Mohd Rafiq Bhat

Mohd Ramzan Mir

Mohd Shafi Bhat

Mohd Yaseen Rather

Mubashir Beigh

Riyaz Ahmad Dar

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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) 
e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 13, Issue 1 Ver. X. (Feb. 2014), PP 44-47 
www.iosrjournals.org 
www.iosrjournals.org                                                     44 | Page 
 
Short-term results of Proximal humeral locking plate fixation in 
displaced proximal humerus fractures. 
 
Mohd Yaseen Rather
1
, Mohd Shafi Bhat
2
 , Mohd Rafiq Bhat
3
,  Riyaz Ahmad 
Dar
4
, Mubashir Beigh 
5
, Mohd Ramzan Mir
6
. 
1 & 3 : Postgraduate Scholars Orthopaedics . 
2 : Postgraduate Scholar and Correspondence Author. 
4 & 5 : Senior residents Orthopaedics.. 
6: Professor and Head Department of Orthopaedics. 
Hospital for Bone and Joint Surgery Barzulla Srinagar Kashmir (India). 
(An associated hospital of Govt Medical College Srinagar.) 
 
Abstract:  A case series of 25 cases ( 21 male and 4 female ) of displaced proximal humerus fractures operated 
at Hospital for Bone and Joint Surgery Barzulla Srinagar Kashmir (India) using the proximal humeral locking 
plate. The study was conducted from Nov 2010 to Oct 2012.The average age of patients was 45.5 years (range 
24-92). Neer’s classification was used for classifying the fractures .There were 4 patients with 4-part fracture, 
12 with 3-part fracture and 9 patients with 2-part fractures. All the cases were operated within 3 weeks of the 
injury. The mean follow-up time was 13.4 months. Average time to union was 15.6 weeks. Final assessment was 
done using Constant Murley Shoulder Score .Excellent or good results were obtained in 20, fair results in 2 and 
poor results in 2 patients. 
Keywords: Proximal humeral fractures, locking plate fixation, internal fixation. 
 
I. Introduction 
           The proximal humeral fractures constitute 4-5% of all fractures and 45% of humeral fractures. Most of 
these fractures occur in woman over the age of 50 with the exception of isolated greater tuberosity fractures 
which occur with increased frequency in young individuals. More than 85% of these fractures are minimally 
displaced or undisplaced and are effectively treated symptomatically with immobilization followed by early 
motion.
1,2
Various techniques are available to surgeon fixing proximal humeral fracture and they include 
minimally invasive techniques like use of krischner wires, tension band, cerclage wires, T-plates, intramedullary 
devices,prosthetic replacements ,the plan tan humerus fixator plate, the polaris nail 
etc
3,4,5,6,7
.However,complications have been reported using these techniques including cutouts and backout of 
screws and plates, avascular necrosis, nonunion, malunion, nail migration, rotator cuff impingement and 
impingement syndrome
4,7
.The rate of these complications have approached as high as 100% for elderly 
people
6,7
. 
The Proximal humeral locking plate is a new addition to vast number of techniques for fixation of 
proximal humeral fractures 
8
.The screws in head are locked into plate and cannot back and toggle, which is 
particularly advantageous in osteoporotic bone
9
.The screws alternatively converge and diverge thus improving 
fixation strength, particularly in osteoporotic bone of elderly. The plate being low profile minimizes the risk of 
impingement.
10
 
 
II. Materials And Method 
This prospective study is a series of 25 patients who were operated from November 2010 to October 
2012 for proximal humerus fractures using proximal humeral locking plate. The study was conducted at 
Hospital for Bone and Joint Surgery Barzulla Srinagar Kashmir. Displaced proximal humeral fractures in 
patients with age > 18 years were included in the study. Undisplaced fractures, open fractures and 4-part 
fracture-dislocations were excluded from the study. The results were evaulated using Constant Murley Shoulder 
score
11
. 
Plain radiographs (antero-posterior ,axillary and lateral views ) were obtained preoperatively to access 
the fracture pattern. The operation
12,13,14 
was performed under GA in supine position with head rotated to the 
contralateral  side and well supported in head rest. Standard deltopectoral approach was used in all the cases. 
The fracture fragments were restroted to their best possible anatomic position with minimal soft tissue 
Short-term results of Proximal humeral locking plate fixation in displaced proximal humerus fractures.  
www.iosrjournals.org                                                     45 | Page 
dissection. Preliminary reduction was held with use of Krishner wires. Reduction was assessed under image 
intensifier .Definitive fixation with Proximal humeral locking plate was done with plate positioned at least 5mm 
distal to the upper end of greater tuberosity to prevent subacromial impingement and atleast 2mm posterior to 
bicipital groove
 
thus sparing the tendon of long head of biceps. Plate was positioned to bone in desired position 
first with use of K-wires and then definitive fixation achieved with use of multidirectional locking screws. After 
plate application range of motion was checked in all directions under image intensifier to look for any 
impingement and screw penetration into the joint. Wound was closed over suction drain and shoulder 
immobilizer applied. 
          Passive ROM exercises were started within 24-48 hours.
12,13,14 
Shoulder immobilizer was used for a 
period of 4 weeks, with immobilizer removed at the time of ROM exercises. The active exercises were started 
after one month . 
 
III. Results 
There were 21 males and 4 females in our study .The average age of our patients was 45.5years (range 
24-92 ) .The mechanism of injury was fall in 13 patients , road traffic accidents  in 11 patients and direct hit to 
shoulder in 1 patient . In our study we had 4 four part fractures, 12 three part fractures  and 9 two part fractures. 
We operated on right side in 15 patients and on left side in 10 patients. 44% of patients in our study were 
operated in first week , another 44% in 2
nd 
week, 3 patients reported after two weeks of injury, nevertheless we 
operated all our patients before 3 weeks. The mean follow-up time was 13.4 months. Average time for union in 
our study was 15.6 weeks with no case of nonunion. We assessed our patients using Constant Murley Shoulder 
Score
11
. We achieved good or excellent results in 20 patients, fair in 2 patients and poor in 3 patients.5 patients 
in our study achieved ROM less than satisfactory, while 20 patients achieved excellent or good range of motion. 
Out of 25 patients, 21 had no pain, 2 patients had occasional pain usually seasonal and 2 patients had pain 
related to activity. 
 
                                                      
 
 
 
 
          
 
                                                               
 
 
 
 
 
 
IV. Discussion 
               Fracture of proximal humerus is still the unsolved fracture in many ways. Much controversy and 
Fig 4. ROM shoulder at final 
follow-up. 
Fig 3. ROM shoulder at final 
follow-up. 
Fig 1 . X-ray AP view shoulder with 
2-part fracture of proximal humerus. 
Fig 2. Post-op X-ray showing the 
proximal humerus locking plate 
fixation. 
[T
yp
e a 
qu
ot
e 
fro
m 
th
e 
do
cu
m
en
t 
or 
th
e 
su
m
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ar
y 
of 
an 
int
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es
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Short-term results of Proximal humeral locking plate fixation in displaced proximal humerus fractures.  
www.iosrjournals.org                                                     46 | Page 
confusion still exists and no treatment protocol or algorithm has been proved to be universally effective. There 
is disagreement with regard to reliability of classification systems. The indications for surgical management 
continue to be modified. 
S.K Moda
15
 in 1990 reported open reduction and internal fixation in 25 severely displaced fractures and fracture 
dislocations of proximal humeral fractures with T plate and semi-tubular plate and reported good or excellent 
results in 84% patients
17
. Wijgman
16
 in 2002 reported good and excellent results in 87% of patients treated with 
T-buttress plate or cerclage wire in three and four part fractures. Hintermann et al
17
 reported favorable results 
with blade plate. 
Over a period of time new techniques have been introduced for treatment of proximal humeral 
fractures. Rajasekhar et al
4
 worked on polaris nail and reported 80% satisfactory to excellent results.They 
operated on 23 two part fractures out of total 27 patients. Proximal humeral locking plate for fixation of 
proximal humerus fractures is a new addition to the vast number of techniques used for fixation of these 
fractures. It is a locking plate with advantages like strong fixation, high union rates and decreased incidence of 
hardware failure
12,13,14
.In a retrospective study Bjorkenheim et al
9
 reviewed 72 patients treated with PHILOS 
Plate.36 patients had good or excellent functional outcome. In a series of 20 patients Atanosis Koukakis et al. 
showed favourable early results with surgical management of proximal humeral fractures using PHILOS plate.  
We assessed our patients using Constant Murley Shoulder Score
11
. Excellent or good results were 
obtained in 80% of patients. The benefit of Proximal humeral locking plate over other techniques available for 
fixation of proximal humeral fractures is its superior fixation even in osteoporotic bone of elderly with low 
incidence of screw back out and cutout as observed by many authors
12,13,14
.The plate being low profile decreases 
the incidence of impingement
12,13
 .The fixation being superior helps in starting early ROM exercises and hence 
superior results in the long term. The plate is situated posterior to biceps tendon avoiding damage to anterior 
humeral circumflex artery, thus decreasing  the risk of avascular necrosis. 
We had complications in the form of superficial infection in one patient which healed with intravenous 
antibiotics. There was no case of deep infection in our study. 
 
 
V. Conclusion 
We can conclude from our observations that proximal humeral locking plate fixation is a successful 
procedure. Strong fixation provided by Proximal humeral locking  plate assists in starting early postoperative 
ROM exercises. 
 
Bibliography 
 
[1.] Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72(4):365-
371. 
[2.] Chu SP, Kelsey JL, Keegan TH, Sternfeld B et al: Risk factors for proximal humeral fracture.Am J epidemiol 2004 ;160(4):360-
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[3.] Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, Biglaini LU. Two-part and three-part fractures of proximal humerus 
treated with suture fixation. J Orthop Trauma.2003;17(5):319-325. 
[4.] Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elbow 
Surg.2001;10(1):7-10. 
[5.]  Robinson CM, Page RS, Hill RM,s anders DL, Court-Brown CM, Waverfield AE. Primary hemiarthroplasty for treatment of 
proximal humeral fractures. J Bone Joint Surg.2003;85A:1215-1223. 
[6.]  Sadowski C, Riand N, Stern R, Hoffmeyer P. Fixation of fractures of the proximal humerus with the  plan tan humerus fixation  
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[8.] Seidel H. Humeral locking nail. A preliminary report.Orthopaedics.1989;12:219-226. 
[9.]  Bjorkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate:a 
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[11.] Constant C R, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; 214:160-164. 
[12.] Sameer Aggarwal, Kamal Bali , Mandeep S Dhillon, Vishal Kumar, Aditya K Mootha .Displaced proximal humeral fractures:an 
Indian experience with locking plates .J Orthop Surg Research 2010;5:60. 
[13.] Bulent KILIC,Mustafa UYSAL ,Bekir murat CINAR ,Gurkan OZKOC, Huseyin DEMIRORS , Secran AKPINAR Early results of 
treatment of proximal humeral fractures with the PHILOS locking plate. Acta Orthop Traumatol Turc 2008 ;42(3):149-153. 
[14.] Mehmet Fatih KORKMAZ, Neslihan AKSU, Abdullah GOGUS, Mursel DEBRE,Ayhan Nedim KARA,Zekeriya Ugur ISIKLAR 
.The results of internal fixation of proximal humeral fractureswith the PHILOS locking plate.Acta Orthop Traumatol Turc 2008;42 
(2) :97-105. 
[15.] SK Moda,N S Chadha, S S Sangwan, D K Khurana et al.Open reduction and internal fixation of proximal humeral fractures and 
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www.iosrjournals.org                                                     47 | Page 
fracture dislocations. J Bone Joint Surg  Br 1990;72-B:1050-2. 
[16.] Wijgman AJ,Roolker W,Patt TW,Raaymakers EL,Marti RK. Open reduction and internal fixation of three and four part fractures of 
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[17.] Hintermann B, Troullier HH, Schafer D. Rigid internal fixation of fractures of the proximal humerus in older patient. J Bone Joint 
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Short-term results of Proximal humeral locking plate fixation in displaced proximal humerus fractures

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Short-term results of Proximal humeral locking plate fixation in displaced proximal humerus fractures

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