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Plate fixation for management of humerus fractures
S33 Injury, Int. J. Care Injured 49S1 (2018) S33–S38 Volume 49 Supplement 1 June 2018 ISSN 0020-1383
Contents lists available at ScienceDirect
Injury Plating of Fractures: current treatments and complications Guest Editors: Peter Augat and Sune Larsson
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y
Plate fixation for management of humerus fractures Lauren L. Nowaka,*, Niloofar Dehghanb, Michael D. McKeec, Emil H. Schemitschd a
Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada The CORE Institute, Banner University Medical Center; Phoenix, Arizona, USA Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA d Division of Orthopaedics, Department of Surgery, Western University, London, Canada b c
K E Y W O R D S
A B S T R A C T
Humeral fractures Plate fixation Open reduction internal fixation Proximal humerus fixation Distal humerus fixation Humeral shaft fixation
Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research. © 2018 Elsevier Ltd. All rights reserved.
Introduction
Proximal humerus fractures
Humerus fractures comprise approximately 8% of all adult fractures, and their incidence increases with age [1]. As such, comorbidities and bone quality can complicate clinical decisionmaking. These injuries represent a significant burden to the patients themselves, as well as the healthcare system. Humeral fractures can involve the proximal, shaft, or distal aspect of the bone, and management depends on the location of the fracture. The most common humeral fracture occurs in the proximal humerus. Accounting for approximately half of all humerus factures, these injuries are a common fragility fracture in older adults and remain one of the most controversial orthopaedic trauma injuries to treat. While there is more consistent evidence surrounding the management of humeral shaft and distal humerus fractures, there are still many issues to consider regarding optimal treatment. In all three humeral fracture types, open reduction and internal fixation (ORIF) is the most common surgical intervention. The objective of this paper is to summarize the fracture types most amenable to plate fixation, as well as challenges and considerations associated with each fracture type.
Representing the third most common fragility fracture in older adults, proximal humerus fractures are increasing in prevalence, and many clinical issues have yet to be clarified. Most proximal humerus fractures occur in patients above the age of 50 years, after a ground level fall. Due to the complexity of the shoulder joint, many factors influence functional recovery, including fracture type, displacement, patient age, bone quality, functional demands, pre-injury shoulder function and patient comorbidities. As such, there is significant controversy surrounding the management of these injuries. While the majority of proximal humerus fractures are treated nonoperatively, several operative treatment options exist. The most common operative procedure is open reduction and internal fixation with locked plating. Unfortunately, there are no undisputed set of indications for surgical treatment, and it remains unclear as to which fractures consistently benefit from plate fixation. Traditionally, indications for plating included displaced fracture types according to the Neer classification system [2]. However, the Neer classification system has been shown to have poor inter- and intra- rater reliability [3]. This is also the case with other classification systems that have been developed for proximal humerus fractures. As such, while “fracture type” may be a traditional indication for surgery, these are not consistently reported between studies or surgeons. Recently, increasing evidence from randomized controlled trials suggests that non-operative treatment offers comparable functional
* Corresponding author at: Institute of Medical Science, Faculty of Medicine, University of Toronto, 55 Queen St. East, STE 800, Toronto, Ontario, M5C 1R Canada E-mail address: [email protected] (L.L. Nowak). 0020-1383/© 2018 Elsevier Ltd. All rights reserved.
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Considerations
Fig. 1. Proximal humeral fracture in a 20-year-old male poly trauma patient with severe displacement, treated with open reduction and internal fixation with a locking plate.
results to operative treatment for even displaced fractures, while complication rates for ORIF still range up to 30% [4]. However, these randomized trials have had small sample sizes, and do not include all fractures. For example, the most recent and largest randomized trial comparing operative to non-operative treatment excluded patients with fracture dislocations, head-split fractures, fractures with no surgical neck involvement, and fractures for which there was a “clear indication for surgery” [5]. This likely indicates there are specific fracture types that may benefit from surgical management. Thus, the focus of research should shift from comparing different treatment modalities, towards identifying specific patients and fractures that would benefit from surgical intervention. Fractures which have been well-documented to have poor outcomes following non-operative treatment include: fracture dislocations, head-split fractures, varus angulation/displacement, and significant/complete head-shaft displacement (Fig. 1) [6]. In the older patient, such fractures may benefit from proximal humeral replacement over plating, due to a higher risk of fixation failure. However, plate fixation is the treatment of choice for younger, more active patients [7].
As a common osteoporotic fracture, the quality of bone must be considered. While locked plating has been shown to provide superior strength to conventional plating, there is still a risk of plate failure, intra articular screw penetration, screw cut out, or peri-implant fractures. Anatomic reduction is also important to reduce the risk of fixation failure. Care should be taken to restore medial support to the calcar, as this helps maintain reduction [12], and the use of a “calcar” screw is essential in preventing varus displacement (Fig. 1). The plate should be placed inferiorly enough to avoid impingement and aid in proper screw placement. Bone grafting can be used to improve outcomes in fractures with significant impaction and assist healing. A minimally invasive injectable graft has been shown to result in lower complications in one small randomized trial [13]. In elderly patients with osteoporotic bone and low functional demands who meet the criteria for surgical intervention, arthroplasty may be indicated. Complications Unfortunately, complication rates following ORIF have remained high. Reported complication rates two years following ORIF for proximal humerus fractures have ranged from 20–60% [14]. The most common complications following proximal humerus plating are: screw cut out and intra articular screws, tuberosity displacement or non-union, impingement, rotator cuff lesions, malunion or non-union, secondary displacement, osteonecrosis of the humeral head, posttraumatic osteoarthritis, screw loosening, heterotopic ossification, infection, and implant failure [14]. Risk factors for complications following ORIF for proximal humerus fractures include fracture-dislocations, smoking, obesity, increasing age, and comorbidities [15,16]. Specifically, risk factors for osteonecrosis include fracture-dislocation, disruption of medial hinge (calcar), and short metaphyseal head extension (<8 mm) [17]. Risk factors for screw cut out include increasing age, nonanatomic reduction of the calcar, fracture-dislocation, fracture type AO/OTA 11-C2 (impacted fracture with marked displacement) [18]. Conclusions
Prior to the introduction of locking plates, internal fixation was performed using a variety of implants, including tension-band wiring, trans-osseous suture fixation, and semi-tubular, buttress and cloverleaf plates. However, locking plate fixation may be more advantageous for osteoporotic bone [8]. When performing locking plate fixation, the insertion of inferomedial “calcar” screws has been shown to decrease varus displacement and provide better functional outcomes [9]. At present the use of polyaxial screws have not shown to have significant benefit compared to monoaxial screws [10].
Although there remains controversy among surgeons and researchers regarding which proximal humerus fractures benefit from operative treatment, there is some consensus for surgery over non-operative treatment for fracture dislocations, head-split fractures and fractures with significant head-shaft displacement. Where ORIF is performed, anatomic reduction, and medial support may improve outcomes. Nevertheless, complication rates following ORIF of proximal humerus fractures remain high, and more research is required to optimize the treatment of these injuries. Elderly patients with such fractures, who have osteoporotic bone or are lower demand, perform poorly with ORIF, and may benefit from arthroplasty instead.
Approach
Humeral shaft fractures
Open reduction and internal fixation of proximal humerus fractures can be achieved through a delto-pectoral, or a minimally invasive deltoid-splitting approach. While the delto-pectoral approach is extensile and the most commonly used approach, the deltoid-splitting approach was proposed to minimize extensive soft tissue trauma and allow better access to the posterior aspect of the humeral head, and especially the greater tuberosity. However, a recent randomized trial comparing the two approaches identified no difference in complication rates, functional scores, or re-operations between the two groups [11].
Humeral shaft fractures account for up to 3% of all orthopaedic injuries. While overall they are evenly distributed between males and females, they do have a bi-modal distribution with the majority of high-energy fractures occurring in young males ages 21–30, and low-energy fractures occurring in older women, ages 60–80 years. Unlike proximal humerus fractures, the OTA/AO classification of humeral shaft fractures has moderate inter-observer reliability [19]. The most common fracture type is type A (simple, including spiral, oblique or transverse fractures), followed by type B (including spiral wedge, bending wedge or fragmented wedge), and type C (complex,
Plate types
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Fig. 3. Open humeral shaft fracture with severe displacement treated with irrigation and debridement and plate fixation via an anterolateral approach.
The antero-lateral approach is extensile, and the preferred approach for middle and proximal third humeral shaft fractures requiring fixation, while the posterior approach is best utilized to expose the distal third of the humerus [25]. Minimally invasive plate osteosynthesis (MIPO) was developed to reduce soft-tissue damage during surgical repair. Recently, this technique has been shown to decrease the risk of iatrogenic radial nerve palsy, although proper reduction via this technique is difficult and requires experience [26]. Reduction of distal-third humeral shaft fractures may be more difficult using MIPO [27]. Plates
Fig. 2. Humeral shaft fracture in a poly-trauma patient with concomitant pelvic and lower extremity injuries. Given the multiple injuries and need for upper extremity ambulation, plate fixation was performed with a 4.5-mm compression plate following anatomic reduction. Immediate upper extremity weightbearing was allowed for mobilization with use of crutches.
including spiral, segmental or irregular) [20]. Most humeral shaft fractures are generally successfully managed with non-operative treatment. However, in some settings, operative treatment can be indicated. Operative treatment may be indicated in fractures with more than 30° of angulation (or other severe deformity), open or pathologic fractures, fractures of the proximal- or distal-third of the shaft, patients with poly-trauma or with ipsilateral brachial plexus or vascular injuries, and fractures with an inability to obtain or maintain reduction (Figs. 2 and 3) [21,22]. Furthermore, obese patients may not tolerate bracing, and may be candidates for surgical management. Operative treatment options include open reduction with plate fixation, which can be successfully performed with union rates as high as 98%, or intramedullary nailing (IMN) [23]. While IMN has been popular in the past, recent studies have reported higher rates of re-operation and insertion site morbidity following this method versus plate fixation for most humeral shaft fracture types; thus, plate fixation is considered the gold standard for operative treatment. Plating is also indicated in cases of failed non-operative treatment (such as mal- or non-union). However, some indications for IMN over plate fixation include pathologic fractures (malignant and osteoporotic) and extensive comminution or segmental injury.
Typically, humeral shaft fractures in patients with normal bone quality can be treated with traditional 4.5mm compression plates (either narrow or broad, depending on the size of patient), with 3 bicortical screws placed on either side of the fracture (Fig. 2). The use of 3.5-mm compression plates in normal sized adults can lead to failure and should be avoided. Fractures with significant comminution may benefit from bridge plating techniques, while patients with poor bone quality may achieve better results with locked plating [28]. Fractures with proximal extension may require a proximal humeral plate (Fig. 3); while dual plating of distal third humeral shaft fractures may be required, if adequate fixation with a single plate is not possible. Considerations Anatomic reduction should be attempted, correcting any angular deformity and maximizing cortical contact. Fortunately, there is little functional effect of bone shortening of up to 3 cm on outcomes, and as such, some shortening and malunion can be well tolerated by the patient. Care must be taken during the procedure to visualize and protect the radial nerve, as radial nerve palsy is one of the most serious complications following plate fixation of humeral shaft fractures. Poor bone quality may result in inadequate strength for stable fixation by plates and screws, which may lead to screw cut out and fixation failure. In such cases, intramedullary nailing may be a better alternative [29]. If plate fixation is chosen, plates used on the distal and proximal portions of the humeral shaft should be properly contoured to fit the bony anatomy. Complications
Approach The optimal surgical approach for plating humeral shaft fractures will depend on the location of the fracture [24]. There are two commonly used surgical approaches, posterior and antero-lateral.
The rate of complications following plate fixation of these fractures is high and has been reported as high as 30% [30]. Most common complications include radial nerve injury, infection, nonunion and shoulder impingement [31]. Modifiable risk factors for
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complications or poor outcomes following plate fixation of humeral shaft fractures include smoking, use of NSAIDs, and obesity. Nonmodifiable risk factors for complications include advanced age, comorbidities, and fractures of the distal third of the humerus [32]. The risk of radial nerve injury is proportional to the energy of the trauma and increases with increasing age [25]. Conclusions In conclusion, while most humeral shaft fractures tolerate nonoperative treatment, there are certain indications for surgery. These include those with a significant gap between fracture fragments, fractures with more than 30° of angulation, proximal third oblique fractures, open or pathologic fractures, fractures of the proximal- or distal-third of the shaft, patients with poly-trauma, or those with ipsilateral brachial plexus or vascular injuries. The surgical approach will depend on the location of the fracture, and the choice of plate will depend on both the type of fracture and quality of bone. During the procedure, care should be taken to protect the radial nerve. If the bone quality of the patient is poor, intramedullary nailing may be preferred. More research is required to determine the role of dual plating for humeral shaft fractures. Distal humerus fractures Distal humerus fractures are the rarest type of humerus fracture and represent a challenge to treat due to the complex geometry of the distal humerus. Similar to humeral shaft fractures, distal humerus fractures have a bimodal distribution, with peaks in young males 12–19 years, and older females, 80 years and older [33]. Most low energy distal humerus fractures are the result of a ground level fall in elderly females, while motor vehicle accidents are a common cause of these injuries in the younger male population [34]. The majority of distal humerus fractures are intra-articular, and compared to other humeral fractures, there is a higher percentage of open fractures [20]. The most common classification system used for distal humerus fractures is the OTA/AO classification, although there are no studies evaluating its reproducibility [35]. Type A fractures are extra-articular (including avulsion, simple and multi-fragmentary); type B fractures are partial articular (including lateral sagittal, medial sagittal and frontal); and type C fractures are complete articular (including simple, metaphyseal comminution, or multi-fragmentary). The most common fracture type is Type A, followed by type C, and type B [20]. The risk of functional disability following non-operative treatment has been shown to be quite high, and therefore operative management is generally accepted as the gold standard for juxtaarticular and intra-articular distal humerus fractures. However, some residual disability, including stiffness and weakness, may persist despite technically successful surgery [36]. Open reduction with dual plate fixation is the most common surgical procedure for treating these injuries. Restoration of satisfactory elbow function relies on anatomic reconstruction of the articular surface and stable fixation of all fracture fragments. Total elbow arthroplasty may be indicated in elderly (>65 years of age) patients with comminuted intra-articular fractures with low demand or sedentary lifestyles [37]. Plate fixation Plates should be contoured to fit the anatomy of the distal humerus and pre-contoured plates may be very helpful. There is some debate surrounding the use of locking plates for distal humerus fractures. While locking plates have been shown to provide better stability for other fractures in patients with lower bone quality, there is a lack of conclusive clinical evidence surrounding
Fig. 4. A transcondylar distal humerus fracture in elderly female patient following a ground level fall. The fracture was amendable to dual plate fixation (parallel plating with a triceps sparing technique).
their use specifically in distal humerus fracture patients [38–40]. The standard fixation technique is dual plating with use of plates on both medial and lateral columns, either placed perpendicular or parallel to each other (Fig. 4). While some biomechanical studies have shown improved stability with parallel plating [41] a recent randomized trial found no statistically significant results in clinical outcomes or complication rates between the two techniques, and further prospective clinical studies are required [42]. Approach The posterior approach is generally agreed to have the best exposure of both columns of the distal part of the humerus as well as the articular surface for intra-articular fractures. This can be performed via an olecranon osteotomy, triceps splitting, or triceps sparing approaches. Medial and lateral approaches can be utilized for partial articular fractures, although these are much less common in adults. The olecranon osteotomy has been the most widely used posterior technique and remains the approach of choice for most complex articular fractures amenable to dual plating when maximum visualization is required. Triceps splitting, reflecting and sparing approaches were developed to minimize the morbidity associated with olecranon osteotomy. The triceps-reflecting anconeous pedicle, or TRAP approach described by O’Driscoll provides visualization of the whole distal humerus [43]. With this technique, the triceps is completely detached and may be at risk of later detachment or weakness. One retrospective study described slightly better functional outcomes and fewer complications with this technique compared with olecranon osteotomy, but prospective studies are required [44]. The triceps reflecting postero-medial approach was described by Bryan and Morrey. The literature surrounding this approach has been mixed when compared with olecranon osteotomy, and well-designed prospective studies are required [45,46]. The triceps sparing paratricipital technique described by Alonso-Llames does not disrupt the tendon insertion, therefore allowing early active range of motion. Compared to a triceps splitting
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approach, this technique has been shown to result in better elbow ROM and triceps strength following plate fixation of extra-articular distal humerus fractures [47]. The triceps splitting approach may be advantageous in the setting of an open distal humeral fracture: in this situation the wound is typically posterior, created as the shaft drives out through the triceps and skin. Incorporating the triceps defect into a triceps split approach makes intrinsic sense and causes less overall impairment of the extensor mechanism. In retrospective studies, the triceps splitting approach has been shown to provide similar functional outcomes when compared with olecranon osteotomy for closed fractures, and better functional outcomes when compared with olecranon osteotomy for open fractures, but prospective studies are required [48,49]. Considerations Care should be taken to identify and release the ulnar nerve at the beginning of the procedure, to reduce the risk of its injury during hardware insertion [34]. The ulnar nerve can be left in-situ at the end of the procedure, or transposed, based on surgeon preference; as a recently presented randomized controlled study reported no differences in outcomes between the two techniques [50]. As with proximal humerus fractures, anatomic reconstruction is important to minimize fixation failure. Stability should be maximized between the distal fragments and the humeral shaft. Patients with poor bone quality may lack the stability required for plate fixation. In patients over age 65 with complex intra-articular fractures, arthroplasty options should be considered, and readily available in the operating room. In these situations, an olecranon osteotomy approach should be avoided, to allow for intra-operative conversion to arthroplasty if the bone quality is judged to be too poor for successful fixation. Complications Outcomes following treatment of distal humerus fractures are typically ‘good” but not “perfect”. The average patient has a flexion extension arc of approximately 100°, a flexion contracture of 20–25°, 75–80% of extension and flexion strength, some pain with heavy exertion, and a low rate of clinically significant posttraumatic arthritis. However, complication rates following plate fixation of distal humerus fractures have been reported to be as high as 44% [51]. The most common complications following operative treatment of these injuries are ulnar nerve dysfunction, hardware irritation, non-union, heterotopic ossification, elbow stiffness, and infection. Non-modifiable risk factors for complications following plate fixation of distal humerus fractures include increasing age, poor bone quality, comorbidities, open fractures, and associated neurovascular injury [52]. Modifiable risk factors for complications have been reported to be smoking, obesity and alcohol abuse. There is conflicting evidence whether time to surgery influences the risk of complications. Conclusions Distal humerus fractures are the least common type of humeral fractures and can represent a challenge to treat. While the gold standard treatment for intra-articular distal humerus fractures is ORIF with dual plates, there is controversy surrounding the optimal surgical approach, as well as plate configuration. Total elbow arthroplasty may be best reserved for elderly low-demand patients with comminuted intraarticular fractures. As with other humerus fracture types, age, comorbidities, and poor bone quality may increase the risk of complications. Further research is required to determine the optimal surgical approach, and plate configuration.
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Summary Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in young or elderly patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. Humeral shaft fractures are generally treated non-operatively; however, certain fractures warrant plate fixation: such as those with more than 30° of angulation or other severe deformity, open fractures, and poly-trauma patients. The majority of intra-articular distal humerus fractures are treated with dual plate fixation, while total elbow arthroplasty remains an option for elderly low demand patients with comminuted intraarticular fractures. Further research is warranted to help identity indications for surgery in proximal humerus and humeral shaft fractures. Controversies in distal humerus fractures include optimal plate positioning and approach, and further studies in these areas are also warranted. Disclosure EHS and MDM receive royalties from Stryker for the development of elbow implants. Acknowledgment The authors of this manuscript express their thanks to the Osteosynthesis and Trauma Care Foundation for the sponsorship of the publication of this Supplement in Injury. References [1] Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br 2001;83(6):799–804. [2] Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52(6):1077–1089. [3] Papakonstantinou MK, Hart MJ, Farrugia R, et al. Interobserver agreement of Neer and AO classifications for proximal humeral fractures. ANZ J Surg 2016;86(4):280–284. [4] Handoll H, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015;12(11). [5] Handoll H, Brealey S, Rangan A, et al. The ProFHer (PROximal fracture of the humerus: Evaluation by randomisation) trial. A pragmatic multicentre randomized controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for pro. Health Technol Assess (Rockv) 2015;19(24):1–279. [6] Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Jt Surg Br 2011;9393(1):1–11. [7] Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced threeand four-part proximal humerus fractures. J Orthop Trauma. 2010;24(4):250–254. [8] Weinstein DM, Bratton DR, Ciccone WJ, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elb Surg 2006;15(2):239–243. [9] Erdoğan M, Desteli EE, İmren Y, Üztürk A, Kılıç M, Sezgin H. The effect of inferomedial screw on postoperative shoulder function and mechanical alignment in proximal humerus fractures. Eur J Orthop Surg Traumatol 2014;24(7):1055–1059. [10] Ockert B, Braunstein V, Kirchhoff C, et al. Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: radiographic analysis of a prospective randomized study. J Trauma 2010;69(6):1545–1551. [11] Buecking B, Mohr J, Bockmann B, Zettl R. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res 2014;(1):1576–1585. [12] Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185–191. [13] Liu Z, Zhang G, Ge T. Use of a proximal humeral internal locking system enhanced by injectable graft for minimally invasive treatment of osteoporotic proximal humeral fractures in elderly patients. Orthop Surg 2011;3(4):253–258. [14] Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013;7(1):34. [15] Petrigliano FA, Bezrukov N, Gamradt SC, SooHoo NF. Factors predicting complication and reoperation rates following surgical fixation of proximal humeral
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[36] Zohman G. Distal humerus intra-articular fractures: open reduction internal fixation. In: Master techniques in orthopaedic surgery: fractures. Philadelphia: Lippincott Williams & Wilkin; 2012. [37] McKee MD, Veillette CJH, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elb Surg 2009;18(1):3–12. [38] Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma 2008;22(2):113–120. [39] Korner J, Diederichs G, Arzdorf M, et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004;18(5):286–293. [40] Caravaggi P, Laratta JL, Yoon RS, et al. Internal fixation of the distal humerus: a comprehensive biomechanical study evaluating current fixation techniques. J Orthop Trauma 2014;28(4):222–226. [41] Schemitsch EH, Tencer AF, Henley MB. Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8(6):468–475. [42] Lee SK, Kim KJ, Park KH, Choy WS. A comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial. Eur J Orthop Surg Traumatol 2014;24(7):1123–1131. [43] O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am 2000;31(1):91–101. [44] Azboy İ, Bulut M, Ancar C, et al. The comparison of triceps-reflecting anconeus pedicle and olecranon osteotomy approaches in the treatment of intercondylar fractures of the humerus. Ulus Travma Acil Cerrahi Derg 2016;22(1):58–65. [45] Chen G, Liao Q, Luo W, Li K, Zhao Y, Zhong D. Triceps-sparing versus olecranon osteotomy for ORIF: Analysis of 67 cases of intercondylar fractures of the distal humerus. Injury 2011;42(4):366–370. [46] Zhang C, Zhong B, Luo CF. Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: Six years clinical experience with both the triceps-sparing approach and olecranon osteotomy. Arch Orthop Trauma Surg 2014;134(6):803–811. [47] Illical EM, Farrell DJ, Siska PA, Evans AR, Gruen GS, Tarkin IS. Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures. Injury 2014;45:1545–1548. [48] McKee MD, Kim J, Kebaish K, Stephen DJ, Kreder HJ, Schemitsch EH. Functional outcome after open supracondylar fractures of the humerus. The effect of the surgical approach. J Bone Joint Surg Br 2000;82(5):646–651. [49] McKee MD, Wilson TL, Winston L, Schemitsch EH, Richards RR. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Jt Surg Am 2000;82-A(12):1701–1707. [50] Schemitsch E, Dehghan N, Vicente M, Nauth A, Hall JA, McKee MD. Simple decompression vs anterior transposition of the ulnar nerve for distal humerus fractures treated with plate fixation – a multi centre randomized controlled trial presented at the American Academy of Orthopaedic Surgeons Annual Meeting; 2017. [51] Obert L, Ferrier M, Jacquot A, et al. Distal humerus fractures in patients over 65: complications. Orthop Traumatol Surg Res 2013;99(8):909–913. [52] Pajarinen J, Björkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: Results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elb Surg 2002;11(1):48–52.
Contents lists available at ScienceDirect
Injury Plating of Fractures: current treatments and complications Guest Editors: Peter Augat and Sune Larsson
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y
Plate fixation for management of humerus fractures Lauren L. Nowaka,*, Niloofar Dehghanb, Michael D. McKeec, Emil H. Schemitschd a
Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada The CORE Institute, Banner University Medical Center; Phoenix, Arizona, USA Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA d Division of Orthopaedics, Department of Surgery, Western University, London, Canada b c
K E Y W O R D S
A B S T R A C T
Humeral fractures Plate fixation Open reduction internal fixation Proximal humerus fixation Distal humerus fixation Humeral shaft fixation
Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research. © 2018 Elsevier Ltd. All rights reserved.
Introduction
Proximal humerus fractures
Humerus fractures comprise approximately 8% of all adult fractures, and their incidence increases with age [1]. As such, comorbidities and bone quality can complicate clinical decisionmaking. These injuries represent a significant burden to the patients themselves, as well as the healthcare system. Humeral fractures can involve the proximal, shaft, or distal aspect of the bone, and management depends on the location of the fracture. The most common humeral fracture occurs in the proximal humerus. Accounting for approximately half of all humerus factures, these injuries are a common fragility fracture in older adults and remain one of the most controversial orthopaedic trauma injuries to treat. While there is more consistent evidence surrounding the management of humeral shaft and distal humerus fractures, there are still many issues to consider regarding optimal treatment. In all three humeral fracture types, open reduction and internal fixation (ORIF) is the most common surgical intervention. The objective of this paper is to summarize the fracture types most amenable to plate fixation, as well as challenges and considerations associated with each fracture type.
Representing the third most common fragility fracture in older adults, proximal humerus fractures are increasing in prevalence, and many clinical issues have yet to be clarified. Most proximal humerus fractures occur in patients above the age of 50 years, after a ground level fall. Due to the complexity of the shoulder joint, many factors influence functional recovery, including fracture type, displacement, patient age, bone quality, functional demands, pre-injury shoulder function and patient comorbidities. As such, there is significant controversy surrounding the management of these injuries. While the majority of proximal humerus fractures are treated nonoperatively, several operative treatment options exist. The most common operative procedure is open reduction and internal fixation with locked plating. Unfortunately, there are no undisputed set of indications for surgical treatment, and it remains unclear as to which fractures consistently benefit from plate fixation. Traditionally, indications for plating included displaced fracture types according to the Neer classification system [2]. However, the Neer classification system has been shown to have poor inter- and intra- rater reliability [3]. This is also the case with other classification systems that have been developed for proximal humerus fractures. As such, while “fracture type” may be a traditional indication for surgery, these are not consistently reported between studies or surgeons. Recently, increasing evidence from randomized controlled trials suggests that non-operative treatment offers comparable functional
* Corresponding author at: Institute of Medical Science, Faculty of Medicine, University of Toronto, 55 Queen St. East, STE 800, Toronto, Ontario, M5C 1R Canada E-mail address: [email protected] (L.L. Nowak). 0020-1383/© 2018 Elsevier Ltd. All rights reserved.
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Considerations
Fig. 1. Proximal humeral fracture in a 20-year-old male poly trauma patient with severe displacement, treated with open reduction and internal fixation with a locking plate.
results to operative treatment for even displaced fractures, while complication rates for ORIF still range up to 30% [4]. However, these randomized trials have had small sample sizes, and do not include all fractures. For example, the most recent and largest randomized trial comparing operative to non-operative treatment excluded patients with fracture dislocations, head-split fractures, fractures with no surgical neck involvement, and fractures for which there was a “clear indication for surgery” [5]. This likely indicates there are specific fracture types that may benefit from surgical management. Thus, the focus of research should shift from comparing different treatment modalities, towards identifying specific patients and fractures that would benefit from surgical intervention. Fractures which have been well-documented to have poor outcomes following non-operative treatment include: fracture dislocations, head-split fractures, varus angulation/displacement, and significant/complete head-shaft displacement (Fig. 1) [6]. In the older patient, such fractures may benefit from proximal humeral replacement over plating, due to a higher risk of fixation failure. However, plate fixation is the treatment of choice for younger, more active patients [7].
As a common osteoporotic fracture, the quality of bone must be considered. While locked plating has been shown to provide superior strength to conventional plating, there is still a risk of plate failure, intra articular screw penetration, screw cut out, or peri-implant fractures. Anatomic reduction is also important to reduce the risk of fixation failure. Care should be taken to restore medial support to the calcar, as this helps maintain reduction [12], and the use of a “calcar” screw is essential in preventing varus displacement (Fig. 1). The plate should be placed inferiorly enough to avoid impingement and aid in proper screw placement. Bone grafting can be used to improve outcomes in fractures with significant impaction and assist healing. A minimally invasive injectable graft has been shown to result in lower complications in one small randomized trial [13]. In elderly patients with osteoporotic bone and low functional demands who meet the criteria for surgical intervention, arthroplasty may be indicated. Complications Unfortunately, complication rates following ORIF have remained high. Reported complication rates two years following ORIF for proximal humerus fractures have ranged from 20–60% [14]. The most common complications following proximal humerus plating are: screw cut out and intra articular screws, tuberosity displacement or non-union, impingement, rotator cuff lesions, malunion or non-union, secondary displacement, osteonecrosis of the humeral head, posttraumatic osteoarthritis, screw loosening, heterotopic ossification, infection, and implant failure [14]. Risk factors for complications following ORIF for proximal humerus fractures include fracture-dislocations, smoking, obesity, increasing age, and comorbidities [15,16]. Specifically, risk factors for osteonecrosis include fracture-dislocation, disruption of medial hinge (calcar), and short metaphyseal head extension (<8 mm) [17]. Risk factors for screw cut out include increasing age, nonanatomic reduction of the calcar, fracture-dislocation, fracture type AO/OTA 11-C2 (impacted fracture with marked displacement) [18]. Conclusions
Prior to the introduction of locking plates, internal fixation was performed using a variety of implants, including tension-band wiring, trans-osseous suture fixation, and semi-tubular, buttress and cloverleaf plates. However, locking plate fixation may be more advantageous for osteoporotic bone [8]. When performing locking plate fixation, the insertion of inferomedial “calcar” screws has been shown to decrease varus displacement and provide better functional outcomes [9]. At present the use of polyaxial screws have not shown to have significant benefit compared to monoaxial screws [10].
Although there remains controversy among surgeons and researchers regarding which proximal humerus fractures benefit from operative treatment, there is some consensus for surgery over non-operative treatment for fracture dislocations, head-split fractures and fractures with significant head-shaft displacement. Where ORIF is performed, anatomic reduction, and medial support may improve outcomes. Nevertheless, complication rates following ORIF of proximal humerus fractures remain high, and more research is required to optimize the treatment of these injuries. Elderly patients with such fractures, who have osteoporotic bone or are lower demand, perform poorly with ORIF, and may benefit from arthroplasty instead.
Approach
Humeral shaft fractures
Open reduction and internal fixation of proximal humerus fractures can be achieved through a delto-pectoral, or a minimally invasive deltoid-splitting approach. While the delto-pectoral approach is extensile and the most commonly used approach, the deltoid-splitting approach was proposed to minimize extensive soft tissue trauma and allow better access to the posterior aspect of the humeral head, and especially the greater tuberosity. However, a recent randomized trial comparing the two approaches identified no difference in complication rates, functional scores, or re-operations between the two groups [11].
Humeral shaft fractures account for up to 3% of all orthopaedic injuries. While overall they are evenly distributed between males and females, they do have a bi-modal distribution with the majority of high-energy fractures occurring in young males ages 21–30, and low-energy fractures occurring in older women, ages 60–80 years. Unlike proximal humerus fractures, the OTA/AO classification of humeral shaft fractures has moderate inter-observer reliability [19]. The most common fracture type is type A (simple, including spiral, oblique or transverse fractures), followed by type B (including spiral wedge, bending wedge or fragmented wedge), and type C (complex,
Plate types
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Fig. 3. Open humeral shaft fracture with severe displacement treated with irrigation and debridement and plate fixation via an anterolateral approach.
The antero-lateral approach is extensile, and the preferred approach for middle and proximal third humeral shaft fractures requiring fixation, while the posterior approach is best utilized to expose the distal third of the humerus [25]. Minimally invasive plate osteosynthesis (MIPO) was developed to reduce soft-tissue damage during surgical repair. Recently, this technique has been shown to decrease the risk of iatrogenic radial nerve palsy, although proper reduction via this technique is difficult and requires experience [26]. Reduction of distal-third humeral shaft fractures may be more difficult using MIPO [27]. Plates
Fig. 2. Humeral shaft fracture in a poly-trauma patient with concomitant pelvic and lower extremity injuries. Given the multiple injuries and need for upper extremity ambulation, plate fixation was performed with a 4.5-mm compression plate following anatomic reduction. Immediate upper extremity weightbearing was allowed for mobilization with use of crutches.
including spiral, segmental or irregular) [20]. Most humeral shaft fractures are generally successfully managed with non-operative treatment. However, in some settings, operative treatment can be indicated. Operative treatment may be indicated in fractures with more than 30° of angulation (or other severe deformity), open or pathologic fractures, fractures of the proximal- or distal-third of the shaft, patients with poly-trauma or with ipsilateral brachial plexus or vascular injuries, and fractures with an inability to obtain or maintain reduction (Figs. 2 and 3) [21,22]. Furthermore, obese patients may not tolerate bracing, and may be candidates for surgical management. Operative treatment options include open reduction with plate fixation, which can be successfully performed with union rates as high as 98%, or intramedullary nailing (IMN) [23]. While IMN has been popular in the past, recent studies have reported higher rates of re-operation and insertion site morbidity following this method versus plate fixation for most humeral shaft fracture types; thus, plate fixation is considered the gold standard for operative treatment. Plating is also indicated in cases of failed non-operative treatment (such as mal- or non-union). However, some indications for IMN over plate fixation include pathologic fractures (malignant and osteoporotic) and extensive comminution or segmental injury.
Typically, humeral shaft fractures in patients with normal bone quality can be treated with traditional 4.5mm compression plates (either narrow or broad, depending on the size of patient), with 3 bicortical screws placed on either side of the fracture (Fig. 2). The use of 3.5-mm compression plates in normal sized adults can lead to failure and should be avoided. Fractures with significant comminution may benefit from bridge plating techniques, while patients with poor bone quality may achieve better results with locked plating [28]. Fractures with proximal extension may require a proximal humeral plate (Fig. 3); while dual plating of distal third humeral shaft fractures may be required, if adequate fixation with a single plate is not possible. Considerations Anatomic reduction should be attempted, correcting any angular deformity and maximizing cortical contact. Fortunately, there is little functional effect of bone shortening of up to 3 cm on outcomes, and as such, some shortening and malunion can be well tolerated by the patient. Care must be taken during the procedure to visualize and protect the radial nerve, as radial nerve palsy is one of the most serious complications following plate fixation of humeral shaft fractures. Poor bone quality may result in inadequate strength for stable fixation by plates and screws, which may lead to screw cut out and fixation failure. In such cases, intramedullary nailing may be a better alternative [29]. If plate fixation is chosen, plates used on the distal and proximal portions of the humeral shaft should be properly contoured to fit the bony anatomy. Complications
Approach The optimal surgical approach for plating humeral shaft fractures will depend on the location of the fracture [24]. There are two commonly used surgical approaches, posterior and antero-lateral.
The rate of complications following plate fixation of these fractures is high and has been reported as high as 30% [30]. Most common complications include radial nerve injury, infection, nonunion and shoulder impingement [31]. Modifiable risk factors for
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complications or poor outcomes following plate fixation of humeral shaft fractures include smoking, use of NSAIDs, and obesity. Nonmodifiable risk factors for complications include advanced age, comorbidities, and fractures of the distal third of the humerus [32]. The risk of radial nerve injury is proportional to the energy of the trauma and increases with increasing age [25]. Conclusions In conclusion, while most humeral shaft fractures tolerate nonoperative treatment, there are certain indications for surgery. These include those with a significant gap between fracture fragments, fractures with more than 30° of angulation, proximal third oblique fractures, open or pathologic fractures, fractures of the proximal- or distal-third of the shaft, patients with poly-trauma, or those with ipsilateral brachial plexus or vascular injuries. The surgical approach will depend on the location of the fracture, and the choice of plate will depend on both the type of fracture and quality of bone. During the procedure, care should be taken to protect the radial nerve. If the bone quality of the patient is poor, intramedullary nailing may be preferred. More research is required to determine the role of dual plating for humeral shaft fractures. Distal humerus fractures Distal humerus fractures are the rarest type of humerus fracture and represent a challenge to treat due to the complex geometry of the distal humerus. Similar to humeral shaft fractures, distal humerus fractures have a bimodal distribution, with peaks in young males 12–19 years, and older females, 80 years and older [33]. Most low energy distal humerus fractures are the result of a ground level fall in elderly females, while motor vehicle accidents are a common cause of these injuries in the younger male population [34]. The majority of distal humerus fractures are intra-articular, and compared to other humeral fractures, there is a higher percentage of open fractures [20]. The most common classification system used for distal humerus fractures is the OTA/AO classification, although there are no studies evaluating its reproducibility [35]. Type A fractures are extra-articular (including avulsion, simple and multi-fragmentary); type B fractures are partial articular (including lateral sagittal, medial sagittal and frontal); and type C fractures are complete articular (including simple, metaphyseal comminution, or multi-fragmentary). The most common fracture type is Type A, followed by type C, and type B [20]. The risk of functional disability following non-operative treatment has been shown to be quite high, and therefore operative management is generally accepted as the gold standard for juxtaarticular and intra-articular distal humerus fractures. However, some residual disability, including stiffness and weakness, may persist despite technically successful surgery [36]. Open reduction with dual plate fixation is the most common surgical procedure for treating these injuries. Restoration of satisfactory elbow function relies on anatomic reconstruction of the articular surface and stable fixation of all fracture fragments. Total elbow arthroplasty may be indicated in elderly (>65 years of age) patients with comminuted intra-articular fractures with low demand or sedentary lifestyles [37]. Plate fixation Plates should be contoured to fit the anatomy of the distal humerus and pre-contoured plates may be very helpful. There is some debate surrounding the use of locking plates for distal humerus fractures. While locking plates have been shown to provide better stability for other fractures in patients with lower bone quality, there is a lack of conclusive clinical evidence surrounding
Fig. 4. A transcondylar distal humerus fracture in elderly female patient following a ground level fall. The fracture was amendable to dual plate fixation (parallel plating with a triceps sparing technique).
their use specifically in distal humerus fracture patients [38–40]. The standard fixation technique is dual plating with use of plates on both medial and lateral columns, either placed perpendicular or parallel to each other (Fig. 4). While some biomechanical studies have shown improved stability with parallel plating [41] a recent randomized trial found no statistically significant results in clinical outcomes or complication rates between the two techniques, and further prospective clinical studies are required [42]. Approach The posterior approach is generally agreed to have the best exposure of both columns of the distal part of the humerus as well as the articular surface for intra-articular fractures. This can be performed via an olecranon osteotomy, triceps splitting, or triceps sparing approaches. Medial and lateral approaches can be utilized for partial articular fractures, although these are much less common in adults. The olecranon osteotomy has been the most widely used posterior technique and remains the approach of choice for most complex articular fractures amenable to dual plating when maximum visualization is required. Triceps splitting, reflecting and sparing approaches were developed to minimize the morbidity associated with olecranon osteotomy. The triceps-reflecting anconeous pedicle, or TRAP approach described by O’Driscoll provides visualization of the whole distal humerus [43]. With this technique, the triceps is completely detached and may be at risk of later detachment or weakness. One retrospective study described slightly better functional outcomes and fewer complications with this technique compared with olecranon osteotomy, but prospective studies are required [44]. The triceps reflecting postero-medial approach was described by Bryan and Morrey. The literature surrounding this approach has been mixed when compared with olecranon osteotomy, and well-designed prospective studies are required [45,46]. The triceps sparing paratricipital technique described by Alonso-Llames does not disrupt the tendon insertion, therefore allowing early active range of motion. Compared to a triceps splitting
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approach, this technique has been shown to result in better elbow ROM and triceps strength following plate fixation of extra-articular distal humerus fractures [47]. The triceps splitting approach may be advantageous in the setting of an open distal humeral fracture: in this situation the wound is typically posterior, created as the shaft drives out through the triceps and skin. Incorporating the triceps defect into a triceps split approach makes intrinsic sense and causes less overall impairment of the extensor mechanism. In retrospective studies, the triceps splitting approach has been shown to provide similar functional outcomes when compared with olecranon osteotomy for closed fractures, and better functional outcomes when compared with olecranon osteotomy for open fractures, but prospective studies are required [48,49]. Considerations Care should be taken to identify and release the ulnar nerve at the beginning of the procedure, to reduce the risk of its injury during hardware insertion [34]. The ulnar nerve can be left in-situ at the end of the procedure, or transposed, based on surgeon preference; as a recently presented randomized controlled study reported no differences in outcomes between the two techniques [50]. As with proximal humerus fractures, anatomic reconstruction is important to minimize fixation failure. Stability should be maximized between the distal fragments and the humeral shaft. Patients with poor bone quality may lack the stability required for plate fixation. In patients over age 65 with complex intra-articular fractures, arthroplasty options should be considered, and readily available in the operating room. In these situations, an olecranon osteotomy approach should be avoided, to allow for intra-operative conversion to arthroplasty if the bone quality is judged to be too poor for successful fixation. Complications Outcomes following treatment of distal humerus fractures are typically ‘good” but not “perfect”. The average patient has a flexion extension arc of approximately 100°, a flexion contracture of 20–25°, 75–80% of extension and flexion strength, some pain with heavy exertion, and a low rate of clinically significant posttraumatic arthritis. However, complication rates following plate fixation of distal humerus fractures have been reported to be as high as 44% [51]. The most common complications following operative treatment of these injuries are ulnar nerve dysfunction, hardware irritation, non-union, heterotopic ossification, elbow stiffness, and infection. Non-modifiable risk factors for complications following plate fixation of distal humerus fractures include increasing age, poor bone quality, comorbidities, open fractures, and associated neurovascular injury [52]. Modifiable risk factors for complications have been reported to be smoking, obesity and alcohol abuse. There is conflicting evidence whether time to surgery influences the risk of complications. Conclusions Distal humerus fractures are the least common type of humeral fractures and can represent a challenge to treat. While the gold standard treatment for intra-articular distal humerus fractures is ORIF with dual plates, there is controversy surrounding the optimal surgical approach, as well as plate configuration. Total elbow arthroplasty may be best reserved for elderly low-demand patients with comminuted intraarticular fractures. As with other humerus fracture types, age, comorbidities, and poor bone quality may increase the risk of complications. Further research is required to determine the optimal surgical approach, and plate configuration.
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Summary Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in young or elderly patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. Humeral shaft fractures are generally treated non-operatively; however, certain fractures warrant plate fixation: such as those with more than 30° of angulation or other severe deformity, open fractures, and poly-trauma patients. The majority of intra-articular distal humerus fractures are treated with dual plate fixation, while total elbow arthroplasty remains an option for elderly low demand patients with comminuted intraarticular fractures. Further research is warranted to help identity indications for surgery in proximal humerus and humeral shaft fractures. Controversies in distal humerus fractures include optimal plate positioning and approach, and further studies in these areas are also warranted. Disclosure EHS and MDM receive royalties from Stryker for the development of elbow implants. Acknowledgment The authors of this manuscript express their thanks to the Osteosynthesis and Trauma Care Foundation for the sponsorship of the publication of this Supplement in Injury. References [1] Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br 2001;83(6):799–804. [2] Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52(6):1077–1089. [3] Papakonstantinou MK, Hart MJ, Farrugia R, et al. Interobserver agreement of Neer and AO classifications for proximal humeral fractures. ANZ J Surg 2016;86(4):280–284. [4] Handoll H, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015;12(11). [5] Handoll H, Brealey S, Rangan A, et al. The ProFHer (PROximal fracture of the humerus: Evaluation by randomisation) trial. A pragmatic multicentre randomized controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for pro. Health Technol Assess (Rockv) 2015;19(24):1–279. [6] Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Jt Surg Br 2011;9393(1):1–11. [7] Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced threeand four-part proximal humerus fractures. J Orthop Trauma. 2010;24(4):250–254. [8] Weinstein DM, Bratton DR, Ciccone WJ, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elb Surg 2006;15(2):239–243. [9] Erdoğan M, Desteli EE, İmren Y, Üztürk A, Kılıç M, Sezgin H. The effect of inferomedial screw on postoperative shoulder function and mechanical alignment in proximal humerus fractures. Eur J Orthop Surg Traumatol 2014;24(7):1055–1059. [10] Ockert B, Braunstein V, Kirchhoff C, et al. Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: radiographic analysis of a prospective randomized study. J Trauma 2010;69(6):1545–1551. [11] Buecking B, Mohr J, Bockmann B, Zettl R. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res 2014;(1):1576–1585. [12] Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185–191. [13] Liu Z, Zhang G, Ge T. Use of a proximal humeral internal locking system enhanced by injectable graft for minimally invasive treatment of osteoporotic proximal humeral fractures in elderly patients. Orthop Surg 2011;3(4):253–258. [14] Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013;7(1):34. [15] Petrigliano FA, Bezrukov N, Gamradt SC, SooHoo NF. Factors predicting complication and reoperation rates following surgical fixation of proximal humeral
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