Surgeon shares tips for successful locked plating of proximal humeral fractures

Proper locked plating fixation of proximal humeral fractures requires that surgeons account for patient age, avoid screw penetration and remain aware of potential risk factors for failure, according to a recent presentation.

David C. Templeman, MD, Trauma Section Editor, shared his experiences using locked plates for proximal humeral fractures at Orthopedics Today Hawaii 2011.

“Locked plates have revolutionized all of our treatments,” he said. “They have multiple stable screws, and they claim to have excellent fixation even in patients with osteoporosis.”

Still, he noted, there are specific factors to watch out for when repairing proximal humeral fractures with locked plates — including patient age, the dangers of screw penetration and the higher risk of failure in varus fracture cases.

The impact of patient age

David C. Templeman

Whether surgeons choose operative or nonoperative treatment for these fractures, Templeman said, the results tend to be highly dependent upon patient age.

“Age overwhelmingly projects how the patients are going to do,” he said. “For nonoperative management, age is a primary determination. Older patients subjectively feel like they are doing better than they are objectively doing by clinical measurements of motion and strength.”

Another factor to consider with older patients is the frequency of co-morbidities, which Templeman noted are “common and severe” in groups who display fair and poor results when undergoing shoulder assessment.

The age of the patient can determine what kind of repair should be used. For younger patients who tend to have better bone and place higher demands on the joint, open reduction and internal fixation is warranted. Older patients with poorer bone who put lower demands on the joint are more appropriately treated with a prosthesis, Templeman said.

Danger of screw penetration

Screw penetration is the biggest complication with locked plating in the proximal humerus, Templeman noted.

“It is hard to know what depth you are at,” he said. “It is hard to know when you penetrate with some of the drill systems because the bone is so bad.”

Templeman said that the literature shows a “pretty consistent” rate of 15% for screw penetration. To help avoid this complication, it is beneficial to obtain quality projections of the axillary and AP views after implantation. In conjunction with internal and external rotation, this can help locate the “approach-withdraw” phenomenon.

“Unfortunately, it will take a while because there are multiple screws. You need to trace each screw as you do this to avoid penetration,” Templeman said. “Have it foremost in your mind: This is a common complication.”

Further tips and tricks

Having an industry representative in the operating room during surgery can also be beneficial. “For almost all the locked platings, not even just exclusive to the shoulder, I would look at having a rep present because there are a lot of differences between the different companies,” Templeman said.

He also explained the differences in displacement between initial valgus impaction and varus malalignment, noting cases in initial varus have shown to be worrisome in terms of loss of reduction over time. Difficulties that can result from this include screw penetration, loss of fixation and screw backout.

Assessment of the height of the humeral head on postoperative films is also helpful, he added.

“You take a line parallel to your plate, and then draw a perpendicular across the top of the plate and across the top of the head,” Templeman said. “You can follow that distance postoperatively, and that is helpful to see if the fracture is collapsing — which will lead to late loss of reduction or screw penetration in elderly patients with poorer bone.”

Reference:

• Templeman, DC. Proximal humeral fractures: Locked plating. Presented at Orthopedics Today Hawaii 2011. Jan. 16-19. Koloa, Hawaii.

• David C. Templeman, MD, can be reached at Hennepin County Medical Center, Department of Orthopaedic Surgery, 701 Park Ave. 862B, Minneapolis, MN 55415; email: templ015@umn.edu.
• Disclosure: Templeman receives royalties from Zimmer and is a consultant for Biomet and Stryker.