seen in our study.
Shahid et al. reported a mean Constant score was 68.31 in 19 patients. Many studies have reported good functional outcomes and recommended the use of locking plates for proximal humerus fractures especially in elderly patients with poor bone quality. The functional outcome not only depends on the quality of bone density but also on the stability provided by the implant. In an internal locking system, the principle of fixed-angle plates enables a gain in torsional stiffness and stability and may therefore promote a superior outcome.,
About 6.3% of study participants had shoulder stiffness and 3.1% had infection during postoperative period. The participants with moderate Constant score have the highest incidence of complications in the current study and is comparable with similar studies.,, Physiotherapy is recommended and some require revision surgery, for implant impingement and loosening. Phase-wise physiotherapy was given to the participants once the clinical union was confirmed. Superficial and deep infections were treated with the appropriate systemic antibiotics. The most common complications encountered were screw penetration and suggested each patient must be scrutinized for extent of trauma, fracture, age, and appropriate number and length of screws used to prevent articular penetrations.
| Conclusion|| |
The fracture of proximal end of humerus accounts for 4%–5% of all fractures. The treatment modality of the fractured humerus is still debatable. The treatment modality depends on the age of the patient, type of fracture, quality of the bone encountered, and surgeon's familiarity with the technique.
- The less severe trauma produced significant injury with advanced age
- In younger participants, proximal humerus fracture is caused by high-energy trauma, especially road traffic accidents
- Majority of the fractures were two- and three-part fractures according to the NEER type
- The proximal humerus locking compression plate by virtue of locking of the threaded heads of the screws in the plate itself provides the axial stability which eliminates the possibility of screw toggling and sliding of the screws in the plate holes
- Earlier the surgery done showed better results and good functional outcome
- Results were good when operative method ended in stable fixation that allows early passive mobilization.
- The functional outcome revealed that part-2- and part-3 fractures showed some excellent results when compared to part-4 fractures
- The overall outcome was also very good with a Constant score mean of 83.2.
- Bone mineral density was not considered in the preoperative investigation as the fractures are more common in the elderly age group in female population (>60 years), which would affect the functional outcome in the study and bone healing
- A large sample size would be required to generalize the results to the general population.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their 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], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4]