Reducing Postoperative Fracture Displacement After Locked Plating of Proximal Humerus Fractures: Current Concepts

Techniques have been used to achieve subchondral purchase of locking screws while reducing iatrogenic articular perforation.⁶⁵ However, given the incidence of fracture settling and subsequent postoperative screw penetration, many authors currently recommend using shorter divergent screws combined with other augmentation techniques, described previously.^17,29,32

Physical Therapy

There is no standardized physiotherapy regimen for postoperative management of proximal humerus fractures treated with locking plates.²⁵ In older patients, immediate active range of motion (ROM) exercises should be delayed until early callus is noted, though there is a risk for stiffness. Lee and Shin⁵⁷ found that a delay in rehabilitation after ORIF was an independent risk for poor clinical outcome. Namdari and colleagues¹⁷ recommended sling use only for comfort and initiated non-load-bearing activities and pendulum exercises immediately after surgery. Patients with adequate reduction at 4 to 6 weeks were advanced to full weight-bearing. Badman and colleagues³⁰ initiated passive-assisted ROM exercises when the wound was healed at 2 weeks in 2-part fractures, whereas patients with 3- and 4-part fractures were immobilized until radiographic healing. Formal therapy was started after 6 weeks. Stiffness was reported in 5% of patients. For patients with stable fixation, Ricchetti and colleagues²⁹ recommended passive shoulder ROM exercises on postoperative day 1; at 4 to 6 weeks, patients should start active shoulder ROM exercises, and then resistance exercises at 10 to 12 weeks. Other authors are more conservative—only sling immobilization and pendulum exercises the first month.⁶⁶ Barlow and colleagues³² immobilized their patients (age, >75 years) for 6 weeks. No patient developed disabling stiffness. The authors suggested that patients older than 75 years may not be prone to stiffness.

Our Preferred Treatment Method

All proximal humerus fractures are approached anteriorly through the deltopectoral interval (Figure 3A). The long head biceps is identified and truncated for later tenodesis. Multiple No. 5 Ethibond sutures (Ethicon) are placed at the bone–tendon interface. The fracture is reduced with a Cobb elevator (Figure 3B), and provisional Kirschner wires are placed within the head (Figure 3C). The plate is affixed to the humeral head with its anterior border paralleling the posterior aspect of the bicipital groove. Multiple locking screws are placed within the superior and posterior humeral head. Nonlocking screws are then used to fix the plate to the shaft to reduce the specific deformity. Under fluoroscopy, any metaphyseal void is filled with calcium phosphate cement (Figure 3D). The remaining inferior screws are placed within the humeral head. Dr. Gruson uses screws 4 to 6 mm short of subchondral bone to reduce the risk for joint penetration. The rotator cuff sutures are tied down through the plate. Patients are started on progressive supine passive ROM exercises at 7 days, followed by supine active-assisted ROM exercises 6 weeks after fracture healing is confirmed radiographically.

Conclusion

Use of locked plating for proximal humerus fractures has increased, particularly in the elderly. Resulting complications include intra-articular screw penetration, postoperative fracture displacement, and AVN. Recognition of the importance of reducing and supporting the medial calcar, filling any metaphyseal defects, and selectively placing screws within the humeral head has lowered the incidence of these complications. Further comparative studies evaluating the efficacy of individual augmentation techniques are needed to determine their contribution to successful fracture healing and their cost-effectiveness. Results of such studies may help in the development of protocols for more standardized implementation of these techniques and in understanding which specific fracture patterns and patients would benefit from their use.