Proximal Humerus ORIF with Locking Plate

Surgical Indications

Absolute Indications for ORIF

• Displaced 3-part proximal humerus fracture in a physiologically young patient with reconstructible bone stock
• Displaced 4-part fracture with intact medial periosteal sleeve (valgus-impacted pattern) in a patient under 60-65 years
• 2-part surgical neck fracture with greater than 50% displacement or angulation greater than 45 degrees that fails closed reduction
• Associated greater tuberosity displacement greater than 5 mm in a young active patient (risk of rotator cuff dysfunction and impingement)

Relative Indications

• Valgus-impacted 4-part fracture in a patient over 65 with good bone quality and no head-split component
• 3-part fracture with significant medial comminution where locking plate can restore calcar support
• Patient preference for anatomic reconstruction over non-operative care or arthroplasty after informed discussion

Contraindications

Absolute:

• Head-split fracture with greater than 40% articular surface involvement (consider hemiarthroplasty or reverse)
• Severe osteoporosis with comminution that precludes stable fixation (consider reverse shoulder arthroplasty)
• Active infection or open fracture with gross contamination

Relative:

• Age greater than 75 with low functional demand and acceptable alignment after closed reduction
• Significant medical comorbidities that increase perioperative risk
• Pre-existing rotator cuff tear arthropathy or glenohumeral arthritis favouring arthroplasty

Evidence for Non-Operative Treatment

• Minimally displaced fractures (less than 1 cm, less than 45 degrees) achieve good to excellent outcomes with early mobilisation in 80-90% of patients
• Valgus-impacted 4-part fractures have a surprisingly good prognosis with non-operative care when the medial hinge remains intact — approximately 70% achieve satisfactory function without surgery
• Non-operative care requires disciplined physiotherapy and radiographic surveillance; loss of reduction occurs in up to 30% of displaced fractures treated non-operatively

Evidence for ORIF with Locking Plate

• Locking plates provide fixed-angle stability that tolerates early motion even in osteoporotic bone
• Biomechanical studies demonstrate that inferomedial calcar screw placement reduces varus collapse by greater than 50%
• Clinical series report union rates of 85-95% when anatomic reduction and calcar support are achieved
• Complications remain significant: screw cut-out 5-15%, avascular necrosis 5-20%, reoperation 10-25% depending on fracture pattern and bone quality

Deltopectoral Approach — Relevant Anatomy

Interval and Superficial Landmarks

• The deltopectoral groove is identified by palpating the coracoid process medially and the acromion laterally
• The cephalic vein lies within the groove and serves as the key landmark for the interval between deltoid (lateral) and pectoralis major (medial)
• The deltoid insertion on the humerus is released for 1-2 cm if additional exposure is required, but the majority of the insertion is preserved

Axillary Nerve

• Exits the quadrilateral space and wraps around the surgical neck on the deep surface of the deltoid
• Lies 5-7 cm distal to the acromion in the average adult
• Motor branches to the anterior and middle deltoid and sensory branch to the lateral shoulder
• Protection: identified by palpation or direct visualisation at the inferior border of subscapularis before any distal dissection; all retractors and the plate must remain proximal to the nerve

Blood Supply to the Humeral Head

• The anterior circumflex humeral artery ascends in the bicipital groove and gives the arcuate artery that enters the head
• The ascending branch travels along the medial calcar and provides critical perfusion through the periosteal sleeve
• In 4-part fractures the head is often perfused solely through the medial periosteal attachments — aggressive medial dissection risks avascular necrosis

Rotator Cuff Insertions

• Supraspinatus inserts on the superior facet of the greater tuberosity
• Infraspinatus inserts on the posterior facet of the greater tuberosity
• Subscapularis inserts on the lesser tuberosity
• Non-absorbable sutures placed through these insertions provide powerful reduction aids and augmentation of plate fixation

Positioning and Preparation

Patient position: Beach-chair position with the head secured, the arm free or on a radiolucent arm board. The scapula must be supported so that the glenoid is perpendicular to the floor. A bump under the ipsilateral scapula improves access.

Image intensifier: Position the C-arm from the opposite side of the table so that true AP, axillary, and scapular-Y views can be obtained without moving the arm excessively. Confirm that the entire proximal humerus including the shaft is visible.

Anaesthesia: General anaesthesia with interscalene block for postoperative analgesia. Hypotensive anaesthesia reduces bleeding but must be balanced against the risk of cerebral hypoperfusion in the beach-chair position.

Preparation: Prep the entire arm including the hand so that the elbow can be flexed and extended intraoperatively to assess reduction and nerve function. Drape so that the coracoid, acromion, and lateral humerus are accessible.

Step-by-Step Operative Technique — Deltopectoral Approach

Step 1: Skin Incision and Superficial Dissection

Make a 12-15 cm incision from the coracoid process distally along the deltopectoral groove, curving slightly laterally toward the deltoid insertion if additional exposure is required. Identify the cephalic vein and develop the interval on either side. Retract the vein laterally with the deltoid (preferred by most surgeons) or medially with pectoralis.

Divide the clavipectoral fascia lateral to the coracoid. Identify the coracoid and the conjoined tendon. Place a self-retaining retractor or a Hohmann retractor under the deltoid laterally.

Step 2: Identify and Protect the Axillary Nerve

With the arm abducted 30-40 degrees, palpate the inferior border of the subscapularis. The axillary nerve can be felt or visualised crossing from medial to lateral at this level. Alternatively, palpate the deep surface of the deltoid 5-7 cm distal to the acromion.

Place a vessel loop around the nerve or simply mark its position mentally. All subsequent distal dissection and plate placement must remain proximal to this landmark.

Step 3: Expose the Fracture and Rotator Cuff

Incise the rotator interval between the supraspinatus and subscapularis. Tag the long head of biceps tendon with a stay suture — it serves as a landmark for the bicipital groove and the junction between greater and lesser tuberosities.

Identify the fracture lines. The greater tuberosity is usually displaced posterolaterally by the supraspinatus and infraspinatus. The lesser tuberosity is displaced medially by subscapularis. The head fragment is typically in varus or valgus depending on the pattern.

Place heavy non-absorbable sutures through the supraspinatus and infraspinatus insertions on the greater tuberosity and through the subscapularis insertion on the lesser tuberosity. These sutures provide reduction handles.

Step 4: Reduce the Tuberosities and Humeral Head

Reduce the greater tuberosity to the head fragment using the tagged sutures. The reduction must be anatomic — even 5 mm of displacement blocks rotation. Use a pointed reduction clamp or K-wires to hold the reduction temporarily.

Reduce the lesser tuberosity similarly. In 4-part fractures the head must be reduced to the shaft while maintaining the medial periosteal hinge.

For valgus-impacted fractures, the head is often already in acceptable valgus; the tuberosities are rotated around the head and must be brought down to the shaft.

Step 5: Apply the Locking Plate

Select a precontoured proximal humerus locking plate of appropriate length. The plate should sit 5-8 mm distal to the superior aspect of the greater tuberosity and slightly posterior to the bicipital groove to avoid impingement.

Secure the plate provisionally with K-wires through the proximal holes. Confirm position on AP and axillary fluoroscopic views.

Place the inferomedial calcar screw first — this is the critical screw that supports the head and prevents varus collapse. It should be a locking screw directed inferomedially into the calcar region.

Place the remaining proximal locking screws, ensuring none penetrate the articular surface. Use the image intensifier in multiple planes after each screw.

Place distal shaft screws (usually 3-4 bicortical non-locking or locking screws) to secure the plate to the humeral shaft.

Step 6: Augment with Rotator Cuff Sutures

Pass the previously placed rotator cuff sutures through the suture holes in the plate or around the plate. Tie them securely to augment the fixation and provide additional rotational stability.

This step is particularly important in osteoporotic bone where screw purchase in the head may be marginal.

Step 7: Verify Reduction and Stability

Obtain final fluoroscopic images in true AP (Grashey), axillary, and scapular-Y views. Confirm:

• Anatomic reduction of the greater and lesser tuberosities
• No intra-articular screw penetration
• Restoration of the medial calcar
• Appropriate head-shaft angle (approximately 130-140 degrees)

Test stability by gently ranging the shoulder under direct vision. The construct should allow at least 30-40 degrees of passive external rotation and 90 degrees of abduction without displacement.

Close the wound in layers. A drain is optional. Apply a sling with abduction pillow.

Post-operative Protocol

Phase 1: Protection and Early Motion (Week 0-4)

• Sling with abduction pillow for 4 weeks
• Pendulum exercises and passive forward flexion to 90 degrees from day 3-5
• Active-assisted external rotation to 30 degrees (protected by suture augmentation)
• No active elevation against gravity for 4 weeks
• Wound review at 10-14 days; radiographs at 2 and 4 weeks

Phase 2: Active Motion and Strengthening (Week 4-8)

• Discontinue sling at 4 weeks if radiographs satisfactory
• Active-assisted to active range of motion in all planes
• Begin rotator cuff and deltoid isometric exercises
• Progressive resistance with theraband from week 6
• Radiographs at 6 and 8 weeks to confirm maintenance of reduction

Phase 3: Advanced Strengthening and Function (Week 8-16)

• Full active range of motion expected by 8-10 weeks
• Progressive resistance strengthening of rotator cuff, deltoid, and scapular stabilisers
• Functional training and proprioceptive exercises
• Return to light work at 8-12 weeks; heavy manual work or sport at 4-6 months

Expected Outcomes

• Union rate: 85-95% with anatomic reduction and calcar support
• Forward flexion: 120-150 degrees in most patients
• External rotation: 30-50 degrees
• Constant score: 60-80 points at 1 year (better in 2- and 3-part fractures than 4-part)

Special Considerations

Osteoporotic Bone

• Use longer plates with more distal screw options
• Consider cement augmentation of screw holes
• More aggressive suture augmentation of the rotator cuff
• Lower threshold for conversion to reverse arthroplasty if fixation is tenuous

Valgus-Impacted 4-Part Fractures

• The medial periosteal hinge is often intact — preserve it
• Percutaneous or limited open reduction may suffice
• Locking plate still provides excellent stability and allows early motion

Associated Greater Tuberosity Fracture

• Anatomic reduction is mandatory — even 5 mm displacement causes impingement and weakness
• Suture augmentation is especially valuable here