Proximalhumeralfractures occur frequently. Most proxi- mal humeralfractures are minimally displaced or non- displaced and are treated conservatively with good results. However, unstable or displaced fractures may lead to non- union, malunion or limited function . Therefore, these displaced or unstable fractures require operative reduction and stabilization for favorable outcome. Various devices have been proposed for fixation, including plates and screws, staples, wire, multiple pins, intramedullary nails, and combination of these items. Intramedullary fixation has been thought as less invasive because it, compared with plate fixation, requires less extensive soft tissue dissection [2, 3].
In present study, LPHP has shown encouraging results in displaced proximalhumeralfractures in osteoporotic bones. Sound union was achieved in all patients. Secondary loss of reduction occurred in 4% patients after screw loosening in proximal fragment. Secondary varus deformity (head–shaft axis angle \ 120°) and retroversion of humeral head occurred in 14% patients in conventional plate osteosyn- thesis. Bone cement had been used to improve the holding power of screws in osteoporotic bones. Implant failure with screw loosening and secondary displacement of fracture fragments necessitated refixation of fracture in 4% patients . No revision surgery was performed in our study due to implant failure. LPHP was associated with significant lower risk of screw loosening and secondary loss of reduction as compared to conventional plates in the present series. LPHP offers the advantage of locking head screws, which enter the humeral head at various angles in order to maximise pur- chase . Fracture in a poor position is associated with poor functional results [3, 5]. Malunion was mainly a hardware related problem. Insufficient fixation of the screws may cause partial loss of reduction with secondary displacement of the humeral head into varus position leading to unsatis- factory result. Whereas, a higher rate (12%) of varus malunion was observed in conventional plate osteosynthesis . We did not have any secondary varus deformity. How- ever, fracture was fixed in varus primarily in 8% patients in our series and both these patients had moderate outcome. Primary malunion can be prevented if fracture is fixed in near anatomical position at the time of fixation. We feel that near anatomical reduction must be achieved before applying multidirectional screws, as plate does not help in reduction of proximal fragments. Rather it fixes the proximal fragments wherever they are. With varus malalignment, the plate must not be positioned too far cranially, otherwise there could be subacromial impingement which occurred in our two patients with varus malnion. Wanner et al.  treated dis- placed proximal humerus fractures with open reduction and internalfixation with two one-third tubular plates on the anterior and lateral aspects of the proximal humerus. High Table 2 Functional outcome in different fracture types, presented as
Materials and Methods: This retrospective study was conducted at Hotel Dieu de France Hospital in Beirut. Inclusion criteria were: (1) Age >18 years old and (2) proximalhumeral fracture operated on with the use of a plate (DCP (Dynamic compression plate) or LCP (Locking compression plate). Only 45 patients met these criteria since more than 70% of patients operated on were treated by other methods or dead. 20 patients presented to last follow up. Data collection included: Fracture type (using 2 classification: Codman/Neer and Hertel), early complications (infection, implant failure, stress riser fracture…), functional evaluation of the patient (using the “simple shoulder test”), and late complications (necrosis of the humeral head (NHH), malunion, osteoarthritis…) evaluated on x-rays by 2 independent physicians.
Constant scores to those recorded in patients with 2-part or 3-part fractures (Table 4). We have noticed that the good functional results were mainly obvious shortly after surgery and 12 months post-operatively after intramedullary nailing of 4-part proximalhumeralfractures. After that time, no further improvement has been recorder at the follow-up. The short intra-operative time, the limited exposure and minimal soft tissue dam- age, the preservation of periosteal blood supply and the rapid functional recovery resulted in good functional scores in this group of patients. However, in our study half of the patients with 4-part fracture proceeded to union at a less than 120° of valgus neck/shaft angle, probably due to reduced grip strength of screws at the osteoporotic bone. Yet the radiologic findings did not correlate with the functional scores. Other studies also report excellent to satisfactory results for the same frac- ture pattern [10,14,17,20,22]. Overall, excellent and satis- factory results with regard to functional outcome (Constant score) was noted in the majority of the patients in this study (92%). Rajasekhar et al.  mea- sured a median Constant score of 75 (25–88) points for patients aged over 60 years, and 70 (34–100) points for those younger than 60 years, in 25 patients treated with the Polarusnail. Sosef et al.  found a more than sat- isfactory shoulder function by recording a median Con- stant score of 89 (range 39–100). Adedapo and Ikpeme  treated 23 patients with displaced 3-, 4-part frac- tures and 3 or 4-part combined with shaft fractures using the Polarusnail and they found a mean Constant score of 88 (40–100), 67 (50–91), and 69 (40–94) points, respectively, at 1-year follow-up. Pain and loss of range of motion were the major reasons for the unsatisfactory results. However, it has been suggested that the pre- injury status of the shoulder seems to influence the Table 5 Review of all studies (215 patients) reporting on the use of Polarusnail for proximalhumeralfractures
9. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Syzszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 2005, 430:176-81. 10. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res 2006, 442:115-20. 11. Kettler M, Biberthaler P, Braunstein V, Zeiler C, Kroetz M, Mutschler W. [Treatment of proximalhumeralfractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures]. Unfallchirurg German 2006, 109:1032-40. 12. Südkamp N, Bayer J, Hepp P, Voiqt C, Oestern H, Kabb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internalfixation of proximalhumeralfractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009, 91(6):1320-8.
Operative intervention has proved an effective and safe treatment option for fractures of the proximal humerus [21, 22]. There are numerous optional fixation devices when surgeons attempt a proximalhumeral fracture oper- ation, including the locking plate, intramedullary nail, and artificial joint (hemiarthroplasty, total shoulder arthro- plasty, and reverse shoulder arthroplasty) [23, 24]. In the majority of cases, arthroplasty options are considered for older adults because osteoporotic bone limits the ability to achieve stable internalfixation . However, because of the possibility of a limited function, which could influence the quality of life, controversy still surrounds the use of artificial joints .
However, unsatisfactory complication rates of up to 40 %, after locking plate osteosynthesis show that the ideal joint-preserving method for treating proximalhumeralfractures has not yet been found . The Humerusblock is a k-wire based implant consisting of two locked, crossed k-wires, which allow for the minimally invasive, closed reduction and internalfixation of proximalhumeral frac- tures. Although previous studies have shown that the Humerusblock provides all of the advantages of a minim- ally invasive device, high rates of pin perforation and high implant removal rates have been observed [8, 12–15].
The inclusion criteria are as follows: (i) internalfixation of displaced proximalhumeralfractures; (ii) included both locking plates and intramedullary nails; (iii) greater than a minimum of 6 months of follow-up; (iv) a mini- mum of 21 patients for a given study; and (v) clinical outcomes during follow-ups included at least one of the following: intraoperative blood loss, operative time, frac- ture healing time, postoperative complications and post- operative infection, constant, neck angle, VAS, external rotation, antexion, intorsion pronation, abduction, NEER, osteonecrosis, additional surgery, impingement syndrome, delayed union, screw penetration, and screw back-out.
Surgical treatments for PHFs include open reduction and internalfixation (ORIF), closed reduction and internalfixation (CRIF), hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) (Fig. 1) . Since the development of the biomechanically more advanta- geous locking plates and locking intramedullary nails, the surgical indications for ORIF have been extended to elderly patients with osteoporosis [9, 10]. However, for both devices, high implant-related complication rates and reoperation rates have been reported [11 – 13]. Although HA may be an attractive treatment method for comminuted fractures in elderly patients, it is known to have poor outcomes when nonunion or malunion of the tuberosity occurs [14, 15]. RSA has recently been used to treat PHFs in elderly patients and reported to
Traditional treatment techniques include open reduction and internalfixation with proximalhumeral plates, hemiarthroplasty, and percutaneous or mini- mally invasive techniques such as pinning, screw osteo- synthesis, and the use of intramedullary nails [12-14,19-24]. All these techniques have been asso- ciated with various complications including implant failure, loss of reduction, nonunion or malunion of the fracture, impingement syndrome, and osteonecrosis of the humeral head [13,25-27]. Locking plate technology has been developed as a solution to the problems encountered during conventional plating to treat frac- tures in osteoporotic bone particularly with metaphy- seal comminution. The key to this technology is fixed angle relationship between the screws and plate. The threaded screw heads are locked into the threaded
is truly technically demanding, and during the operation process, surgeons are exposed to radiation, and may need to try more than once to select very suitable annulated lag screws after the closed reduction and temporary guide pin fixation have been achieved. Of course, the process of placing screws should also be done very carefully, since improper fixing of fragile fragments can lead to further comminuting. Removal of the screws after facture heal- ing is achieved is also quite a difficult process because the percutaneous incisions are usually small and the deltoid muscle is rather strong. The removal operation often re- quires a longer incision than the therapeutic process; just as everything in the world has 2 sides, a minimally inva- sive surgical technique will inevitably entail more difficul- ties during internalfixation removal.
reason may be that the internalfixation system used by PHILOS combined with allogeneic fem- oral head bone grafts does not need to be fully attached to the bone surface. This can reduce damage caused by friction, thus protecting the local blood supply and improving bone metabo- lism after surgery. Studies have proven that local or systemic inflammatory reactions are caused by blood scab absorption at fracture sites and foreign body stimulation formed by PHILOS and allogeneic femoral head bone gr- afts, while inflammatory cytokines damage tis- sues and affect fracture healing [17-19]. In this study, there were no significant differences in levels of inflammatory cytokines IL-1β, IL-6, and IL-22 between the study group and control group. This suggests that, although PHILOS Figure 2. Comparison of biochemical markers of bone turnover between the two groups. OC, osteocalcin; PINP, amino-terminal pro-peptide of type I procollagen; BALP, bone alkaline phosphatase; PYD, pyridinoline; TRAP, tar- trate-resistant acid phosphatase; CTX, cross-linked carboxy-terminal telopeptide of type I collagen; D-pyr, deoxy pyridinoline. Compared with the research group, *** P<0.001.
The characteristics of the seven included studies [5,9,11,17-20] are presented in Table 1. The studies were published between 1988 and 2012. A total of 291 pa- tients (142 operative fixation cases and 149 conservatively treated cases) with proximalhumeralfractures were con- sidered in this meta-analysis. The studies' sample sizes ranged between 12 and 93, and patients' ages ranged be- tween 65.2 and 75.0 years. Various operative approaches were conducted. Plate fixation was performed in two of the seven studies [11,20], tension band wiring fixation in two studies [9,18], and Steinmann pin fixation in one study . Also, AO angular blade plate, screw fixation and cerclage, antegrade screw nails, and retrograde pin fixation were used in one study each . Data for single operative approaches were not provided. In the remaining article , no details were given for the open reduction with internalfixation approach.
Management of displaced proximalhumeralfractures is subject of ongoing debate (1-4). The PROFHER random- ized clinical trial recently showed no superiority of surgi- cal over non-surgical treatment of adults with displaced fractures of the proximal humerus (4). Previous studies showed that the treatment of proximalhumeralfractures largely depends on patient characteristics and surgeon’s preferences and is not necessarily associated with fracture classification (5). For similar Neer types of 2-, 3- and 4- part fractures there are Level II and III studies supporting non- operative treatment, open reduction and internalfixation using various techniques, and arthroplasty (6-9).
In our opinion, the fibular allograft was a reasonable option to maintain the anatomical reduction in the treat- ment of comminuted PHFs in the elderly patients. The fibular allograft could be used as tool to indirectly re- duce the fracture. Gardner et al.  first introduced the use of screw to push the fibular allograft medially so that the graft could indirectly reduce the fractured medial cortex. Subsequently, many authors preferred to push the graft upward instead of medial because it could sup- port the humeral head in a proper height [15, 28]. How- ever, in some cases, the intramedullary cavity in elderly patients accompanied osteoporosis was relatively large, the graft could not be easily manipulated. So we placed a guide pin at the apex of the humeral head. Then, the fibular allograft was pushed upward in the intramedul- lary cavity through the guide pin as in retrograded nail- ing. Especially in cases with medial cortex disruption, using fibular allograft as a pillar to support the humeral head from intramedullary cavity was more helpful in maintaining reduction. The added stability provided by the fibular allograft allowed for an early rehabilitation program and reduced the complication rate. In our study, the FA group showed significant lower rates of varus malunion and screw penetration. The fibular allo- graft also had disadvantages, such as risk of infection, disease transmission, and high cost. The fibular allograft contains cortical bone, so it might be fractured during insertion of the screws.
Proximal femoral nailing is a technically demanding procedure, but has several biological and biomechanical advantages. Intramedullary implants for internalfixation of the proximal femur tolerate higher static and several times higher cyclical loading as compared to sliding screw implants. As a result the fracture heals even without the primary restoration of the medial support. The implant temporarily compensates the function of the medial column. When this function is not restored in a limited period of time, the internalfixation, although correctly performed, fails. In this series of 40 completely evaluated PFN implantations, fracture consolidation was seen in 97.5% of the cases within 18 weeks. Intraoperative difficulties were noted in 50% of the implantations and the overall rate of late technical and mechanical complications was 40%. Comparison of failures in this study to those in other series is not easy because an exact definition of failure is absent in most cases. Distal locking difficulties in this series were seen in 4 (10%) cases. These can be avoided by firmly tightening the bolt joining the nail and the insertion handle at the time of distal locking. In 20% of cases, only 1 locking screw could be inserted distally. The result of the reduction was considered acceptable in 60% of the patients and anatomical in 32.5% of patients. Poor reduction was noted in 8% of patients and it was associated with poor outcome. In I.B.SCHIPPER’s series (Schipper, 2004), reduction was good to acceptable in 96.2% of their patients and poor reduction was seen only in 2.9% of their patients. The high stress concentration at the distal holes of the locking bolts, the suggested necessary over-reaming of the shaft that had been seen to weaken the entire shaft and the frequent drilling for a proper distal interlocking because of misalignment
nique has a low risk of epiphyseal necrosis, which is instead strongly favored by the necessary huge dissection for implanting plates or other internal devices in an already jeopardized area by the vascular point. Nevertheless, in order to have a good functional result, it is necessary to get an anatomical reduction of the fracture as much as possi- ble, also at the cost of performing an open reduction, real- izable with a mini-invasive approach, respecting epiphy- seal vascularization .
Introduction This study describes our experience with antegrade short locked intramedullary nail in the treatment of humeralfractures of the surgical neck and in the ones with extension of the line’s fracture in the epiphyseal region. The anterograde closed nails are inserted through a small incision with minimal soft-tissue trauma and with respect to the periosteal vascularization. Possible damage of the rotator cuff has been evaluated with ultrasound studies after the surgery. Materials and methods From June 2008 to September 2010, 31 patients (18 females and 13 males; range, 25–84 years) were treated by surgical internalfixation with a short locked intramedullary nail. The mean follow-up was 22 months (range, 3–33) and all patients were evaluated with clinical, radiographic and ultrasound examination. Results The mean Constant score was 80 (min. 72, max. 95). The fractures healed in an average time of 2,5 months. The most func- tional outcomes were obtained by patients with two-part fractures of the surgical neck, but in the ones of epiphyseal region the result depended on a good quality of bone fragments’ reduction during the surgery. Among the complications, 1 patient underwent surgical revision for humeral fracture in which the short locked intramedullary nail was removed and a long one was inserted, another patient had a delayed union of the surgical neck. In the remaining cases the results have been good and no nails have been removed yet. The rotator cuff has not shown significant damages with regard to the surgical procedure.
However with the advent of new tools and techniques the armamentarium of a trauma surgeon is enriched. Open reduction and internalfixation with plates give good radiological reduction but are fraught with complica- tions like infection and radial nerve palsy  . We aim to propose a technique, never used for the fractures of the humeral shaft, after seeking approval from the hospital ethics committee which could be undertaken at any district level hospital, with minimum instrumentation with a relatively low learning curve.
There is an increasing trend of shaft of humerus fractures being treated operatively . Denies  in his study compared conventional plating with intramedullary interlocking nail in 91 patients. He reported high complica- tion rate with intramedullary nail and suggested plating as primary treatment for humeral shaft fractures. In most instances dynamic compression plating is preferred   . The most commonly used approach are the post- erior and anterolateral approaches  . Oh  in his study compared open reduction with internalfixation and minimally invasive plate osteosynthesis in humeral shaft fractures he reported no difference in fracture un- ion however radiation hazard was high with mippo technique. Boschi  in his study concluded subbrachial ap- proach as practical and effective and the loss of muscle strength was significantly less with subbrachial approach. In our study medial plating was done through anterolateral approach without splitting the brachialis, the brachia- lis was elevated and retracted laterally