Long PHILOS plate fixation in a series of humeral fractures

The purpose of the article is to highlight a specific fracture pattern encountered by us in the osteoporotic upper humerus. We present our results of management of such metadiaphyseal fractures of the upper humerus with less invasive plating. The additional steps taken to improve final outcome and the reasoning behind each are discussed.

In our department, a total of 13 fractures (in 12 patients) were managed for a metadiaphyseal fracture of the upper humerus between 2010 and 2013. There were 2 males and 10 females. The average age in the cohort was 74.3 (52-95) years. In 9 fractures, the fracture line was extending above the surgical neck. All patients were managed with a locking compression plate (long PHILOS or LCP) using two approach windows (proximal deltopectoral and a distal anterior or lateral). Patients were evaluated for clinical outcome using the Quick DASH score and assessed for radiological union, complications or re-operations retrospectively.

The mean follow-up was 14.3 months (4-36). All fractures were united, and there was no evidence of avascular necrosis or non-union. Two patients showed varus collapse of the anatomical head of which one patient needed change of screws at 12 weeks from index surgery. In patients, when a distal lateral window was used, 2 patients out of 4 had radial nerve palsy post-operatively. In the rest, when the plate was twisted by 45° to allow anterior placement using the brachialis split, none had radial nerve injury.

The osteoporotic bone failing under a low-energy mechanism seemed to dictate this fracture pattern. The fracture is either a bending wedge or a long spiral with or without a large butterfly and often extends into the humeral head. The fractures are better managed surgically, a primary reduction allowing contact of fragments is essential, and using an anterior window distally with a 45° contoured plate will achieve good plate placement as well as decreases the risk of radial nerve injury considerably compared to total lateral plate positioning.