Abstract

Background: Fractures of proximal humerus are common and debilitating injuries increasing seen in the elderly population [1]. Neer classification remains most widely used today [7]. Optimal treatment of three- or four-part fractures of proximal part of the humerus in elderly patients is controversial. However, recent advances in fracture fixation technology has led to development of fixed angle locked plates (PHILOS) that maintain angular stability under load [18].

Methods: This retrospective study included 41 patients aged > 18 years with fractures of the proximal humerus, including two-, three-, and four-part fractures, treated by open reduction and internal fixation with PHILOS plating. Patients were functionally evaluated based on subjective (35 points) and objective (65 points) parameters as per the Neer scoring system.

Results: All these operated patients were followed up for 12 - 18 months. Functional outcome based on the Neer scoring system showed 32 patients had good outcome scores (78%) which include excellent and satisfactory result, whereas 9 patients had poor outcome scores (22%) which include unsatisfactory and failure results, out of which 4 patients had avascular necrosis and were treated with Shoulder Hemiarthroplasty, 4 patients presented with varus malunion and treated with Osteotomy and revision plating and 1 patient underwent implant removal and physiotherapy.

Conclusion: Proximal humerus locking plate is a preferred option for management of in all types of Neer’s fracture types of proximal humerus and fracture dislocation of proximal humerus. The present study concludes that it is a promising implant working by a dual mechanism i.e. a buttressing effect laterally and inferomedial support by locking screws, which prevent varus displacement of proximal fragment and thus it provides a good functional outcome in proximal humerus fractures.

  However, complications are not uncommon with PHILOS plates. And therefore, a thorough understanding of fracture morphology using pre-operative planning with 3D CT scan, sound surgical techniques and proper plate positioning is necessary to achieve good functional outcomes.

Keywords: Proximal Humerus Fracture; Neer Classification; Locking Plates

References

1. Court Brown CM., et al. “The epidemiology of proximal humeral fractures”. Acta Orthopaedica Scandinavica 72 (2001): 365-371.
2. Palvanen M., et al. “The epidemiologpy of proximal humeral fractures”. Clinical Orthopaedics and Related Research 442 (2006): 87-92.
3. Young TB and Wallace WA. “Conservative treatment of fractures and fracture – dislocation of the upper end of the humerus”. The Journal of Bone and Joint Surgery British 67B (1985): 373-377.
4. Codman EA. “The Shoulder. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa”. Boston: privately printed (1934).
5. Neer CS. “Four segment classification of proximal humeral fractures: purpose and reliable use”. Journal of Shoulder and Elbow Surgery 11 (2002): 389-400.
6. Clifford PC. “Fractures of neck of humerus: a review of the late results”. Injury 12 (1980): 91-95.
7. Platzer P., et al. “The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity”. Injury 36 (2005): 1185-1189.
8. Court Brown CM., et al. “The translated two part fracture of the proximal humerus Epidemiology and outcome in order patient”. The Journal of Bone and Joint Surgery British 83 (2001): 799-804.
9. Court Brown CM., et al. “Impacted valgus fractures B1.1 of the proximal humerus. The results of non operative treatment”. The Journal of Bone and Joint Surgery British 84B (2002): 504-508.
10. Edelson G., et al. “Natural history of complex fractures of the proximal humerus using a three dimensional classification system”. Journal of Shoulder and Elbow Surgery (2008): 399-409.
11. Green A., et al. “Humeral head replacement for acute four part proximal humeral fractures”. Journal of Shoulder and Elbow Surgery 2 (1993): 249-254.
12. Walsh S., et al. “Biomechanical comparison of unique locking plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model”. Clinical Biomechanics 21 (2006): 1027-1031.
13. Brian D Solberg and Moon CN Franco DP. “Surgical treatment of three and four part proximal humeral fractures”. Journal of Bone and Joint Surgery American (2009): 1689-1697.
14. Rockwood and Green’s Fractures in Adults, 7^th edition, volume 1. Proximal humerus fractures 1066.
15. Murray IR., et al. “Proximal humeral fractures: current concepts in classification, treatment and outcomes”. The Journal of Bone and Joint Surgery British 93 (2011): 1-11.
16. “Displaced proximal humeral fractures”. Journal of Bone and Joint Surgery 6 (6): 1077-1089.
17. P Hoffmeyer. “The operative management of displaced fractures of the proximal humerus”. Journal of Bone and Joint Surgery (2002): 84.4 (2002): 469-480.
18. Lill H., et al. “The angle stable locking-proximal-humerus plate for proximal humeral Fractures using a small anterior-lateral deltoid-splitting-approach”. Zentralblatt fur Chirurgie 1 (2004): 43-48.
19. Hertel R., et al. “Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus”. Journal of Shoulder and Elbow Surgery 13 (2004): 427-433.
20. Functional outcome and complications following PHILOS plate fixation in proximal humeral fractures.
21. Lei Zhang., et al. “The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study”. International Orthopaedics 35 (2011): 1655-1661.
22. Second generation locked plating for complex proximal humerus fractures in very elderly patients.
23. Brian D Solberg., et al. “Surgical treatment of three And four-part proximal humeral fractures”. The Journal of Bone and Joint Surgery 91 (2009): 7.
24. Rockwood and Matsen. “The Shoulder”. W.B. Saunders company (1993): 337-379.
25. Samuel L Turek. “Orthopaedics- Principles and their applications” 4^th edition 2 (): 920-922.
26. Kenneth J Koval Maureen. “Functional outcome after minimal displaced fracture of proximal Humerus”. Journal of Bone and Joint Surgery 2 (1997): 203-208.
27. Hattrup SJ and Cofield RH. “Osteonecrosis of humeral head - Results of replacement”. Journal of Shoulder and Elbow Surgery 9 (2000): 177.
28. Jeffrey AS and David MD. “Proximal fractures malunions”. OCNA (2000).
29. Kozlowski P. “Subcut Osteosynthesis for non-union of humeral shaft fractures”. Journal of Bone and Joint Surgery (1997): 79.
30. Campbell JT. “Periprosthetic humeral fractures - Mechanism of fracture and treatment options”. Journal of Shoulder and Elbow Surgery 7 (1998): 406.
31. Partick G., et al. “Fracture of an implant after total shoulder arthroplasty”. Journal of Shoulder and Elbow Surgery 79 (1997): 4.
32. Crosby LA. “Complications, Total Shoulder arthroplasty, Rosemont lll, 2000”. American Academy of Orthopaedic Surgeons (2000).
33. Sperling JW and Cofield RH. “Infection after total shoulder arthroplasty”. Clinical Orthopaedics 382 (2001): 206.
34. Fabis J. “Boguckia-shoulder cuff Ruptures”. Journal of Bone and Joint Surgery (1997): 79B.
35. Zwierzchowski H and Fabis J. “Cuff tear-Primary and Secondary Bone Impingement”. Journal of Bone and Joint Surgery (1997): 79.
36. Richard J Hawkins., et al. “The three part fractures of proximal part of humerus”. Journal of Bone and Joint Surgery 68-A (1986): 1410-1414.
37. M Pritsch and A Greental. “Closed pinning for proximal humerus fractures”. Journal of Bone and Joint Surgery (1997):79B.
38. Gerber C., et al. “Internal fixation of complex fractures of the proximal humerus”. Journal of Bone and Joint Surgery 60 (2004): 848-855.
39. Kenneth A Egol., et al. “Early complication of proximal humerus fractures treated with locked plates”. Orthopaedics and Traumatology 22 (2008): 159-164.
40. Herscovici D. “Case controversies. Proximal humerus fracture”. Journal of Orthopaedic Trauma 15 (2001): 146-148.
41. Rizwan Shahid., et al. “Proximal humerus fracture treated with locking compression plate”. Acta Orthopaedica Belgica 74 (2008): 602-608.
42. MA Fazal and FS Haddad. “PHILOS plate fixation for displaced proximal humeral fractures”. Journal of Orthopaedic Surgery 1 (2009): 15-18.
43. Cofield RH. “Comminuted fractures of the proximal humerus”. Clinical Orthopaedics 230 (1988): 49-57.
44. Cordasco FA and Bigliani LU. “Complications of proximal humerus fractures”. Techniques in Orthopedics (1997): 12-50.
45. Frigg R. “Development of the locking compression plate”. Injury 34 (2003): 6-10.
46. AA Martinez., et al. “Proximal humerus locking plate for proximal humerus fracture-retrospective study”. Journal of Orthopaedic Surgery 1 (2009): 10-14.
47. Neer CS. “Displaced proximal humeral fracture: Part 1: Classification and evaluation”. Journal of Bone and Joint Surgery 52-A (1970): 1077-1089.
48. Evan L Flatow. “Fracture of the proximal humerus”. Chapter-25, In: Text book of Rockwood and Green’s fractures in adults. Volume 1, New York: Lippincott Williams and Wilkins (2001): 997-1035.
49. Neviaser AS., et al. “Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant”. Archives of Orthopaedic and Trauma Surgery 12 (2011): 1617-1622.
50. Kavuri V., et al. “Complications Associated with Locking Plate of Proximal Humerus Fractures”. The Indian Journal of Orthopaedics 2 (2018): 108-116.
51. Dheenadhayalan J., et al. “Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases”. Journal of Orthopaedic Surgery2 (2019): 230949901984816.

Citation

Citation: Dhruv Pandya and Krunal Soni. “Analysis of Functional Outcome in Proximal Humerus Plating (PHILOS) in Displaced Proximal Humerus Fracture".Acta Scientific Orthopaedics 3.11 (2020): 37-49.

Copyright

Copyright: © 2020 Dhruv Pandya and Krunal Soni. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.