S Anjaiah¹, Syed Saad Kadri^2*

^1,2Consultant, Department of Orthopaedic, Sai Sanjeevni Hospital, Kothapeth Hyderabad, Telangana, INDIA.

Email: dr.syedsaad@gmail.com

RESULTS

In present study, 32 cases satisfying study criteria were studied. Majority were males (65.63 %), > 60 years age (56.25 %), mode of injury due to RTA (71.88 %), injury on right side (56.25 %) and had co-morbidities such as hypertension (31.25 %), diabetes mellitus (21.88 %), coronary artery disease (15.63 %). Majority were 2 part fracture (46.88 %) as compared to part 3 (28.13 %) and part 4 (25 %).

Table 1: General characteristics

Complications noted were Plate impingement (9.38 %), Varus malunion (6.25 %) and Stiffness (6.25 %).

Table 3: Complications among patients.

The Neer’s scoring system of the severity of pain, function, range of movement, anatomy, was done to determine the end results. In present study excellent, satisfactory and unsatisfactory results were noted in 28.13%, 56.25% and 15.63% patients.

Table 3: Neer’s scoring system

DISCUSSION

Neer recommended open reduction and internal fixation for displaced two and three parts fractures. Most of the poor results following open reduction and internal fixation of three-part fracture are due to imperfect technique.⁸ However, with the aim of getting anatomically accurate reductions, rapid healing and early restoration of function, which is a demand of today’s life, open reduction, and internal fixation, is the preferred modality of treatment. The goals of surgery are to obtain anatomic fracture reduction and stable primary fixation to ensure rapid fracture healing and immediate post-operative functional therapy without prolonged immobilization.⁹ The PHILOS plate is an internal fixation system that enables stabilization thanks to multiple angular stable interlocking screws, with the goal of preserving the biological integrity of the humeral head while securing an anatomical reduction.¹⁰ In study of 30 patients, Arumugam S et al.,¹¹ noted that the majority of the patients were males, elderly aged, with RTA being the commonest mode of injury, involving 2 part, 3 part and 4 part fractures of the proximal humerus. Excellent and satisfactory results were found in 76.7% of patients with unsatisfactory results in 23.3 % according to Neer’s criteria. There were 100 % union rates and no failures. In study by Chintan Doshi et al.,¹² average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes. Sameer Aggarwal et al.,¹³ studied 47 patients who completed a minimum follow up of 1 year, average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation. Internal fixation with non-locking plates has resulted in poor clinical outcomes and high failure rates in the past. Pre-countoured anatomical locking compression plates are more versatile with higher rates of union, especially in osteoporotic bones. They provide more stable buttress laterally and the diverging screw options in the cancellous bone, makes them the implant of choice in complex fractures.^14,15 Locking compression plate (LCP) has demonstrated satisfactory results for severely displaced PHF compared with conventional plate. The fixed-angle construct could improve the fracture stability and increase the resistance to pull out through the bone-plate interface with a single beam construct, especially useful in poor-quality cancellous bone of the proximal humerus. However, some complications, such as avascular necrosis (AVN), screw cut out, implant failure, plate impingement, head collapse, and infection, have been reported.¹⁶ Other studies have shown high complication rates ranging from 16 - 36%, which include articular screw penetration, subacromial impingement, varus malalignment, nonunion, implant failure, and osteonecrosis of the humeral head which adversely affects the final outcome. Further, most of these complications were attributed to poor surgical technique, improper implant positioning, and failure of accurate intraoperative assessment of reduction and screw length. Additionally, meticulous surgical dissection to preserve vascularity of humeral head is necessary to prevent potential complications such as AVN..^17,18,19 Surgery followed by early physiotherapy by rehabilitation programme plays important role in functional outcome of surgical management of proximal humerus fracture, thus allowing early mobilization and return to pre operative functional status.

CONCLUSION

Locking compression plate for management of fractures of proximal humerus is beneficial mainly due to stable fixation, angular stability and early functional aftercare is possible. It helps patients for early mobilization, to regain good shoulder function and resume normal activities much earlier.

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