Figure A shows varus collapse and intra-articular joint penetration of the the proximal locking screws. This could have potentially been prevented by the addition of an inferomedial calcar screw, which would have provided greater strength to the fixation construct and resistance to fracture collpase. Illustration A is an immediate post-operative fluoro image of the fracture and shows the proximal humerus to be near anatomically aligned. The illustration also demonstrates simulated overlay of where the recommended inferomedial locking screw would be placed. Illustration B shows ORIF of a different proximal humerus fracture with placement of an inferomedial calcar screw.
Konrad et al present a prospective, multicenter, observational study to evaluate the functional outcome and the complication rate after ORIF of proximal humeral fractures with use of a locking proximal humeral plate. At 1 year follow-up, they found an overall complication rate of 34%: most commonly due to screw perforation through the humeral head. Nineteen percent of the patients required re-operation within 1 year of their index surgery.
Gardner et al discuss a technique of using a segment of fibula allograft, placed endosteally and incorporated into the locking construct, to aid in the reduction and restoration of the mechanical integrity of the medial column of the proximal humerus. An example of this fixation construct is shown in Illustration C.
Gardner et al, in another study, sought determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support. They found that achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.
Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:85-95.
PMID:20194347 (Link to Abstract)
Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008 Mar;22(3):195-200.
PMID:18317054 (Link to Abstract)
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 Mar;21(3):185-91.
PMID:17473755 (Link to Abstract)