To the Editor:
After reading the article Percutaneous Plate
Fixation of Two- and Three-part Proximal Humerus Fractures
(31:237-242) by Drs Robert Gallo, Thomas Hughes, and Gregory Altman, I would
be cautious in attempting the surgical technique described, as placing the
plate along the lateral border of the humerus without direct visualization of
the axillary nerve can be fraught with potential complication. Additionally,
the percutaneous placement of screws with the danger of entanglement of the
axillary nerve is concerning.
While I am sure that in the hands of an experienced
shoulder/elbow surgeon and/or traumatologist this can be done safely and
effectively, recommending this to the general orthopedic surgeon can be
potentially hazardous. I would argue that a well-performed deltopectoral
approach can be safely done, keeping the axillary nerve out of harms way
and allowing for direct visualization of the fracture fragments. The advantage
of this approach is that it allows for access to the rotator cuff. The
placement of tagging sutures in the rotator cuff can be used to reinforce
fixation of the fracture by passing the sutures through the plate and
augmenting the fixation of the plate and screws. While some patients are
concerned about cosmesis after a proximal humerus fracture, I find that the
majority of patients are most interested in gaining the greatest amount of
function back with the avoidance of any nerve injury, stiffness, malunion, or
Joseph A. Abboud, MD
We agree that the goal of treating any fracture,
especially proximal humerus fractures, is to maximize functional outcome while
minimizing adverse events such as nerve injury, stiffness, malunion, nonunion,
and avascular necrosis. Based on AO principles and available data regarding
proximal humerus fractures and patient outcomes, our treatment of these
fractures is based on 1) obtaining secure and accurate fixation of all fracture
fragments, particularly the greater tuberosity, and torn tendons; 2) limiting
the amount of soft tissue stripping and disruption to the local vascularity;
and 3) initiating early motion. Cosmesis is a secondary benefit of minimally
invasive fracture fixation. For most proximal humerus fractures, no surgical
scar (ie, nonoperative treatment) yields superior cosmetic results to any
During the past 5 years, we have gradually shifted our
surgical approach from deltopectoral to a minimally invasive lateral incision.
Frustrated by the difficulty of obtaining satisfactory fracture reduction and
the amount of soft tissue stripping and retraction necessary to gain exposure
with a deltopectoral approach, we began making an accessory lateral
incision.1 This smaller lateral incision afforded us better
visualization of the greater tuberosity, which is usually posteriorly and
superiorly displaced, and the rotator cuff tendons, which are torn or avulsed
in 40% of these patients.2 We also found that due to the contour of
most available locking proximal humerus plates, proper positioning of the plate
was facilitated by using this accessory incision.
More recently, we have adopted the percutaneous approach
originally presented by Laflamme et al.3 Before we performed this
technique in patients, we honed our skills on several cadaveric specimens and
determined safe methods of inserting the plate and screw construct.4
Several studies have detailed the course of the axillary nerve about the
proximal humerus,5-7 while others have mapped out safe zones for
screw placement of the 2 most frequently used proximal humeral locking
plates.8,9 These studies and our experience allowed us to develop a
technique similar to the one described by Laflamme et al.10
Like most operative procedures, meticulous technique and
caution are required to prevent iatrogenic injury to the axillary nerve during
percutaneous plating of the proximal humeral fractures. We reiterate several
tips that facilitate safe placement of the plate and screws. The most important
initial step in the procedure is to identify the axillary nerve. The superior
mini-lateral incision should be deep to the subdeltoid bursa, ie, to the level
of the periosteum. Using this incision, the surgeon can palpate the axillary
nerve on the undersurface of the deltoid distally. If scarring or hematoma
prevents palpation of the nerve, the surgeon can consider extending the
incision and directly identifying the nerve using a technique described by
Robinson et al.11 The plate should only be inserted after the
fracture has been reduced and the nerve identified. The plate is inserted
directly onto the lateral aspect of the humerus while a finger from the
surgeons other hand retracts the axillary nerve out of harms way.
Screws are placed with the same meticulous technique with which all
percutaneous screws are placed: skin incision, blunt dissection, and
identification of the bone. No screw should be prepared or inserted if soft
tissue is interposed between the drill or screw tip and the bone. Dangerous
screw holes such as those outlined in the literature should be
avoided.8,9 The surgeon should be protecting and palpating the nerve
throughout the course of the procedure to prevent iatrogenic injury. We, like
the other published series of which we are aware,10 have not had any
cases of iatrogenic nerve injury using this technique.
While the deltopectoral approach is the most frequently
used interval to expose proximal humerus fractures, this method has significant
disadvantages. Complete exposure of all fracture fragments is often difficult
using this anterior interval. Often, the greater tuberosity fragment is
externally rotated by the teres minor and infraspinatus tendons and must be
retrieved from the posterior shoulder. Poor outcomes have been attributed to
malreduction of this fragment.12-14 To visualize the greater
tuberosity and insert the plate, extensive soft tissue stripping and at least
partial release of the deltoid origin or insertion and/or the pectoralis major
insertion must be performed. In addition, the anterior humeral circumflex
artery, which courses along the inferior border of the subscapularis and
lateral border of the bicipital groove, can be jeopardized by this exposure.
Injury to this vessel, which serves as the principal blood supply to the
humeral head,15 can cause avascular necrosis of the humeral head.
Finally, nerve injury and muscle atrophy following proximal humerus fractures
can also occur using the deltopectoral approach.16,17 Visser et
al17 reported that electromyography-detected nerve injury was
present in up to 82% of displaced proximal humerus fractures treated
operatively and nonoperatively; the axillary nerve was injured in 58%.
The success of any procedure is based on the ultimate
functional outcome of patients. As locked plating is a recent technological
advancement, few studies are available to evaluate the effectiveness of locked
plating in the treatment of proximal humerus fractures. Among published studies
with a minimum 1-year follow-up, percutaneous locked plating yielded an
equivalent or higher functional score than locked plating performed through a
deltopectoral approach (Table).10,16,18,19 Furthermore, the
operative time was reduced (53 minutes for percutaneous vs 86 minutes for
deltopectoral), and complications such as avascular necrosis and nerve injury
were no more likely to occur with a minimal lateral incision.10,18
We appreciate that a degree of skepticism is applied to
any new technique, especially those that require limited exposure (eg,
iliosacral screws, arthroscopic Bankart repairs). However, while more studies
are needed, percutaneous locked plating for proximal humerus fractures offers
rigid fixation without extensive soft tissue stripping and thus may allow for
earlier range of motion and improved function compared to other methods. As
with any surgical procedure, meticulous technique and attention to detail are
necessary to avoid devastating iatrogenic injury when using this percutaneous
Robert A. Gallo, MD
Gregory T. Altman, MD
- Gallo RA, Zeiders GJ, Altman GT. Two-incision technique for
treatment of complex proximal humerus fractures. J Orthop Trauma. 2005;
- Gallo RA, Sciulli R, Daffner RH, Altman DT, Altman GT. Defining the
relationship between rotator cuff injury and proximal humerus fractures.
Clin Orthop Relat Res. 2007; (458):70-77.
- Laflamme GY, Berry G, Benoit B. Percutaneous plating of the proximal
humerus: a prospective multi-center clinical trial. Poster presented at: 21st
Annual Meeting of the Orthopaedic Trauma Association; October 20-22, 2005;
- Gallo RA, Altman GT. Evaluation of the safety of percutaneous plate
fixation of the proximal humerus. Paper presented at: 19th Congress of the
European Society for Surgery of the Shoulder and Elbow; September 23, 2005;
- Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a
safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J
Bone Joint Surg Am. 2006; 88(11):2395-2399.
- Bono CM, Grossman MG, Hochwald N, Tornetta P III. Radial and axillary
nerves. Anatomic considerations for humeral fixation. Clin Orthop Relat
Res. 2000; (373):259-264.
- Burkhead WZ, Scheinberg RR, Bos G. Surgical anatomy of the axillary
nerve. J Shoulder Elbow Surg. 1992; (1):31-36.
- Smith J, Berry G, Laflamme Y, Blain-Pare E, Reindl R, Harvey E.
Percutaneous insertion of a proximal humeral locking plate: an anatomic study.
Injury. 2007; 38(2):206-211.
- Röderer G, Abouelsoud M, Gebhard F, Böckers TM, Kinzl L.
Minimally invasive application of the non-contact-bridging (NCB) plate to the
proximal humerus: an anatomical study. J Orthop Trauma. 2007;
- Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ.
Percutaneous humeral plating of fractures of the proximal humerus: results of a
prospective multicenter clinical trial. J Orthop Trauma. 2008;
- Robinson CM, Khan L, Akhtar A, Whitaker R. The extended
deltoid-splitting approach to the proximal humerus. J Orthop Trauma.
- Keene JS, Huizenga RE, Engber WD, Rogers SC. Proximal humeral
fractures: a correlation of residual deformity with long-term function.
Orthopedics. 1983; 6:173-178.
- Cofield RH. Comminuted fractures of the proximal humerus. Clin
Orthop Relat Res. 1988; (230):49-57.
- Hessmann M, Baumgaertel F, Gehling H, Klingelhoeffer I, Gotzen L.
Plate fixation of proximal humeral fractures with indirect reduction: surgical
technique and results utilizing three shoulder scores. Injury. 1999;
- Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of
the humeral head. An anatomical study. J Bone Joint Surg Am. 1990;
- Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A
new locking plate for unstable fractures of the proximal humerus. Clin
Orthop Relat Res. 2005; (430):176-181.
- Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal
humeral fractures. J Shoulder Elbow Surg. 2001; 10(5):421-427.
- Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical
approach for locking plate osteosynthesis of displaced proximal humeral
fractures influences the functional outcome. J Shoulder Elbow Surg.
- 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
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