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      The Mechanical Benefit of Medial Support Screws in Locking Plating of Proximal Humerus Fractures

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          Abstract

          Background

          The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures.

          Methods

          Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed.

          Results

          Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture.

          Conclusions

          Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.

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          Most cited references21

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          Epidemiology of adult fractures: A review.

          Charles Court-Brown, Ben Caesar (2006)
          The epidemiology of adult fractures is changing quickly. An analysis of 5953 fractures reviewed in a single orthopaedic trauma unit in 2000 showed that there are eight different fracture distribution curves into which all fractures can be placed. Only two fracture curves involve predominantly young patients; the other six show an increased incidence of fractures in older patients. It is popularly assumed that osteoporotic fractures are mainly seen in the thoracolumbar spine, proximal femur, proximal humerus and distal radius, but analysis of the data indicates that 14 different fractures should now be considered to be potentially osteoporotic. About 30% of fractures in men, 66% of fractures in women and 70% of inpatient fractures are potentially osteoporotic.
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            The importance of medial support in locked plating of proximal humerus fractures.

            Dean Lorich, John Barker, Yoram Weil … (2007)
            The purpose of this study was to determine what factors influence the maintenance of fracture reduction after locked plating of proximal humerus fractures, and particularly the role of medial column support. University medical center. Thirty-five patients who underwent locked plating for a proximal humerus fracture were followed up until healing. For the initial and final radiographs, 2 lines were drawn perpendicular to the shaft of the plate, one at the top of the plate and one at the top of the humeral head, and the distance between them was measured as an indicator of loss of reduction. Medial support was considered to be present if the medial cortex was anatomically reduced, if the proximal fragment was impacted laterally in the distal shaft fragment, or if an oblique locking screw was positioned inferomedially in the proximal humeral head fragment. Multivariate linear regressions were performed to determine the effects that age, sex, fracture type, cement augmentation, and medial support had on loss of reduction. The presence of medial support had a significant effect on the magnitude of subsequent reduction loss (P < 0.001). Age, sex, fracture type, or cement augmentation had no effect on maintenance of reduction. Eighteen patients were determined to have adequate mechanical medial support (+MS group), and the remaining 17 patients did not have medial support (-MS group). In the +MS group, the average loss of humeral head height was 1.2 mm, and 1 case of articular screw penetration occurred that required removal. In the -MS group (without an appropriately placed inferomedial oblique screw and either nonanatomic humeral head malreduction with lateral displacement of the shaft or medial comminution), loss of humeral height averaged 5.8 mm (P < 0.001). There were 5 cases in this group in which screw penetration of the articular surface occurred (P = 0.02), 2 of which required reoperation for removal. All fractures in both groups healed without delay, and none required revision to arthroplasty. Achieving mechanical support of the inferomedial region of the proximal humerus seems to be important for maintaining fracture reduction. Locked plates in general do not appear to be a panacea for these fractures and are unable to support the humeral head alone from a lateral tension-band position. However, there are several factors that are in the surgeon's control that may improve the mechanical environment. Achieving an anatomic or slightly impacted stable reduction, as well as meticulously placing a superiorly directed oblique locked screw in the inferomedial region of the proximal fragment, may achieve more stable medial column support and allow for better maintenance of reduction.
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              A systematic review of locking plate fixation of proximal humerus fractures.

              Zlatko Devcic, Brian Feeley, Robert C Sproul … (2011)
              Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates. The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias. Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%. Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique. Copyright © 2010 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Mikko Lammi: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2014
                Publication date (Electronic): 1 August 2014
                Volume: 9
                Issue: 8
                Electronic Location Identifier: e103297
                Affiliations
                [1 ]Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
                [2 ]Department of Orthopaedics, Zhuhai People's Hospital, Jinan University Affiliated Zhuhai Hospital, Guangdong, China
                University of Eastern Finland, Finland
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: Wen Zhang LQZ CQZ BFZ YFC. Performed the experiments: Wen Zhang LQZ. Analyzed the data: Wei Zhang. Contributed reagents/materials/analysis tools: YJL YP YFC. Wrote the paper: Wen Zhang LQZ.

                Article
                Publisher ID: PONE-D-14-00127
                DOI: 10.1371/journal.pone.0103297
                PMC ID: 4118867
                PubMed ID: 25084520
                SO-VID: 565db213-48a1-4657-8682-00dbb52c7d04
                Copyright statement: Copyright @ 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 3 January 2014
                Date accepted : 28 June 2014
                Page count
                Pages: 8
                Funding
                There were no funding sources for this study.
                Categories
                Subject: Research Article
                Subject: Biology and Life Sciences
                Subject: Anatomy
                Subject: Musculoskeletal System
                Subject: Biomechanics
                Subject: Biotechnology
                Subject: Bioengineering
                Subject: Medical Devices and Equipment
                Subject: Engineering and Technology
                Subject: Medicine and Health Sciences
                Subject: Clinical Medicine
                Subject: Critical Care and Emergency Medicine
                Subject: Trauma Medicine
                Subject: Trauma Surgery
                Subject: Surgical and Invasive Medical Procedures

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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