5/16/2017
Proximal Humeral Fractures
ORIF with Locking Plates
Trauma 101
2017
John D Wyrick MD
University of Cincinnati
Disclosures
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Consultant with Stryker
Educational stipend Smith Nephew
Indications
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Younger patients
Good bone stock
Healthy rotator cuff
Multiple trauma
Caution in pts >70, studies tending to
recommend RTSA better than hemi
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Classification
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Codman originally
described the 4 parts
in 1934
Classification
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Neer 1970 JBJS
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Codman 1934
Widely used standard
Provides treatment
guidelines
4 parts
>1cm or 45 deg
Classification
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Varus angulation
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Original angulation or
reduction
Associated with higher
risk of failure in recent
literature on ORIF
Not accounted for in
Neer classification
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Fracture Patterns
3 and 4 part fxs
 Fx – dislocations
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Tuberosity fxs
Proximal fx with shaft extension
3-Part Fractures
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Usually fracture through surgical neck and
greater tuberosity
CT useful for surgical planning
3 and 4-Part Fractures
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Historical treatment
recommendations
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ORIF in young
Elderly, hemiarthroplasty
We need to learn to fix in
the young population
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Valgus Impacted 3 & 4-Part
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Not to be confused with
valgus impacted surgical
neck
Reduced AVN rate
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4 part 21 to 75%
Valgus impacted 8 to 26%
More common than
previously recognized
Valgus Impacted 3 & 4-Part
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Treatment
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Court-Brown JBJSB 02 most
managed nonop
Most can be anatomically
reduced and fixed
Some amenable to min
invasive techniques
CT useful
Valgus Impacted 3 & 4-Part
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Treatment
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Court-Brown JBJSB 02 most
managed nonop
Most can be anatomically
reduced and fixed
Some amenable to min
invasive techniques
CT useful
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Valgus Impacted 4 part
Plating Technique
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Beach chair position
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Mini C-arm
Plating Technique
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Beach chair position
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Mini C-arm
Deltopectoral
approach
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Plating Technique
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Beach chair position
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Mini C-arm
Deltopectoral
approach
Tag the tuberosities
Plating Technique
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Beach chair position
Deltopectoral
approach
Tag the tuberosities
Provisional fixation
Plating Technique
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Beach chair position
Deltopectoral
approach
Tag the tuberosities
Provisional fixation
Definitive fixation
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Recent Studies on ORIF with
Locking Proximal Humerus Plate
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Thenasus et al, JSES 2009
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Review of 12 studies, no comparisons
Included 2,3,& 4 part fxs
Constant score avg 74.3
AVN 7.9% overall, 14.5% in 4 part fxs
Reoperation 14%
Screw cutout 12%
Nonunion 1.6%
Recent Studies on ORIF with
Locking Proximal Humerus Plate
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Solberg et al, JBJSA 2009, Compared 3 and 4
part fxs treated with ORIF vs hemiarthroplasty
Nonrandomized, pts > 55y/o
ORIF 38 pts, Hemi 48 pts
 Constant scores
 ORIF 69, 3 part=72, 4 part=65
 Hemi 61, 3 part=60, 4 part=60
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ORIF outcomes dependent on initial fx
displacement, poorer for varus fxs
Recent Studies
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PROFHER study, JAMA 2015
PRS, PH fxs to nonop vs op (ORIF or
hemi)
270 pts, no diff in outcomes
Much higher costs in op
Higher complication rate
No diff in revision rate
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Recent Studies
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ORIF better vs HA, RTSA
ORIF higher reop rate
15% tub NU rate in HA
Recent Studies
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Predicting Failure after Surgical Fixation of
Proximal Humerus Fractures
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Krappinger et al, Injury 2011
Parameters associated with failed fixation
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Age, BMD, nonanatomic reduction, lack of medial
support
Proximal Humerus Cage
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New device
Expandable cage
Design to improve support for head
Screws can purchase cage
Can decrease secondary screw penetration
Promising for valgus impacted fxs
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62 yo female, fall
Displaced 2 part, ORIF
62 yo F
Failed ORIF
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3 & 4 Part Fx – Dislocations
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Very challenging
Some of the most difficult
surgeries
CTs on most all
Not middle of the night cases
3 & 4 Part Fx – Dislocations
3 & 4 Part Fx – Dislocations
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3 & 4 Part Fx – Dislocations
3 & 4 Part Fx – Dislocations
3 & 4 Part Fx – Dislocations
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Segmental Neck-Shaft Fractures
Segmental Neck-Shaft Fractures
Segmental Humeral Fractures
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Segmental Humeral Fractures
Segmental Humeral Fractures
Locking Proximal Humeral Plate
Complications
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Primary screw
penetration 15%
Secondary 8%
Screw loosening
Check screw positon
flouroscopically in OR
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Locking Proximal Humeral Plate
Complications
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Loss of fixation up to 13%
Associated with
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Initial varus angulation >
60°
Varus malreduction > 20°
Lack of screws in inferior
head
Locking Proximal Humeral Plate
Complications
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AVN
Much lower than
originally stated
Overall around 8%
3 & 4 part fxs 1518%
Summary
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High energy, fx-dislocations common in
young
Appropriate imaging
Stable fixation with locking implants
Be aware of complications, failed fixation,
screw penetration
Good luck!
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Bibliography
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5.
6.
Hertel, RJ et al, Geometry of the proximal humerus and
implications for prosthetic design. JSES 2002, 11:331
Boileau, P et al, Three dimensional geometry of the proximal
humerus. JBJS Br 1997, 79:857
Thanasus, C et al, Treatment of proximal humerus fractures with
locking plates: A systematic review. JSES 2009, 18:837
Sudkamp, N et al, Open reduction and internal fixation of
proximal humral fractures with use of the locking proximal
humerus plate. JBJSA 2009, 91:1320
Brunner, F et al, Open reduction and internal fixation of proximal
humerus fractures using a proximal humeral locked plate: A
prospective multicenter analysis. JOT 2009, 23:163
Solberg, B et al, Surgical treatment of three and four-part
proximal humeral fractures. JBJSA 2009, 91:1689
Bibliography
7.
8.
Solberg, B et al, Locked plating of 3-and 4-part proximal humerus
fractures in older patients: The effect of initial fracture pattern on
outcome. JOT 2009, 23:113
Gardner, M et al, The importance of medial support in locked
plating of proximal humerus fractures. JOT 2007, 21:85
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