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The outcomes of treatment of the proximal humeral fractures with LPHP through a small skin incision on the anterolateral shoulder

Geran An*, Zeng Bingfang, Wang Yeming, Shi zhong-min

*Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital , Jiaotong University  200233 , Shanghai, P. R. China

Address for Correspondence:

An Geran 
Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital, Jiaotong University  200233 , Shanghai, P. R. China


Study design:
Prospective, clinical research.
to evaluate the clinical, radiographic and fictional outcomes of patients with proximal humerus fractures treated minimal invasive plating osteosynthesis through a anterolateral small incisions.
The proximal humerus fractures are traditionally treated with open reduction and internal fixation through pectrodeltoid approaches. There are few literature report about the results of the fractures treated through anterolateral small incisions.
Methods and Measures:
Sixteen patients with proximal humerusl fractures, 2 patients were of Neer 2-part fracture, 7 of 3-part and 7 of 4-part fractures, were surgically reduced and fixated with locking proximal humerus plates through small anterolateral incision of the shoulder. The operation time, time to bone healing and functional assessments were performed an average follow-up of 6.1 months (range 5- 14 months)  to the affected shoulders in 15 pateitns using Constant-Murley scoring system .
The mean operation time was 143.75±38.81 min. The mean healing time is  14.85 weeks (range 8-19 weeks). The latest follow-up demonstrated a normal sensation on the lateral arms and a mean anterior flexion of 150.42 degrees (range 120-170 degrees) in the shoulder. According to Constant-Murley scoring system, the mean score of the shoulder was 76.82 points (range 59-89.5 points).
This clinical study demonstrated further that surgical treatment of the proximal humerus fractures through a small anterolateral shoulder incision has the advantages of simplifying operative maneuver, reducing tissue damage, shortening bone healing time and improving functional recovery.

J.Orthopaedics 2007;4(2)e3


The ideal treatment of dislocated proximal humeral fractures is still the center of scientific debate. Various methods of osteosynthesis including external fixators [1,2], cannulated screws [3] , intramedullary Kirschner wires [4] , intramedullary nail [5,6] plates [7,8] and prosthetic replacement [9] have been tested and investigated, demonstrating the results vary from excellent to poor.

Drawbacks of above methods including unreliable stabilities provide by the implants that early range of motion was not permitted. Additionally, the wide-open approach combined with extensive soft-tissue stripping remains a reason of non-union or necrosis of humeral head [2, 4, 7, 8].

Recently, a new method has developed to treat the fractures using locking proximal humeral plateLPHPwhich has advantages of fixed-angle stability provided by locking screw and plates that can provide effective stabilities for the fractures even in osteoporotic fracture [10] . Usually, a pectrodeltoid approaches were used to reduce and apply the plates on the lateral aspect of proximal humerus. The long incisions and the great trauma for the tissue around the shoulder are the main disadvantages of the approaches and also the main cause of avascular necrosis of the humeral head after severe proximal fractures of humerus. Gardner et al [11] recommended the extended anterolateral acromial approach to reduce and fixate the fractures and the axillary was firstly dissected and protected from injury. Gallo et al [12] described a two-incision technique for treatment of complex proximal humerus fractures in which a deltopectoral incison is used to expose the humeral shaft and head while the greater tuberosity is visualized through a lateral incision. More extensive tissue trauma is the main disadvantages of these methods. Here, we report our results of open reduction and internal fixation with LPHP for treatment of the proximal humerus fractures through a small anterolateral approache of the shoulder.

Material and Methods :

2.1. Patients

From May 2004 to Sep 2005, 16 patients with displaced fractures of proximal humerus were surgically treated with open reduction and internal fixation with LPHP through a small anterolateral incision on the shoulders. The mean age of the patients was 45.00±13.21 years (range 18-63 years). There were 7 male and 9 female patients; The right shoulder was involved in 13 patients and the left in 3 patients. Thirteen patients injured by fall on the ground and 3 by road traffic accidents. One patient associated with ipsilateral femoral neck fracture and another one with Vaquez’s disease. According to Neer’s Classification system [13], 2 patients had the 2-part fractures, 7 had the 3-part fractures and 7 had the 4-part fractures.

The criteria for inclusion in the study were displaced unstable fractures of the proximal humerus. The criteria for exclusion were undisplaced proximal humeral fractures, open fractures and pathological fractures. All the patients underwent operation at mean 7.81±6.54 days after injury (range 2-30days).

2.2. Operative technique
The operation is performed under the regional anesthesia. The patient is placed into a beach-chair position with the affected arm resting on a translucent part of the operating table and free-draped for mobility. A 5 cm incision was made from a point 1.5 cm anterior to the lateral rim of acromion and extended toward the insertion of deltoid muscle while the arm was kept in neutral position (fig 1). he fibers of deltoid muscle were divided by blunt dissection until the superior edge of axillary nerve. The soft tissue around the axillary and anterior circumflex humeral artery and vein should be kept intact to avoid the damage to the nerve and the artery. 

 The capsule of the shoulder was longitudinally opened. The hematoma among the fragments was cleaned and fracture fragments were identified.Firstly the impacted humeral head was elevated using two 2.5mm K-wires inserted into the humeral head and then reduce the greater tuberosity to humeral head. The reduction of the humeral head to humeral shaft was performed with manual traction.TLastly the arm was external rotated and the displaced lesser tuberosity was reduced. In each step, the reduction was provisionally maintained with k-wires and then determined with image intensifier on the AP scapular view (fig2). Once the fractures have been reduced, a sub-deltoid muscular  tunnel was made by small elevator and a locking proximal humeral plate (LPHP) was introduced beneath the deltoid. The proximal end of the plate was located posterior to the greater tuberosity ridge and inferior to the articular surface of the humeral head. A 2.0mm K-wire was used to fix the proximal end of plate to humerus through wire hole. The adequate positioning of the distal end of plate to the humeral shaft was adjusted and confirmed by an additional small incision made on the lateral arm using a same LPHP as template (fig 3a). The distal end of the plate was temporally fixed to the humeral shaft with a K-wire through a screw hole and more K-wires were used to fix the proximal end of plate through wire holes. The reduction and the position of plate were re-evaluated by image intensifier on the AP scapular view and axillary view (fig 3b). Four locking screws were used to fix the proximal end of plate to the proximal humerus and three conventional cortical screws were applied to the distal end of plate through the small incision or percutaneously. The last position of fragment, plates and the length of screws were confirmed with image intensifier after all the K-wires were removed. The possible torn rotator cuff tissues were repaired and the wound was closed as usual.

Fig.1 An incision was started  from a point 1.5cm anterior to the lateral rim of the acromion Fig.2 The fractures were reduced and provisionally fixed with K-wire

Postoperative management included in 4- to 6-week protection of affected arm with neck-wrist sling. The active range-of-motion exercises of the shoulder and elbow were encouraged immediately after operation, especially the abduction and external rotation of the shoulder. 

2.3. Follow-up
All the patients were followed up by clinical and radiographic assessment. The operation time was defined as time from skin incision to skin closure. Also recorded were the hospital stay after operation, the time of bone healing, sensation of the lateral arm, complications and functional outcome of shoulder, especially the active motions in anterior flexion, abduction, external rotation and internal rotation were recorded.

Radiographic assessment was made by conventional anteroposterior scapular, lateral scapular, and axillary views.

The union was defined with the presence of a bridge callus in two views, and AVN was defined with loss of bony substance and presence of diffuse sclerotic area in the humeral head. Malunion was defined if there was a displacement of more than 5 mm or an angulation of more than 40 degrees of any fragment. The results were evaluated using the Constant Shoulder Scoring system [14].

Fig. 3a  An other LPHP was used as a template to identify the most distal screw hole Fig.3b a stab incision was made and a 2.0mm K-wire was inserted into the distal hole(b).

Results :

The mean operation time was 143.75±38.81min (range 80-240min). The mean hospital stay after surgery was 7.31±2.41days (range2-12 days). No local complications were observed. One patient was lost. Fifteen patients were followed-up with mean time of 6.1 months (range 5-14 months). All the fractures were united with mean duration of 14.85 weeks (range 8-19 weeks). The sensitivity of lateral shoulder is normal. There was no failure of internal fixation. No AVN has occurred yet. The latest visited result showed 120-170 degrees of active anterior flexion (average 150.42 degrees) of the shoulders (fig 4). According to Constant-Murley scoring system, the mean score of the shoulder was 76.82 points (range 59-89.5 points), 4 patients had excellent results, 5 good results, 6 moderate.


Discussion :

The anterolateral aspect of the shoulder is covered with the middle and anterior head of the deltoid muscles originated from the inferior surface of the lateral third of the clavicle, acromion and innervated by anterior branch of the axillary nerve. The axillary nerve arises from posterior cord of brachial plexus and passes through the quadrangular space in company with the posterior humeral circumflex artery and then divides into anterior and posterior branches. The anterior branch winds around the surgical neck of the humerus, beneath the deltoid, with averaged 22 degrees of angle superior to the perpendicular of the humerus axis. The anatomic studies have demonstrated that the anterior branch of the axillary nerve transverse the interval between the anterior and middle portions of deltoid muscle and the average distance from the undersurface of the acromion to the superior border of the nerve measured 63.3mm(range53.2-70.4) and the nerve can also elevated from the lateral cortical surface at least 10mm without placing tension on the nerve [11].

Therefore, when the anterolateral approach was applied to reduce and stabilize proximal humerus fractures, the length of the incision should be kept within 60 mm. Besides, when sub-deltoid muscle tunnel was prepared for pass through LPHP, the height of the tunnel should not exceed 10mm so that the axillary nerve could be protected from injury.

In our case series, when the patients were lastly visited, the sensory examination of the lateral arm was normal. The contour of the shoulder as well as the strength of the anterior and middle potion of the deltoid muscle were not significant affected, indicated that it is security to accomplish the reduction and fixation of the proximal humeral fractures through the small anterolateral shoulder incision.

Gardner et al [11] recommended the extended anterolateral incision in which the axillary nerve was first dissected and protected. We don not think that it is necessary to dissect the nerve only to avoid iatrogenic axillary nerve injury. It will increase the risk of nerve injury and take long operating time. In fact, in the first two patients, the nerve was carefully dissected and protected, but in remaining patients only the neurovascular bundle was partially exposed. According to Bono et al [15] , the distance from the lateral prominence of the greater tuberosity to the superior edge of axillary nerve was 35.5mm (range 32.1-42.5), and the distance from the surgical neck to the axillary nerve was 17 mm (range7-40 mm). This limits is large enough to reduce the fragments, drill the hole and insert four locking screw at the proximal plate.

In obese patient whose fractures were difficult to expose through the small incisions, the nerve should be dissected. In that condition, only the neurovascular bundle was exposed. There was no necessary to free the nerve completely. But for very fatty patient, the deltopectral approach was recommended.

We prefer to use the small elevator to prepare the sub-muscular tunnel and keep the tip of the elevator close to the cortical surface of lateral humerus so that the risk of the nerve injury was decreased. The periosteum beneath the nerve was stripped and the tip of the elevator was not exceeded about 5mm distal the nerve. The remaining part of the tunnel was prepared using LPHP.  

According to Horak et al [16], the majority of the proximal humerus fractures were the two part, the three and four part fractures represent 13% to 16% of all the fractures. Most of them could be reduced by indirect or close methods [4, 17, 18] except to the greater tuberosity, which could be reduced on the direct visualization through the incision. The Neer type IV fractures are associated with the impacted humeral head and widened joint space. Resch et al [3] recommended a method to reduce the head with an elevator advanced into the gap between the greater and lesser tuberosity and beneath the head and raised the impacted head. We reduced the impacted the humeral head using two 2.0mm K-wires drilled in the head after slightly distracting the displaced greater and lesser tuberosities toward lateral and medial side respectively. The impacted humeral head was then slowly elevated through the two K-wires while one assistant maintained the traction along the longitudinal axis of upper extremity. The elevated head was temporally fixed to the humeral shaft using one K-wire inserted from lateral side of humeral shaft or from the head. The displaced greater tuberosity was then reduced. The reduction of the lesser tuberosity was carried out by external rotation of the arm.  Under the assistant of image intensifier combined with direct and indirect reduction technique, the proximal humerus fractures even if the four part fractures could also be anatomically reduced through this small incision.

In comparison with the deltopectoral approach, open reduction and internal fixation of the proximal humeral fractures through the anterolateral access has advantages of small incision; more direct to expose the fractures, less damages to soft tissue and less time needed to expose the fracture. More importantly, it may reduce the damages to the blood supply to the fragments and thereby decrease the risk of avascular necrosis of humeral head. According to Hesmann et al [19], when the fracture was reduced indirectly the incidence of avascualr necrosis of humeral head is significant low. In our case series, all the procedures including the exposure and reduction of the fragments, introduction of the plate and screws adhere to the principles of minimal invasive techniques and therefore promoting the rehabilitation and the union of the bone.  In this case series, the mean operating time is 143.75minthe mean time of bone union is 14.85weeks and the mean time of hospitalization after surgery is 7.31days. The overall clinical results, with a mean Constant and Murley score of 76.82 points in patients with an average age of 45 years are comparable with the results reported by Frankhause et al[10,20]. None of our patients had a non-union and failure of implants.

LPHP is locking plate exclusively designed for treatment of proximal humerus fractures [21]. It is not necessary to mold the plate intraoperatively because the size and contour of the plate are matching with appearance of lateral aspect of the proximal humerus. The size of LPHP is small with thickness of only 2.0mm. The distal end of plate is taper-shaped so that it can be very easily inserted sub-muscularly and passed by fracture site at the epiphysis. It is a guarantee of MIPO technique and easier to apply .The reduction of the fragments of the proximal humerus could be firmly maintained with the angular stability between the locking screws and the proximal end of the plate. There are also 6 wire holes in the proximal end of the plats used to fix the small fragments of proximal humerus to the plate with sutures or wires when necessary. In this series, the four locking screws and three conventional screws were applied to the most proximal and distal screw holes on the plates leaving the others intact to avoid the nerve injury. If it necessary to insert the screws at these holes the percutaneous techniques were selected.


In this case series of proximal humerus fractures, the advantages of LPHP were adequately fulfilled. The fractures were exposed and reduced directly through the small incision. The distal end of the plate was positioned sub-muscularly and fixed to the humeral shaft with percutaneous screws orientated with a same LPHP as template. Obviously, it is LPHP that made the possibility to treat the proximal humerus fractures with open reduction and internal fixation through the anterolateral small incision in the shoulder. It should be a good method to apply LPHP through the small anterolateral incision of the shoulder to treat the proximal humerus fractures

Reference :

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2.         Ko JY, Yamamoto R. Surgical treatment of complex fracture of the proximal humerus. Clin Orthop Relat Res. 1996;(327): 225-37.

3.         Resch H, Povacz P, Frohlich R, Wambacher M. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br. 1997;79(2): 295-300.

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8.         Esser RD. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clinical Orthoppaedics and Related Research 1994;299: 244-245.

9.         Robinson C M, Page RS, Hill RMF, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J bone Joint Surg Am. 2003; 85-A: 1215-1223.

10. 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.

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12.     Gallo RA, Zeiders GJ, Altman GT. Two-incision technique for treatment os complex proximal humerus fractures. J Orthop Trauma 2005;19: 734-740.

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15.     Bono CM, Grossman MG, Hochwald N, Tornetta P 3rd.Radial and axillary nerves. Anatomic considerations for humeral fixation. Clin Orthop Relat Res. 2000;373: 259-64.

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19.     Hessmann M, Gotzen L, Gehling H, Baumgaertel F, Klingelhoeffer I.Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases. Acta Chir Belg. 1998;98(5):212-9.

20.     Bjorkenheim 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):741-5.

21.  Frigg R. development of the locking compression plate. Injury  (Suppl 2) 2003; 34:6-10.

This is a peer reviewed paper 

Please cite as : Geran An :The outcomes of treatment of the proximal humeral fractures with LPHP through a small skin incision on the anterolateral shoulder

J.Orthopaedics 2007;4(2)e3





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