Second-generation concepts for locked plating of proximal humerus fractures

Displaced fractures of the proximal humerus remain particularly difficult to treat. Because of the poor quality of cancellous bone, it seemed that locking plates would be ideally suited for fixation in this region. However, as clinical reports begin to become available, it appears that these plates are not a panacea for these fractures and may be associated with a high complication rate. Coupled with the generally poor long-term outcomes of hemiarthroplasty, new fixation methods must be sought. Several technical factors, techniques, and alternative approaches have recently been described as possibly improving fixation stability in these fractures. Specifically, the anterolateral acromial approach, which avoids vascularity exposure, allows direct access to the lateral plating zone, and minimizes soft-tissue dissection, may be useful. Mechanical support of the medial column when anatomic cortical contact is not possible is also critical to maximizing stability. This may be achieved either with purposeful inferomedial humeral head screws or endosteal fibula allograft augmentation.