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03 Jun 2024
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Multifragmentary Proximal Humerus Shaft Fracture

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Clinical Details

Clinical and radiological findings:  A 70-year-old overweight female sustained a multifragmentary humerus shaft fracture with proximal extension to the surgical neck following an awkward ground-level fall. The injury was closed, and the patient was neurovascularly intact. Initial conservative management at an external hospital was poorly tolerated due to the patient's habitus, making conservative bracing inappropriate. Thus, surgical management was pursued.

Preoperative Plan

Planning remarks:  The planned surgical approach was an open reduction and internal fixation using a plate. The anatomical approach included a deltopectoral approach combined with an anterolateral approach to the distal aspect of the arm (aggregate anterior approach).

Surgical Discussion

Patient positioning:  The patient was positioned in a semi-beach chair position on a radiolucent operating table, with the left arm placed at the table's edge and the forearm secured in a spider pneumatic positioner.

Anatomical surgical approach:  A longitudinal incision was made along the anterolateral aspect of the arm, starting at the level of the acromion. The deltopectoral interval was identified, and the deltoid insertion, biceps brachii and brachialis muscles were identified. Limited soft tissue dissection was performed to preserve vascularity. Sequential clamping and individual lag screw fixation of each intermediate fragment were performed. A long PHILOS plate was contoured to match the anatomy: it sat on the posterolateral aspect of the humeral head, curved posteriorly around the deltoid insertion, preserving the majority of its insertion on one of the intermediate fragments, before curving anteriorly to sit on the anterior aspect of the distal mid-shaft between heads of brachialis muscle. Multiplanar fluoroscopy confirmed adequate plate positioning before final fixation using four distal bicortical locking screws and one bicortical plus three monocortical proximal locking screws.

Operative remarks: 

The multifragmentary nature of the fracture, consisting of four intermediate fracture fragments between the humeral head and distal shaft, complicated reduction and fixation. Confirmation of axis alignment was achieved through radiographic identification of both the anteroposterior axis of the humeral head and the axis of the forearm. Sustained longitudinal traction was provided by the spider positioner. Care was taken to maintain the integrity of the deltoid muscle insertion on one intermediate fragment. The bridge plate construct provided relative stability, with intermediate fragments fixed using individual lag screws for provisional positioning rather than absolute stability.

Postoperative protocol:   Not specified

Orthopaedic implants used:   Contoured long PHILOS plate

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User Discussion (1)

Guest User

i need to know the advantage of this twist. is it a precontouring? by manufaturer of by you ? does it help preserve deltoid insertion or what?

Exactly. deltoid insertion was hanging on to a long thin intermediate fragment. i didnt want to release it, so twisted the plate posteriorly around it.


Dr Ed Oates

  • Germany , Schleswig Holstein
  • Area of Specialty - General Trauma
  • Position - Specialist Consultant
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