The prolonged life span leads to proximal humerus fractures as a common clinical condition in general orthopedic practice. The treatment to be administered to the patient should maximize the functional expectation of the patient and reduce the pain to the lowest level. The fracture line passing through the humeral neck affects blood flow to the humeral head. In short fractures with medial calcar, all vascular structures that make anastomosis to the arcuate artery supplying the humeral head are injured.
In proximal humerus fractures, clinical conditions having an absolute requirement for surgery include open fractures and progressive neurovascular deficits. In addition, surgery should be considered urgently for fracture-dislocations that cannot be reduced. Other clinical conditions that require surgery include fractures being severely displaced or unstable after closed reduction, three- to four-part fractures, and greater tuberosity fractures greater than 5 mm preventing rotator cuff function.
In patients in whom we consider plate and screw fixation, our preference is the deltopectoral approach in the beach chair position. The position, size, and bone quality of fracture fragments as well as the tendons of rotator cuff muscles and the long head of the biceps tendon are evaluated before reduction. Ethibond suture 5-0 or fiber wire suture 5-0 are placed into the rotator cuff tendons in such a way as to include the bone close to the bone-tendon junction as possible as by considering the fracture fragments because these sutures are used for the manipulation and reduction of fracture fragments. K-wires are used to provide temporary stabilization of particularly proximal parts before plate placement. The most important point to keep in mind for maintenance of stabilization in the reduction is to maintain medial continuity.
Possible complications after locking plate applications in proximal humerus fractures include technical errors, poor bone quality, lack of anatomical reduction (especially lack of medial cortical continuity), and early aggressive rehabilitation.
Even if the locking plate gives very good results in proximal humerus fractures related to the most mobile joint in the human body, it should be kept in mind that 80% of these fractures can heal without problems with conservative follow-up. The most important criterion for success in patients undergoing surgery is stable anatomical fracture reduction that can provide medial support in particular. Locking plates are necessary for osteosynthesis in patients with unstable osteoporotic multipart fractures. Proper rehabilitation is essential for success as it is in other treatment modalities.
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We kindly thank Prof. Ulunay Kanatli for the images from his private archive.
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