Treatment of unstable, displaced, and comminuted fractures of the proximal humerus remains challenging, and optimal treatment continues to be controversial. Fifty-six patients with displaced 3- and 4-part fractures of the proximal humerus had open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate (Synthes, Stratec Medical Ltd, Mezzovico, Switzerland).
Data were collected retrospectively, and clinical and radiological outcomes were assessed. Mean follow-up was 40 months (range, 18-62 months). The study shows that the PHILOS plate gives good results in the treatment of displaced 3- and 4-part fractures of the proximal humerus. Good fracture stability can be achieved early, allowing early mobilization without compromising fracture union. Most importantly, it requires minimal soft tissue dissection, does not need contouring, and gives good stability. No differences were observed in the functional outcomes of patients younger and older than 65 years.
Few complications were associated with the plate, and the number of >2 surgeries was minimal. The complications noted were 1 case each of superficial wound infection, failure of the plate, and persistent stiffness. One patient had screw perforation of the humeral head articular surface, and 1 had subacromial impingement. Of the 32 patients who had been in active employment before the injury, 28 returned to their previous occupation.
Fractures of proximal humerus account for nearly 5% of all fractures1 and occur most commonly in the elderly population. The majority of these fractures are minimally displaced and can be treated nonoperatively with good functional results.2,3 However, unstable, displaced fractures have high morbidity, especially in older patients.4
Treatment of these unstable, displaced 3- and 4-part fractures remains a challenge, and optimal treatment continues to be controversial. Many different techniques of internal fixation have been described, including bone sutures, tension band, cerclage wires, K-wires, T-plates, intramedullary devices, double tubular plates, semitubular blade plate, Plan-Tan Humerus Fixator plate (Plan Tan Medizin-tecknik GmbH, Lambrechtshagen, Germany) and Polarus nail (Acumed, Inc, Beaverton, Oregon).5-11 Various complications have been reported using these techniques, including cutout or backout of the screws and plates, avascular necrosis, nonunion, malunnion, nail migration, rotator cuff impairment, and impingement syndrome.6,7,10,12 These can result in a painful shoulder with poor function.11,13 Prosthetic replacement of the humeral head in these fractures has also yielded unsatisfactory functional results.14,15
To overcome the common problems associated with the treatment of these fractures, the AO/ASIF group developed the proximal humeral internal locking system (PHILOS) plate (Synthes, Stratec Medical Ltd, Mezzovico, Switzerland). It aims to preserve the biology of the humeral head by minimizing soft tissue dissection and securely holding the reduction using multiple screws with angular stability, thereby improving stability in osteoporotic bone.4,16
This goal of this retrospective study was to evaluate the results of PHILOS plating in 56 patients for treatment of displaced 3- and 4-part fractures of the proximal humerus.
Materials and Methods
A retrospective analysis was undertaken of a consecutive series of patients who presented to our institution between November 2003 and June 2008 with a displaced 3- or 4-part fracture of the proximal humerus. Inclusion criteria consisted of age older than 18 years and a displaced, unstable 3- or 4-part proximal humerus fracture that was <3 weeks old. Patients with fractures >3 weeks old or pathological fractures were excluded from the study.
During this 5-year period, patients meeting these criteria were treated with internal fixation with the PHILOS plate. Unreconstructable and severely comminuted fractures were treated with primary hemiarthroplasty.
A total of 56 patients met the inclusion criteria. Thirty-four women and 22 men had a mean age of 68.7 years (range, 34-86 years). Patients with multiple injuries and those with pathological fractures were excluded from the study. Thirty-two patients were older than 65 years, and the remaining 24 were younger. Mechanism of injury was fall in 44 patients (25=simple fall at home, 10=fall down the stairs, 9=fall on the pavement), and motor vehicle accident in 12.
Using plain radiographs, all fractures were classified according to Neer17 by 1 author (R.S.G.) to exclude interobserver error. A total of 31 patients had 3-part fractures and 25 had 4-part fractures.
Mean time to operation was 16 hours after the injury (range, 8 hours to 4 days). All surgeries were performed under general anesthetic by a consultant trauma surgeon and a trainee registrar. All patients received a single dose of 1.5 g cefuroxime intravenously at induction of anesthesia. A standard deltopectoral approach was used for open reduction and internal fixation with the patient in beach-chair position.
The wound was closed over a suction drain, which was removed after 24 hours. The arm was placed in a sling, and pendular exercises were started from the first postoperative day. Rotation exercises were started on postoperative day 2 or 3, followed by active exercises at 3 weeks. Eccentric strengthening exercises and resistive strengthening were begun after fracture union was confirmed.
All patients were followed up at 2 and 6 weeks and thereafter at 3, 6, and 9 months. The functional outcome was assessed according to the Constant score.18 Standard anteroposterior, lateral, and axillary radiographs were obtained at each follow-up to check the position of the plate and the progress of fracture healing (Figure 1). The functional outcome in patients older than 65 years was compared with that of those younger than 65 years. Student t test with 95% confidence intervals was used to compare the functional outcome between the 2 groups. Statistical significance was set at P=.05.
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|Figure 1: AP shoulder radiograph of a 3-part fracture of the proximal humerus in a 72-year-old man (A). Satisfactory reduction and fixation with a PHILOS plate. Note the multiple-angle screw fixation and restoration of neck shaft angle (B). |
Outcome and Analysis
Mean follow-up was 40 months (range, 18-62 months). No patients were lost to follow-up. A total of 55 fractures (98.2%) united clinically and radiologically, with a mean neck/shaft angle of 127.1°. One patient (1.8%) had revision for implant failure with a longer PHILOS plate and iliac crest bone graft. This went on to unite at 20 weeks. The mean time to union was 9 weeks (range, 7-20 weeks). The mean Constant score at final review was 72.1 (range, 36-96). A total of 28 patients (50%) had an excellent outcome, 22 (39.2%) had a satisfactory outcome, and 6 (10.82%) had a poor outcome. The mean score in patients older than 65 years was 70.3 (range, 36-80) and in patients younger than 65 years was 72.5 (range, 42-96). The difference was not statistically significant (P=.09).
One superficial wound infection was treated with and responded to oral antibiotics. No deep infection or vascular or nerve injuries were noted.
One complication was related to the implant. This occurred in a 76-year-old woman who had sustained a low-energy 4-part fracture. Postoperative radiographs showed good reduction. However, at 6 weeks there was some varus collapse. At 3 months, the threads on the distal-most locking screw head had cut out, and the screw disengaged from the plate (Figure 2). The fracture had collapsed into increasing varus. A subsequent revision was undertaken with a longer PHILOS plate and cancellous bone grafting from the same side iliac crest. Thereafter, the fracture united uneventfully.
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| ||Figure 2: AP shoulder radiograph of a 3-part fracture of the proximal humerus 3 months after fixation in a 76-year-old woman, with the threads on the distal-most locking screw head cut out and the screw disengaged from the plate. This was revised with a longer PHILOS plate and cancellous bone graft (B, C). |
Persistent stiffness developed in a 70-year-old man who had sustained a 3-part fracture of the proximal humerus following a fall on the pavement. Intensive physiotherapy did not lead to any significant improvement of his range of movement, and his Constant score was 36. Radiographs showed a good fracture union with good position of the implant. At 14 months postoperatively, the patient had manipulation of his shoulder under anesthesia, which led to some improvement, and his Constant score improved to 62. Removal of implant was offered at 18 months, but he declined further surgery.
Excessive stiffness was noted in 3 other patients, which improved with intensive physiotherapy.
In 1 patient there was screw perforation of the humeral head articular surface. This led to persistent stiffness with a Constant score of 42. The screw was removed as an outpatient procedure. Symptoms improved significantly following the screw removal.
Subacromial impingement was observed in 1 patient. This was related to the plate being placed too high, with the tip of the plate almost at the level of greater tuberosity. The implant was removed at 15 months. Subsequently, the symptoms improved gradually.
Of the 32 patients who had been in active employment before the injury, 28 returned to their previous occupation.
Various treatment methods have been used in the treatment of displaced 3- and 4-part fractures of the proximal humerus. Open reduction and internal fixation with plates and screws has been associated with screw loosening, especially in osteoporotic patients, subacromial impingement, and avascular necrosis from excessive periosteal and soft tissue stripping.19 Kristiansen and Christensen20 reported 55% unsatisfactory results in a series of 20 patients with 2-, 3-, and 4-part fractures that were managed with plates and screws. Paavolainen et al13 reported excellent to satisfactory results in only 74.2% of patients treated operatively for proximal humerus fractures with the use of the T-buttress plate. Sturzenegger et al21 reported a high incidence (34%) of avascular necrosis. However, Hintermann et al22 reported good to excellent results in 30 of 42 patients (71.4%) using blade plate for fixation of proximal humeral fractures.
Goldman et al23 described 26 hemiarthroplasties performed for acute 3- and 4-part proximal humerus fractures. Their study indicated that hemiarthroplasty for acute 3- and 4-part fractures can generally be expected to result in pain-free shoulders. However, recovery of function and range of motion are less predictable.23 Bufquin et al24 described 43 patients who had reverse shoulder arthroplasty performed for 3- and 4-part proximal humerus fractures; satisfactory mobility was obtained despite frequent migration of the tuberosities.
To our knowledge, only a few studies in the English literature describe the use of the PHILOS plate.4,12,25 Björkenheim et al25 reported 72 patients who had PHILOS plate fixation of 2-, 3-, and 4-part proximal humerus fracture. There were 2 cases (3%) of nonunion, 3 cases (4%) of avascular necrosis, and 2 implant failures (3%) with loss of fixation. The mean Constant score was 72 at 6-month follow-up. The authors recommend the use of the PHILOS plate, especially in elderly patients with osteoporotic bone.25
Koukakis et al12 described a study of 20 patients who had PHILOS plate fixation of 2-, 3-, and 4-part proximal humerus fractures. They reported 1 plate pulloff from the shaft, 1 case of avascular necrosis of the humeral head, and 1 case of prominent metalwork. The mean Constant score was 76 at follow-up. There was no difference in functional outcome between patients younger and older than 65 years. They observed that in displaced 4-part fractures in osteoporotic bones, when the articular fragment has insufficient subchondral bone left to allow good screw purchase, the PHILOS plate should not be used. They recommend primary hemiarthroplasty in these cases.
Moonot et al4 described 32 patients who had PHILOS plate fixation of 3- and 4-part proximal humerus fractures. They reported 1 avascular necrosis of the humeral head and 1 implant failure with breakage of the distal screw and nonunion. The mean Constant score was 66.5 at final follow-up. They recommend the use of the PHILOS plate for treatment of displaced 3- and 4-part fractures. In osteoporotic bone, they recommend packing the humeral head and shaft with bone graft or bone substitutes.
In our study, all but 1 fracture united primarily, and this was successfully treated with revision to a longer plate and bone grafting. One patient required plate removal for subacromial impingement, and 1 had persistent stiffness. The mean Constant score was 72.1 at final follow-up. Our study suggests that treatment with the PHILOS plate gives a satisfactory outcome in patients with displaced 3- and 4-part fractures of the proximal humerus. The fixation is stable enough to allow early mobilization.
Although there are certain limitations in this studythe number of cases is small, the follow-up is relatively short, and it is a retrospective studyit shows that good fracture stability can be achieved early, allowing early mobilization without compromising fracture union. Most importantly, it requires minimal soft tissue dissection, does not need contouring, and gives good stability. We stress the importance of minimal soft tissue dissection to preserve the vascularity of the head, indirect methods of reduction, and early mobilization.
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- Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand. 2003; 74(5):580-585.
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- Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg. 1982; 100(4):249-259.
- Hintermann B, Trouillier HH, Schäfer D. Rigid internal fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br. 2000; 82(8):1107-1112.
- Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995; 4(2):81-86.
- Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br. 2007; 89(4):516-520.
- Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004; 75(6):741-745.
Mr Gaheer and Ms Hawkins are from the Department of Trauma and Orthopedics, Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom.
Mr Gaheer and Ms Hawkins have no relevant financial relationships to disclose.
Correspondence should be addressed to: Rajinder Singh Gaheer, MS(Orth), MRCS(Ed), MRCPS(Glasg), MCh(Orth), DipSports Med(UK), Department of Trauma and Orthopedics, Dumfries and Galloway Royal Infirmary, Bankend Rd, Dumfries, United Kingdom DG1 4AP (firstname.lastname@example.org).