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Selected

Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
M ARK W. P AGNANO
EDITOR, VOL. 62

C OMMITTEE
M ARK W. P AGNANO
CHAIR

C RAIG J. D ELLA V ALLE

K ENNETH A. E GOL
R OBERT A. H ART
P AUL T ORNETTA III
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academys Annual Meeting, will be available
in March 2013 in Instructional Course Lectures, Volume 62.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Proximal Humeral Fractures:

Internal Fixation
Daniel Aaron, MD, Joshua Shatsky, MD, Juan Carlos Paredes, MD, Chunyun Jiang, MD
Bradford O. Parsons, MD, and Evan L. Flatow, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Fractures of the proximal part of the

humerus represent 4% to 5% of all
fractures1,2. Older individuals are more
likely to sustain these injuries: 71% of
proximal humeral fractures occur in
patients over the age of sixty years3,4. As
the population ages, such data suggest a
potential increase in the total number
of proximal humeral fractures. Some
authors have estimated a threefold increase in the upcoming thirty years5.
Neer asserted that most proximal humeral fractures are minimally displaced
or nondisplaced, allowing nonoperative
treatment to yield high rates of union
and functional restoration6; however, a
recent multicenter study noted that 64%
were displaced7. Management strategies
for displaced fractures have evolved

recently because of advances in technology and improved understanding of

pathophysiology. Unless contraindications exist, the recommended general
strategy for the management of displaced
proximal humeral fractures is operative,
with use of various forms of internal fixation. These include pins, screws, tensionband wires, plate and screw constructs,
heavy sutures, and intramedullary devices.
Arthroplasty, which has also undergone
dramatic advances in recent years, is an
additional option. Each technique has
particular indications, and each is subject
to its own set of potential complications.
Therefore, familiarity with all of these
techniques is essential for the practitioner
caring for fractures of the proximal part of
the humerus.

Look for this and other related articles in Instructional Course Lectures,
Volume 62, which will be published by the American Academy of
Orthopaedic Surgeons in March 2013:
Proximal Humeral Fractures: Prosthetic Replacement, by Daniel Aaron,
MD, Bradford O. Parsons, MD, Francois Sirveaux, MD, and Evan L. Flatow, MD

Anatomy
To understand the pathophysiology of
fractures of the proximal part of the
humerus, knowledge of the osseous,
muscular, and vascular anatomy is
imperative. The commonly used classification schemes rely on this anatomy
as do the deforming forces that must be
overcome by reduction maneuvers and
fixation. Furthermore, prognostic information is a direct correlate of the
specific sites of anatomic disruption.
The proximal part of the humerus
initially had a primary ossification
center and two secondary ossification
centers (greater and lesser tuberosities)
that fuse, but as Codman first recognized, fractures tend to occur along
these physeal lines, even with skeletal
maturity6.
The supraspinatus, infraspinatus, and teres minor muscles attach to
the greater tuberosity and exert abduction and external rotation forces.
The subscapularis tendon attaches
to the lesser tuberosity and exerts a
medial and internal rotation vector.
The deltoid, pectoralis major, and

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in
this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2012;94:2280-8

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latissimus dorsi muscles all insert distal to the tuberosities. The pectoralis
major muscle is a strong deforming
force, and it is important to recognize
this during reduction maneuvers and
when fracture fixation is selected and
placed8.
The vascular anatomy of the
proximal part of the humerus is
complex, and has implications for the
risk of the development of osteonecrosis of the humeral head after a
fracture. The principal vascular supply to the humeral head is via the
anterolateral branch of the anterior
humeral circumflex artery, which
arises from the axillary artery9,10. The
anterior circumflex system courses at
the inferior border of the subscapularis tendon near its insertion to the
lesser tuberosity, and then underneath
the biceps tendon to penetrate bone at
the superomedial border of the greater
tuberosity9,11,12. A relatively minor
segment of the posteromedial aspect
of the humeral head is directly supplied by the posterior circumflex artery9. There is a rich network of other
arteries, including the profunda brachii, thoracoacromial, subscapular,
and suprascapular arteries10, that can
sustain the humeral head even in the
event of injury to both circumflex
systems or axillary artery disruption13,14. An injury in which both
tuberosities are fractured with a concomitant metaphyseal fracture places
the patient at high risk for osteonecrosis of the humeral head15. The
operating surgeon must be aware of
this risk to make educated decisions
about fixation or arthroplasty, the

P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

importance of anatomic reductions, as

well as to appropriately counsel the
patient.
Classification
The most widely used classification
scheme for proximal humeral fractures
is the Neer classification system6,16,17. In
this system, the humeral articular surface, greater tuberosity, lesser tuberosity, and humeral shaft are considered
the parts of the proximal aspect of the
humerus. A part is considered to be
displaced if it is angulated 45 or
displaced 1 cm. Recently, a valgusimpacted subset of four-part fractures
was added18. This is an important
addition because valgus-impacted
fractures retain an intact medial calcar
hinge, which makes them biomechanically relatively stable and likely to have
a preserved blood supply to the humeral head. Therefore, percutaneous
fixation is a viable option and the
prognosis is good8. Head-splitting
fractures and large (>40%) humeral
impression fractures compose a separate category, for which arthroplasty is
considered.
The AO classification system is
based on the vascular supply to the
humeral head19. It consists of three
main types: extra-articular unifocal,
extra-articular bifocal, and intraarticular. Each type contains three
subtypes based on the severity of the
injury as indicated by displacement,
comminution, or glenohumeral joint
dislocation. This scheme is more
complex than the Neer classification
system, yet there is no evidence that it
is more reliable17,20.

Evaluation
Evaluation of the patient with a fracture
of the proximal part of the humerus
begins with a history and physical
examination. Relevant medical comorbidities must be identified. A social history
should be obtained to assess the patients
level of activity and demand on the
shoulder, as well as his or her expectations
after intervention. Physical examination
should begin with assessment of the skin
condition and the neurovascular status.
Motor function of the deltoid muscle
should include voluntary isometric contraction of all three heads. Palpation of the
distal pulses and careful inspection for
signs of arterial injury should be performed
acutely. Any question about vascular compromise should prompt Doppler examination and, if necessary, angiography.
Imaging assessment begins with a
standard series of radiographs, including
anteroposterior, true anteroposterior,
axillary lateral, and scapular-Y radiographs of the proximal humeral fracture.
Anteroposterior radiographs with the
arm in internal and external rotation may
better characterize tuberosity fractures or
occult fractures of the surgical neck.
Computed tomography (CT) can provide additional information for both
classification and preoperative planning21,
particularly with a fracture of the lesser
tuberosity22. CT is also helpful in fractures
with articular surface involvement and
for enumeration of fracture fragments
(Figs. 1-A, 1-B, and 1-C). The number of
fragments in the setting of severe comminution is underestimated by standard
radiography in >60% of cases23.
Magnetic resonance imaging
(MRI) is not part of the routine

Fig. 1

Anteroposterior radiograph (Fig. 1-A), axial CT scan (Fig. 1-B), and coronal CT scan (Fig. 1-C) of a comminuted head-split fracture.

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P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Fig. 2

Anteroposterior radiograph of a valgus-impacted four-part fracture.

evaluation of proximal humeral fractures. While traumatic rotator cuff tearing at the time of a proximal humeral
fracture is rare, some authors have
recommended consideration of the use
of MRI24. Rutten et al. recently described
an ultrasonographic sign that reliably
detected occult proximal humeral fractures25. The so-called double-line sign
was present in 93% of patients with
occult fractures.
Surgical Indications
Many proximal humeral fractures with
minimal displacement are amenable
to nonoperative treatment. Displaced
two, three, and four-part fractures are
indications for surgical management to
optimize anatomic healing and improve functional outcome. Displacement of the tuberosities above the
humeral head, as in three or four-part
fractures or in varus two-part fractures,
often yields a poor functional outcome,
even if healing occurs nonoperatively.
Surgery is aimed at restoring the proximal
humeral anatomy, including the neckshaft angle, version, and tuberosity-tohead and tuberosity-to-tuberosity
relationships, and bone-preserving
options include percutaneous techniques, intramedullary nailing, and
locked plating.

Percutaneous Fixation
Indications
Percutaneous fixation with pins is a
minimally invasive strategy with a theoretically lower rate of osteonecrosis than
that with open fixation. However, it
offers less stability than other forms of
fixation, and is technically demanding. It
is advocated for unstable two-part surgical neck fractures, but also has a role in
more complex three-part and valgusimpacted four-part fractures8 (Fig. 2).
This form of fixation is generally reserved
for patients with good bone quality;
minimal comminution, particularly involving the tuberosity; and an intact
medial calcar. It is also essential that
patients are compliant with postoperative
follow-up and immobilization8.
Technique
A detailed description of the percutaneous pinning technique has been previously published26. Pearls of management
are discussed below. Percutaneous
techniques should be performed within
five to seven days of injury to avoid
difficulties associated with early callous
and scarring.
Proper setup and timing of surgery
is critical to outcome. The patient is placed
in a supine or modified beach-chair position on a radiolucent table with the

shoulder and arm off the edge of the bed. It

must be ensured that a good anteroposterior and axillary radiograph can be made
prior to skin preparation. Once the c-arm
fluoroscopic image intensifier is properly
positioned, sterile preparation and draping
of the shoulder is performed.
Careful pin placement is essential
to avoid neurovascular injury. Lateral pins
should be distal to the anterior branch of
the axillary nerve27 but proximal to the
deltoid insertion to avoid the radial nerve.
The musculocutaneous nerve, cephalic
vein, and biceps tendon are at risk from
placement of the anterior pins.
Reduction of the humeral shaft
under the humeral head is done by
applying longitudinal traction with a
posterolateral force to the arm. If this
does not reduce the fracture, a 2.5-mm
terminally threaded pin inserted through
the greater tuberosity into the humeral
head can be used as a so-called joystick.
Another reduction technique is to use a
small so-called reduction portal to manipulate the fragments with instruments
such as elevators, tamps, or hooks28 (Figs.
3-A and 3-B).
Once adequate reduction is
achieved, a 2.5-mm terminally threaded
pin is driven from the lateral metaphysis
into the humeral head. As the pin nears
the articular surface of the humeral head,
driving it in by hand with use of a Thandled chuck rather than a power driver
provides better tactile feedback and
minimizes the risk of penetrating the
articular cartilage. Insertion should also
be done under image guidance to further
minimize the risk of pin penetration.
If penetration occurs, the pin must be
removed and a completely new track
createdif the pin is simply withdrawn,
it may migrate and penetrate over time.
When inserting the pin, the surgeon
must recognize that the humeral head
is retroverted 20 to 40. Two or three
antegrade pins in a parallel configuration
are usually adequate for fixation of the
humeral head to the shaft29, although a
retrograde pin from the greater tuberosity to the humeral shaft is sometimes
used to augment stability30. Fixation of
the tuberosities in displaced three and
four-part fractures is achieved with 3.5 or
4.0-mm cannulated screws placed

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Fig. 3-A

P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Fig. 3-B

Fig. 3-C

Use of an elevator (Fig. 3-A) and a hook (Fig. 3-B) in fracture reduction during percutaneous pinning. Fig. 3-C Final construct after percutaneous pinning.

antegrade from the tuberosity either

bicortically into the calcar (for the greater
tuberosity) or unicortically into the head
(for the lesser tuberosity). Pins and
screws are buried underneath the skin
(Fig. 3-C). The arm is immobilized for
three to four weeks, and the pins are
removed after four to six weeks.

Pin-Track Infection

Prognosis and Outcomes

Functional outcome is correlated with
the adequacy of reduction and the
residual deformity. Union rates are high,
and good results should be expected
with two-part and three-part fractures28,31,32. If acceptable alignment cannot be obtained at the time of surgery,
open reduction is recommended.

Osteonecrosis

Complications
Malunion

Malunion rates have been reported to be

as high as 28%31. Patients with osteoporotic bone and those who have fracture
comminution have the highest risk. Varus
angulation of the humeral head with
posterosuperior displacement of the
greater tuberosity is the most common
deformity8.
Pin Migration and/or Loosening

Despite the use of terminally threaded

pins, the migration of pins occurs in up
to a third of patients28,31. Migration into
the chest and other vital structures has
been described8. Weekly evaluation and
radiographs are performed to monitor
fracture reduction and pin alignment.
Pins that become loose or migrate
should be removed prior to four weeks.

Superficial infections are treated with

local wound care, antibiotics, and
pin removal. Ensuring that the pins
remain below the skin lessens the
chance of infection. One must beware of a deeper infection including
osteomyelitis.
Osteonecrosis of the humeral head is
most likely related to the magnitude
of the injury, with four-part fractures
associated with a prevalence of osteonecrosis of up to 28%28,31,33. Kralinger
et al. found a significantly lower rate of
osteonecrosis after percutaneous pinning compared with open reduction and
internal fixation34.
We followed a series of twentyseven patients treated with percutaneous
pin fixation for a minimum of three
years after surgery. Osteonecrosis was
noted in 26% at an average fifty months
(range, eleven to 101 months), including
half of the four-part fractures, two of
the twelve three-part fractures, and none
of the two-part fractures. The mean
American Shoulder and Elbow Surgeons
(ASES) score was 65 for patients with
osteonecrosis and 84 for patients without osteonecrosis26.
Neurovascular Injury

Despite cadaveric studies demonstrating

potential neurovascular injury with
percutaneous fixation, clinical rates are
low27,35,36. A good knowledge of anatomy
and normal variants is essential to
prevent complications.

Intramedullary Nailing
Indications
Intramedullary nails are accepted as an
effective method to treat two-part surgical neck fractures, although their use
in more complex proximal humeral
fractures has varied37-39. Small incisions,
closed reduction, and excellent nailbone purchase in osteoporotic bone are
advantages.
Gradl et al. treated displaced
proximal humeral fractures with an
antegrade nail (Targon PH; Aesculap,
Tuttlingen, Germany) and had better
functional results in patients with twopart and three-part fractures than in
those with four-part fractures40. The
published results have varied41-45. The
intramedullary nail may be rigid and
locked or flexible and unlocked. Locked
intramedullary nails are axially and
rotationally stable, whereas flexible intramedullary nails are not. Shoulder
impairment and iatrogenic fractures are
risks with locked intramedullary nails46-48.
Advantages of the flexible intramedullary
nails are relatively little blood loss, no
soft-tissue stripping at the fracture site,
minimal muscular trauma, and low risk
of radial nerve injury. A disadvantage of
flexible intramedullary nails, particularly
among patients with osteoporotic bone,
is restricted early motion and delayed
physiotherapy due to relatively low construct stability49.
Technique
Rigid Intramedullary Nail

The patient is placed supine in the

beach-chair position, and the image

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intensifier device is positioned to ensure

that anteroposterior and axillary radiographs of the affected shoulder can be
obtained intraoperatively.
A 4-cm longitudinal incision is
made anterolateral to the acromion. The
deltoid is split from the anterolateral
corner of the acromion distally for 4 cm.
The humeral head fragment is exposed,
and the head fragment is reduced, with
use of a 2.5-mm Kirschner wire or
Steinmann pin, under fluoroscopic
guidance. For displaced four-part fractures, 1.25-mm Kirschner wires can be
used for temporary fragment reduction.
A 1-cm incision is made in the supraspinatus tendon in line with its fibers.
An awl or a guide pin is used to enter
the medullary canal. For the straight
150-mm Targon PH nail (Aesculap), the
recommended entry point is about
8 mm medial to the cartilage-bone
transitional zone at the sulcus between
the humeral head and the greater tuberosity50. For the 6 angled Stryker T2
Proximal Humerus nail (Stryker, Kiel,
Germany), the recommended entry
point is 10 mm posterior to the anterior
edge of the supraspinatus and at the
junction of the greater tuberosity and
the articular cartilage50. The entry point
for the proximal humeral nail (Synthes,
West Chester, Pennsylvania) is just lateral to the articular margin in the sulcus
between the greater tuberosity and the
articular margin38. The entry point of
the intramedullary nail is important;
however, cortical apposition may be lost
following the insertion of the nail as a
result of the specific humeral pathology
and anatomic characteristics50. The
medullary canal is reamed. The nail is
inserted manually with its targeting
device. The depth of nail insertion may
vary according to manufacturer and
design. Precise orientation of the targeting device is necessary to avoid injury
to the long head of the biceps and
neurovascular structures51. Fixation
screws are inserted. We recommend
placement of all of the proximal screws,
particularly if the tuberosities are fractured. The rotator cuff tendon and
deltoid are repaired, and active-assisted
to active shoulder motion is begun on
the third postoperative day.

P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Flexible Intramedullary Nails

Complications

Retrograde flexible intramedullary nailing

utilizes more than one 2-mm-diameter,
curved, flexible nail to achieve multiplepoint intramedullary fixation. The fracture pattern and the diameter of the
medullary canal dictate the number of
nails that are inserted. Usually, three,
four, or five nails are necessary to obtain sufficient stability. Once closed reduction has been achieved, the nails are
advanced from distal to proximal from an
entry point 3 cm proximal to the olecranon tip under fluoroscopic guidance to
the medial half of the humeral head, diverging in the subchondral region37.
Pendulum movements of the
shoulder are started on the first postoperative day, with mobilization of the
elbow joint. Passive movement exercises
may be initiated on the third week, and
active exercises may be started on the
fourth week onward.

Nonunion

In a systematic review by Lanting et al.

(sixty-six articles with results on 2653
fractures), nonunion was as high as 4%
in two and three-part fractures39.
Nail Migration

Verbruggen and Stapert stated that rates

of flexible nail migration as high as 29%
and rates of fracture distraction of up
to 41% have been reported48.
Malunion

Malunion is one of the commonly

reported complications, and the rate of
postoperative varus deformity of the
humeral neck has been reported to be as
high as 7.7% to 37%39,54,57.
Nerve Injury

Prognosis and Outcomes

When appropriate patients are chosen,
careful placement of the nail entry point
and effective postoperative rehabilitation lead to a successful result38,40,50.

The locking screws that are used with

the nails may pose a danger to the
axillary nerve51. Closed reduction and
implant insertion place the radial
nerve at risk. Blunt dissection and use
of protection sleeves during drilling
and screw insertion can prevent this
injury.

Rigid Intramedullary Nail

Rotator Cuff Injury

Several recent cohort studies have demonstrated 100% union rates, low complication rates, and favorable subjective
outcomes with rigid intramedullary
nailing38,52,53. Three recent comparisons
of rigid intramedullary nailing and
locked plate fixation did not reveal a
significant difference in objective or
subjective outcomes54-56. One study did
show a trend of more complications and
lower relative Constant scores with nail
fixation, but this did not reach significance55. Another showed a higher rate of
complications but better outcome scores
with locked plate fixation at one year;
however, no difference was detected
between the locked plate group and the
nail fixation group at three years56.
Matziolis et al. found no significant difference in absolute Constant
scores between Zifko nailing and fixedangle plating for two-part fractures. The
score for the subitem activity of daily
life was significantly higher in the plate
group than in the Zifko group37.

Insertion of the nail through the rotator

cuff tendon causes different degrees of
injury to the supraspinatus tendon that
can lead to shoulder pain38,46,52. Care
should be taken in the dissection of the
supraspinatus tendon and in its meticulous repair.
Open Reduction and Locked
Plate Fixation
Background
Prior to the advent of locked plating,
hemiarthroplasty had been advocated
for most three and four-part fractures.
Anatomic proximal humeral locking
plates represent an advance in construct
stability58,59 and have a lower rate of
implant failure compared with unlocked
plating. However, the complication rate
remains substantial. Continued innovation in technology (i.e., polyaxial
systems and suture eyelets) and technique (i.e., structural allograft and
rotator cuff sutures) are aimed at
improving current outcomes.

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P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Fig. 4

Anteroposterior radiographs of a comminuted proximal humeral fracture with a head split made preoperatively (Figs. 4-A and 4-B) and immediately after
open reduction and locked-plate fixation (Fig. 4-C).

The importance of medial cortical support has been demonstrated

with the locking construct, as the
screw buttressing the inferomedial
portion of the proximal segment aids
in medial column support60. Restoration of medial calcar and medial support plays an important role in
maintaining reduction61. This screw
functions as a so-called kickstand and
is beneficial in maintaining the stability and ultimate reduction of the
construct. Additionally, anatomic or
slightly impacted reductions aid in
construct stability61.
Other constructs have attempted
to utilize pegs as alternatives to screws
to prevent articular perforation.
Schumer et al. found no significant
difference in joint perforation between
the two constructs62. Newer locking
constructs offer polyaxial locking
mechanisms. In a comparison of
monoaxial and polyaxial constructs,
the polyaxial system had equal biomechanical performance with the advantage of more head fixation63.
In a comparison of a locked plate
and locked nail, plates were found to be
stronger in torsion, equivalent in axial
stiffness64, and superior in varus bending65. In comparison with proximal
humeral blade plates, locking plates
provided better torsional fatigue resistance and stiffness66.
Proximal humeral fracture fixation fails because of bending and rotational moments60-67. Because locking

plates are biomechanically more stable

than the tested constructs under these
circumstances, the added stability may
reduce the fracture failure rate.
Indications
Most displaced two, three, or four-part
fractures of the proximal part of the
humerus can be treated with locked
plates. Fracture dislocations and headsplitting fractures in patients older than
forty years are relative contraindications
to plate fixation. Both are higher-energy
injuries associated with risk of osteonecrosis of the humeral head; however,
in younger patients in whom jointpreserving strategies are most appropriate, head-splitting and high-energy
fractures may be fixed with a locked
plate (Figs. 4-A, 4-B, and 4-C). Few
other contraindications exist, except
prohibitive medical comorbidities, pediatric fractures, or patterns of injury
amenable to less invasive techniques68,69.
Proximal Humeral Exposures70
Multiple exposures for the proximal part
of the humerus, including the classic
deltopectoral, anterolateral deltoidsplitting approach, and two-incision
techniques9,71-73, have been described.
There are advantages and disadvantages
of each. The anterolateral and twoincision approaches were developed
with the primary purposes of improving
visualization, minimizing soft-tissue
dissection, and allowing more direct
plate application, which may permit

improved preservation of the blood

supply. However, these approaches may
place the axillary nerve at risk72-77. Conversely, the classic deltopectoral approach is the only truly internervous
approach and is the most widely utilized
exposure. Controversy exists as to what
approach to use for locking plate fixation9,71-74. We use the deltopectoral approach because of its extensile nature
and long track record of safety.
Deltopectoral Approach
The deltopectoral approach utilizes the
internervous plane between the deltoid
(axillary nerve) and the pectoralis major
(medial and lateral pectoral nerves)70.
The patient can be positioned in the
beach-chair position or supine, depending on the available equipment and
the surgeon preference. The skin incision is approximately 10 to 15 cm long,
beginning at the coracoid and angled
distally to the deltoid tuberosity.
The cephalic vein is identified in
the deltopectoral interval and is usually
mobilized laterally to protect the many
deltoid branches78; however, it may be
taken medially as well. The clavipectoral
fascia is opened, and the conjoint tendon is retracted medially. Deltoid or
pectoralis major detachment is not
needed, and no more than one-fifth of
each should be released79.
Continuity of the axillary nerve
can be tested with the so-called tug test80
at the inferior border of the subscapularis and beneath the deltoid. The

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d

distance from the coracoid to the point

of entrance of the main musculocutaneous nerve trunk into the coracobrachialis averages 5.6 cm (range, 3 to 8
cm)81.
The rotator cuff interval may be
incised at the level of penetration of the
biceps tendon to mobilize the tuberosities and to allow visualization and
palpation of the articular surfaces. The
long head of the biceps tendon is
uncovered in its groove and is followed
proximally to its insertion on the superior aspect of the glenoid. The tendon
may be tenotomized and tenodesed to
the pectoralis major, removing a source
of postoperative pain82. It is important to
avoid excessive dissection and cauterization in the bicipital groove to preserve
the ascending branch of the anterior
humeral circumflex artery.
Reduction
Control of the rotator cuff is the most
important step to reduce and control
the multiple fracture fragments. Nonabsorbable sutures are placed in the
subscapularis to control the lesser tuberosity, and in the supraspinatus and
infraspinatus to control the greater
tuberosity and humeral head. Elevators, if necessary, are placed in the
fracture planes to disimpact the fragments and to correct varus or valgus
positioning of the head. The tuberosities are reduced to their anatomic
position with respect to the head and
the metaphysis and shaft. Tuberosity
reduction is a key predictor of functional outcome83,84. If there is insufficient metaphyseal bone, the surgeon
may place a fibular strut allograft
within the intramedullary canal and
impact the head onto it to provide
control and structural support85.
Fixation
Locking plates have a low profile, a hole
for a kickstand screw to buttress the
medial calcar, divergent proximal
locking screws, and eyelets to allow
passage of rotator cuff sutures through
the plate68. The plate should be placed
lateral to the bicipital groove, 1.5 to 2
cm distal to the greater tuberosity (2 to
3 cm from the superior aspect of the

P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

head). If the plate is placed too high,

there is a risk of impingement. If it is
placed too low, head fixation can be
compromised. Proximal screws should
remain short of the subchondral bone
to reduce the risk of perforation with
humeral head collapse. Rotator cuff sutures are then tied to the plate to neutralize the displacing force of the cuff
muscles and offload the proximal screws.
Screw penetration into the joint is a risk,
and rotator cuff sutures add additional
stability and are believed to stabilize the
fracture enough to allow early motion
and decrease fixation failure86-88. After
completion of fixation, fluoroscopy
should be utilized and the humeral
articular surface should be palpated to
ensure that no screws violate the joint.
Rehabilitation
Postoperative rehabilitation is a balance between early motion and not
disrupting the fixation 89. Initially, the
arm is placed in a sling. Active range
of motion of elbow, wrist, and hand,
as well as pendulum exercises may
begin on the first postoperative day.
Gentle passive range of motion of the
shoulder is started as soon as the
patient is comfortable. Active shoulder motion should begin at four to six
weeks, and strengthening exercises
should not be started until twelve
weeks.
Results and Complications
The results of locked plate fixation are
evolving, but the overall complication
rate remains high86,90-94. The most common complications are screw joint
perforation (13.7% to 23%) and osteonecrosis (3.1% to 16.4%). The rate of
revision surgery has been reported to
range from 13% to 26.7%. However, in
a study comparing the functional outcomes of patients with three and fourpart proximal humeral fractures treated
with locked plating or with a hemiarthroplasty, the University of California
at Los Angeles shoulder score, the
Constant score, patient satisfaction, and
motion were superior in the lockedplate group95.
Strategies to augment locked plate
fixation and minimize complications are

being developed. Improved results and

decreased complications were detailed
in a series by Ricchetti et al., in which the
authors supplemented plate-and-screw
fixation with suturing of the rotator cuff
tendons to the plate69. Hettrich et al.
used endosteal fibular strut allografts or
medial semitubular plates and noted
only one substantial loss of reduction
and no implant failures or screw cutout96. Egol et al. used calcium phosphate
cement to prevent settling and screw
cutout, and less humeral settling was
seen97.
In conclusion, locked plating has
been a major advance in the treatment
of displaced proximal humeral fractures, and has allowed many more
fractures to be successfully treated
with a joint-preserving method instead of arthroplasty. Complications
remain substantial, but the techniques
and technology of proximal humeral
locked plating are areas of active
research.
Overview
Percutaneous, intramedullary, and
locked-plate fixation can be reliable
fixation strategies for proximal humeral
fractures with the correct indications
and careful patient selection, which are
based on an understanding of the anatomy and biomechanics of the injury.
Each method has advantages and disadvantages that the surgeon must consider and individualize for a particular
patient. Regardless of the technique
selected, meticulous surgical technique
and anatomic reduction are essential.
Careful postoperative rehabilitation is
essential. Each method also has specific
complications, which may be mitigated
as techniques and technology continue
to evolve.

Daniel Aaron, MD
Joshua Shatsky, MD
Bradford O. Parsons, MD
Evan L. Flatow, MD
Department of Orthopaedic Surgery,
Mount Sinai Hospital, 5 East 98th Street,
Box 1188, New York, NY 10029.
E-mail address for E.L. Flatow:
Evan.flatow@mountsinai.org

2287
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O L U M E 9 4-A N U M B E R 24 D E C E M B E R 19, 2 012
d

P R O X I M A L H U M E R A L F R A C T U R E S : I N T E R N A L F I X AT I O N

Juan Carlos Paredes, MD

St. Lukes Medical Center,
279 East Rodriguez Sr. Boulevard,
Quezon City, 1102 Philippines

Beijing Ji Shui Tan Hospital, No. 31

Xinjiekoudonggjie Street,
Xicheng District,
100035 Beijing, China

Chunyun Jiang, MD
Department of Orthopaedic Surgery,

Printed with permission of the American

Academy of Orthopaedic Surgeons. This

article, as well as other lectures presented at the

Academys Annual Meeting, will be available
in March 2013 in Instructional Course
Lectures, Volume 62. The complete volume
can be ordered online at www.aaos.org, or by
calling 800-626-6726 (8 a.m.-5 p.m., Central
time).

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