Twisted long PHILOS plate fixation in a series of humeral fractures

M. Bilici, B. Arumilli, N. Suhm, M. Jakob, D. Rikli

Introduction

The upper humerus is a common site for osteoporotic fractures, and low-energy falls can result in complex fracture patterns in this region, which often extend into the humeral head. These fractures involving the metadiaphyseal area of the proximal humerus may be preferably treated surgically. Minimally and less invasive plating has been performed in the humerus using locking compression plates with good results. The concept of a contoured long plate to be applied over the lateral part of the proximal humerus and anteriorly over the distal part is not new.

Figure 1: Preoperative anteroposterior and lateral radiographs showing a long Spiral metadiaphyseal fracture of the right humerus with a large butterfly fragment

Patients and methods

10 female and 2 male patients with 13 metadiaphyseal fractures (1 bilateral) of the upper humerus managed in our unit between June 2010 and January 2013 were retrospectively reviewed. The average age was 74.3 (52 - 95) years. Non of the patients had a nerve palsy on presentation. In 9 fractures, the fracture line was extending into the proximal humerus.

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.

Figure 2: Anteroposterior and lateral views of a contoured 10-hole PHILOS plate applied to a humerus model. End on view of 45° contoured long PHILOS plate to appreciate the orientation
Figure 3: Anteroposterior and lateral views of a contoured 10-hole PHILOS plate applied to a humerus model. End on view of 45° contoured long PHILOS plate to appreciate the orientation

Results

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.

Figure 4: Post-operative anteroposterior and lateral radiographs of the right humerus at 3-month follow-up showing union
Table 1: The demography, fracture, management, complications and outcome details of the cohort

Discussion

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.