Complications of ORIF in Proximal Humeral Fractures

  • Luca La Verde
  • Edoardo Franceschetti
  • Filippo Familiari
  • Francesco Franceschi


Proximal humeral fractures (PHFs) are complex lesions with difficult management problems, representing a challenge for the orthopaedic surgeon. Many different treatment options have been proposed for these fractures. Open reduction and internal fixation (ORIF) of the proximal humerus represents a good option in selected patients, with encouraging clinical and functional outcomes reported in the literature. Several complications related to ORIF of the proximal humerus have been described over the years. Osteosynthesis of proximal humeral fractures presents different degrees of difficulty according to fracture type and bone quality. Elderly patients, severe osteoporosis, high-energy trauma and severe comminution of the fracture represent the most important predicting factors for risk of complications. Surgeon’s experience represents also a crucial influencing factor for positive outcomes. Complications after ORIF of the proximal humerus can be broadly categorized in three subgroups: (1) alterations of the healing process (malunions, non-unions, avascular necrosis of the humeral head and heterotopic ossifications), (2) hardware failure (screw loosening and pull-out, implant failure, malpositioning and articular perforation) and (3) others (surgical infections, neurovascular lesions, etc.). The aim of this chapter is to present an overview of the complications affecting ORIF in proximal humeral osteosynthesis, with some tips and tricks to avoid them.


Proximal humeral fractures ORIF Open reduction and internal fixation Complications Failure Osteosynthesis 


  1. 1.
    Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92.PubMedCrossRefGoogle Scholar
  2. 2.
    Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996;18(Suppl 3):209S–13S.PubMedCrossRefGoogle Scholar
  3. 3.
    Lauritzen JB, Schwarz P, Lund B, McNair P, Transbol I. Changing incidence and residual lifetime risk of common osteoporosis-related fractures. Osteoporos Int. 1993;3(3):127–32.PubMedCrossRefGoogle Scholar
  4. 4.
    Kristiansen B, Barfod G, Bredesen J, Erin-Madsen J, Grum B, Horsnaes MW, et al. Epidemiology of proximal humeral fractures. Acta Orthop Scand. 1987;58(1):75–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury. 1998;29(5):349–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007;15(1):12–26.PubMedCrossRefGoogle Scholar
  7. 7.
    Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. J Bone Joint Surg Am. 2004;86-A(Suppl 1 (Pt 2):143–55.CrossRefGoogle Scholar
  8. 8.
    Cuomo F, Flatow EL, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus. J Shoulder Elbow Surg. 1992;1(6):287–95.PubMedCrossRefGoogle Scholar
  9. 9.
    Wanner GA, Wanner-Schmid E, Romero J, Hersche O, von Smekal A, Trentz O, et al. Internal fixation of displaced proximal humeral fractures with two one-third tubular plates. J Trauma. 2003;54(3):536–44.PubMedCrossRefGoogle Scholar
  10. 10.
    Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res. 2006;442:115–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, Bigliani LU. Two-part and three-part fractures of the proximal humerus treated with suture fixation. J Orthop Trauma. 2003;17(5):319–25.PubMedCrossRefGoogle Scholar
  12. 12.
    Resch H, Povacz P, Frohlich R, Wambacher M. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg. 1997;79(2):295–300.CrossRefGoogle Scholar
  13. 13.
    Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002;84-A(11):1919–25.CrossRefGoogle Scholar
  14. 14.
    Calvo E, de Miguel I, de la Cruz JJ, Lopez-Martin N. Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results. J Shoulder Elbow Surg. 2007;16(6):774–81.PubMedCrossRefGoogle Scholar
  15. 15.
    Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317–24.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006;442:100–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Hirschmann MT, Quarz V, Audige L, Ludin D, Messmer P, Regazzoni P, et al. Internal fixation of unstable proximal humerus fractures with an anatomically preshaped interlocking plate: a clinical and radiologic evaluation. J Trauma. 2007;63(6):1314–23.PubMedCrossRefGoogle Scholar
  18. 18.
    Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008;90(2):233–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23(2):113–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Sudkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kaab M, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91(6):1320–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Spross C, Platz A, Rufibach K, Lattmann T, Forberger J, Dietrich M. The PHILOS plate for proximal humeral fractures--risk factors for complications at one year. J Trauma Acute Care Surg. 2012;72(3):783–92.PubMedCrossRefGoogle Scholar
  23. 23.
    Calori GM, Colombo M, Bucci MS, Fadigati P, Colombo AI, Mazzola S, et al. Complications in proximal humeral fractures. Injury. 2016;47(Suppl 4):S54–S8.PubMedCrossRefGoogle Scholar
  24. 24.
    Duparc F. Malunion of the proximal humerus. Orthop Traumatol Surg Res. 2013;99(1 Suppl):S1–11.PubMedCrossRefGoogle Scholar
  25. 25.
    Abdelhady AM. Timing of shoulder arthroplasty in comminuted proximal humerus fracture, how much does it matter? Eur J Orthop Surg Traumatol. 2013;23(5):515–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am. 1998;80(10):1484–97.PubMedCrossRefGoogle Scholar
  27. 27.
    Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg. 2001;10(4):299–308.PubMedCrossRefGoogle Scholar
  28. 28.
    Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011;25(10):612–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg. 2009;18(4):612–21.PubMedCrossRefGoogle Scholar
  30. 30.
    Bachelier F, Pizanis A, Schwitalla J, Pohlemann T, Kohn D, Wirbel R. Treatment for displaced proximal humerus fractures: comparison of interlocking plate fixation versus minimal invasive techniques. Eur J Orthop Surg Traumatol. 2014;24(5):707–14.PubMedCrossRefGoogle Scholar
  31. 31.
    Calvo E, Merino-Gutierrez I, Lagunes I. Arthroscopic tuberoplasty for subacromial impingement secondary to proximal humeral malunion. Knee Surg Sports Traumatol Arthrosc. 2010;18(7):988–91.PubMedCrossRefGoogle Scholar
  32. 32.
    Porcellini G, Campi F, Paladini P. Articular impingement in malunited fracture of the humeral head. Arthroscopy. 2002;18(8):E39.PubMedCrossRefGoogle Scholar
  33. 33.
    Ladermann A, Denard PJ, Burkhart SS. Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning. Arthroscopy. 2012;28(9):1220–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Solonen KA, Vastamaki M. Osteotomy of the neck of the humerus for traumatic varus deformity. Acta Orthop Scand. 1985;56(1):79–80.PubMedCrossRefGoogle Scholar
  35. 35.
    Russo R, Vernaglia Lombardi L, Giudice G, Ciccarelli M, Cautiero F. Surgical treatment of sequelae of fractures of the proximal third of the humerus. The role of osteotomies. Chir Organi Mov. 2005;90(2):159–69.PubMedGoogle Scholar
  36. 36.
    Mansat P, Guity MR, Bellumore Y, Mansat M. Shoulder arthroplasty for late sequelae of proximal humeral fractures. J Shoulder Elbow Surg. 2004;13(3):305–12.PubMedCrossRefGoogle Scholar
  37. 37.
    Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg. 1995;4(4):271–80.PubMedCrossRefGoogle Scholar
  38. 38.
    Antuna SA, Sperling JW, Sanchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral malunions: long-term results. J Shoulder Elbow Surg. 2002;11(2):122–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the proximal humerus: malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elbow Surg. 1993;2(1):11–21.PubMedCrossRefGoogle Scholar
  40. 40.
    Bjorkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004;75(6):741–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Erasmo R, Guerra G, Guerra L. Fractures and fracture-dislocations of the proximal humerus: a retrospective analysis of 82 cases treated with the Philos((R)) locking plate. Injury. 2014;45(Suppl 6):S43–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011;42(11):1283–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Court-Brown CM, McQueen MM. Nonunions of the proximal humerus: their prevalence and functional outcome. J Trauma. 2008;64(6):1517–21.PubMedCrossRefGoogle Scholar
  44. 44.
    Hernigou J, Schuind F. Smoking as a predictor of negative outcome in diaphyseal fracture healing. Int Orthop. 2013;37(5):883–7.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Boesmueller S, Wech M, Gregori M, Domaszewski F, Bukaty A, Fialka C, et al. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury. 2016;47(2):350–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Schlegel TF, Hawkins RJ. Displaced proximal humeral fractures: evaluation and treatment. J Am Acad Orthop Surg. 1994;2(1):54–78.PubMedCrossRefGoogle Scholar
  47. 47.
    Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52(6):1090–103.PubMedCrossRefGoogle Scholar
  48. 48.
    Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg. 2012;20(1):17–27.PubMedGoogle Scholar
  49. 49.
    Pavlopoulos DA, Badras LS, Georgiou CS, Skretas EF, Malizos KN. Hemiarthroplasty for three- and four- part displaced fractures of the proximal humerus in patients over 65 years of age. Acta Orthop Belg. 2007;73(3):306–14.PubMedGoogle Scholar
  50. 50.
    Liu K, Liu PC, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Med Sci Monit. 2015;21:496–504.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427–33.PubMedCrossRefGoogle Scholar
  52. 52.
    Bastian JD, Hertel R. Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg. 2008;17(1):2–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Burrus MT, Cancienne JM, Boatright JD, Yang S, Brockmeier SF, Werner BC. Correction to: shoulder arthroplasty for humeral head avascular necrosis is associated with increased postoperative complications. HSS J. 2018;14(2):225.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Archer LA, Furey A. Rate of avascular necrosis and time to surgery in proximal humerus fractures. Musculoskelet Surg. 2016;100(3):213–6.PubMedCrossRefGoogle Scholar
  55. 55.
    Xia S, Zhang Y, Wang X, Wang Z, Wang W, Ma X, et al. Computerized virtual surgery planning for ORIF of proximal humeral fractures. Orthopedics. 2015;38(5):e428–33.PubMedCrossRefGoogle Scholar
  56. 56.
    Rotini R, Cavaciocchi M, Fabbri D, Bettelli G, Catani F, Campochiaro G, et al. Proximal humeral fracture fixation: multicenter study with carbon fiber peek plate. Musculoskelet Surg. 2015;99(Suppl 1):S1–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Schliemann B, Hartensuer R, Koch T, Theisen C, Raschke MJ, Kosters C, et al. Treatment of proximal humerus fractures with a CFR-PEEK plate: 2-year results of a prospective study and comparison to fixation with a conventional locking plate. J Shoulder Elbow Surg. 2015;24(8):1282–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Naraghi FF, DeCoster TA, Moneim MS, Miller RA, Rivero D. Heterotopic ossification. Orthopedics. 1996;19(2):145–51.PubMedGoogle Scholar
  59. 59.
    Chao ST, Joyce MJ, Suh JH. Treatment of heterotopic ossification. Orthopedics. 2007;30(6):457–64.. quiz 65–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Zhang R, Oyajobi BO, Harris SE, Chen D, Tsao C, Deng HW, et al. Wnt/beta-catenin signaling activates bone morphogenetic protein 2 expression in osteoblasts. Bone. 2013;52(1):145–56.PubMedCrossRefGoogle Scholar
  61. 61.
    Orzel JA, Rudd TG. Heterotopic bone formation: clinical, laboratory, and imaging correlation. J Nucl Med. 1985;26(2):125–32.PubMedGoogle Scholar
  62. 62.
    Taussky D, Cserhati M, Pescia R. Preoperative radiotherapy without femoral shielding for prevention of heterotopic ossification in hydroxyapatite-coated hip prostheses. Arch Orthop Trauma Surg. 2001;121(5):271–3.PubMedCrossRefGoogle Scholar
  63. 63.
    Sodemann B, Persson PE, Nilsson OS. Prevention of periarticular heterotopic ossification following total hip arthroplasty. Clinical experience with indomethacin and ibuprofen. Arch Orthop Trauma Surg. 1988;107(6):329–33.PubMedCrossRefGoogle Scholar
  64. 64.
    Cella JP, Salvati EA, Sculco TP. Indomethacin for the prevention of heterotopic ossification following total hip arthroplasty. Effectiveness, contraindications, and adverse effects. J Arthroplast. 1988;3(3):229–34.CrossRefGoogle Scholar
  65. 65.
    Macfarlane RJ, Ng BH, Gamie Z, El Masry MA, Velonis S, Schizas C, et al. Pharmacological treatment of heterotopic ossification following hip and acetabular surgery. Expert Opin Pharmacother. 2008;9(5):767–86.PubMedCrossRefGoogle Scholar
  66. 66.
    Balboni TA, Gobezie R, Mamon HJ. Heterotopic ossification: pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys. 2006;65(5):1289–99.PubMedCrossRefGoogle Scholar
  67. 67.
    Blokhuis TJ, Frolke JP. Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures?: a systematic review. Clin Orthop Relat Res. 2009;467(2):526–30.PubMedCrossRefGoogle Scholar
  68. 68.
    Ahrengart L, Lindgren U, Reinholt FP. Comparative study of the effects of radiation, indomethacin, prednisolone, and ethane-1-hydroxy-1,1-diphosphonate (EHDP) in the prevention of ectopic bone formation. Clin Orthop Relat Res. 1988;229:265–73.Google Scholar
  69. 69.
    Matta JM, Siebenrock KA. Does indomethacin reduce heterotopic bone formation after operations for acetabular fractures? A prospective randomised study. J Bone Joint Surg. 1997;79(6):959–63.CrossRefGoogle Scholar
  70. 70.
    Fransen M, Neal B. Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty. Cochrane Database Syst Rev. 2004;3:CD001160.Google Scholar
  71. 71.
    Neal BC, Rodgers A, Clark T, Gray H, Reid IR, Dunn L, et al. A systematic survey of 13 randomized trials of non-steroidal anti-inflammatory drugs for the prevention of heterotopic bone formation after major hip surgery. Acta Orthop Scand. 2000;71(2):122–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Hunt RH, Harper S, Watson DJ, Yu C, Quan H, Lee M, et al. The gastrointestinal safety of the COX-2 selective inhibitor etoricoxib assessed by both endoscopy and analysis of upper gastrointestinal events. Am J Gastroenterol. 2003;98(8):1725–33.PubMedCrossRefGoogle Scholar
  73. 73.
    Brunnekreef JJ, Hoogervorst P, Ploegmakers MJ, Rijnen WH, Schreurs BW. Is etoricoxib effective in preventing heterotopic ossification after primary total hip arthroplasty? Int Orthop. 2013;37(4):583–7.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Weber EW, Slappendel R, Durieux ME, Dirksen R, van der Heide H, Spruit M. COX 2 selectivity of non-steroidal anti-inflammatory drugs and perioperative blood loss in hip surgery. A randomized comparison of indomethacin and meloxicam. Eur J Anaesthesiol. 2003;20(12):963–6.PubMedCrossRefGoogle Scholar
  75. 75.
    Padgett DE, Holley KG, Cummings M, Rosenberg AG, Sumner DR, Conterato D, et al. The efficacy of 500 CentiGray radiation in the prevention of heterotopic ossification after total hip arthroplasty: a prospective, randomized, pilot study. J Arthroplast. 2003;18(6):677–86.CrossRefGoogle Scholar
  76. 76.
    Sperling JW, Cofield RH, Rowland CM. Heterotopic ossification after total shoulder arthroplasty. J Arthroplast. 2000;15(2):179–82.CrossRefGoogle Scholar
  77. 77.
    Erggelet C, Eggensperger G, Steinwachs M, Lahm A, Reichelt A. Postoperative ossifications of the shoulder. Incidence and clinical impact. Arch Orthop Trauma Surg. 1999;119(3–4):168–70.PubMedCrossRefGoogle Scholar
  78. 78.
    Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma. 2004;18(8):488–93.PubMedCrossRefGoogle Scholar
  79. 79.
    Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am. 2006;88(Suppl 4):189–200.PubMedGoogle Scholar
  80. 80.
    Wagner M. General principles for the clinical use of the LCP. Injury. 2003;34(Suppl 2):B31–42.PubMedCrossRefGoogle Scholar
  81. 81.
    Tingart MJ, Lehtinen J, Zurakowski D, Warner JJ, Apreleva M. Proximal humeral fractures: regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws. J Shoulder Elbow Surg. 2006;15(5):620–4.PubMedCrossRefGoogle Scholar
  82. 82.
    Schliemann B, Wahnert D, Theisen C, Herbort M, Kosters C, Raschke MJ, et al. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury. 2015;46(7):1207–14.PubMedCrossRefGoogle Scholar
  83. 83.
    Roderer G, Scola A, Schmolz W, Gebhard F, Windolf M, Hofmann-Fliri L. Biomechanical in vitro assessment of screw augmentation in locked plating of proximal humerus fractures. Injury. 2013;44(10):1327–32.PubMedCrossRefGoogle Scholar
  84. 84.
    Katthagen JC, Lutz O, Voigt C, Lill H, Ellwein A. Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures. Obere Extrem. 2018;13(2):123–9.PubMedPubMedCentralCrossRefGoogle Scholar
  85. 85.
    McMillan TE, Johnstone AJ. Primary screw perforation or subsequent screw cut-out following proximal humerus fracture fixation using locking plates: a review of causative factors and proposed solutions. Int Orthop. 2018;42(8):1935–42.PubMedCrossRefGoogle Scholar
  86. 86.
    Lill H, Hepp P, Korner J, Kassi JP, Verheyden AP, Josten C, et al. Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens. Arch Orthop Trauma Surg. 2003;123(2–3):74–81.PubMedCrossRefGoogle Scholar
  87. 87.
    Padegimas EM, Zmistowski B, Lawrence C, Palmquist A, Nicholson TA, Namdari S. Defining optimal calcar screw positioning in proximal humerus fracture fixation. J Shoulder Elbow Surg. 2017;26(11):1931–7.PubMedCrossRefGoogle Scholar
  88. 88.
    Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011;42(4):408–13.PubMedCrossRefGoogle Scholar
  89. 89.
    Schliemann B, Siemoneit J, Theisen C, Kosters C, Weimann A, Raschke MJ. Complex fractures of the proximal humerus in the elderly--outcome and complications after locking plate fixation. Musculoskelet Surg. 2012;96(Suppl 1):S3–11.PubMedCrossRefGoogle Scholar
  90. 90.
    Acklin YP, Michelitsch C, Sommer C. Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome. BMC Musculoskelet Disord. 2016;10(17):119.CrossRefGoogle Scholar
  91. 91.
    Raja S, Imbuldeniya AM, Garg S, Groom G. Difficulties encountered removing locked plates. Ann R Coll Surg Engl. 2012;94(7):502–5.PubMedPubMedCentralCrossRefGoogle Scholar
  92. 92.
    Schwarz N, Euler S, Schlittler M, Ulbing T, Wilhelm P, Fronhofer G, et al. Technical complications during removal of locking screws from locking compression plates: a prospective multicenter study. Eur J Trauma Emerg Surg. 2013;39(4):339–44.PubMedCrossRefGoogle Scholar
  93. 93.
    Kavuri V, Bowden B, Kumar N, Cerynik D. Complications associated with locking plate of proximal humerus fractures. Indian J Orthop. 2018;52(2):108–16.PubMedPubMedCentralGoogle Scholar
  94. 94.
    Spross C, Jost B, Rahm S, Winklhofer S, Erhardt J, Benninger E. How many radiographs are needed to detect angular stable head screw cut outs of the proximal humerus – a cadaver study. Injury. 2014;45(10):1557–63.PubMedCrossRefGoogle Scholar
  95. 95.
    Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23(3):163–72.PubMedCrossRefGoogle Scholar
  96. 96.
    Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741–8.PubMedCrossRefGoogle Scholar
  97. 97.
    Westphal T, Woischnik S, Adolf D, Feistner H, Piatek S. Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings. J Shoulder Elbow Surg. 2017;26(3):464–71.PubMedCrossRefGoogle Scholar
  98. 98.
    Wu CH, Ma CH, Yeh JJ, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71(5):1364–70.PubMedCrossRefGoogle Scholar
  99. 99.
    Gavaskar AS, Chowdary N, Abraham S. Complex proximal humerus fractures treated with locked plating utilizing an extended deltoid split approach with a shoulder strap incision. J Orthop Trauma. 2013;27(2):73–6.PubMedCrossRefGoogle Scholar
  100. 100.
    Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472(5):1576–85.PubMedCrossRefGoogle Scholar
  101. 101.
    Acklin YP, Stoffel K, Sommer C. A prospective analysis of the functional and radiological outcomes of minimally invasive plating in proximal humerus fractures. Injury. 2013;44(4):456–60.PubMedCrossRefGoogle Scholar
  102. 102.
    Ruchholtz S, Hauk C, Lewan U, Franz D, Kuhne C, Zettl R. Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. J Trauma. 2011;71(6):1737–44.PubMedGoogle Scholar
  103. 103.
    Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20(9):602–7.PubMedCrossRefGoogle Scholar
  104. 104.
    Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Joint J. 2013;95-B(1):70–4.PubMedCrossRefGoogle Scholar
  105. 105.
    Jameson SS, James P, Howcroft DW, Serrano-Pedraza I, Rangan A, Reed MR, et al. Venous thromboembolic events are rare after shoulder surgery: analysis of a national database. J Shoulder Elbow Surg. 2011;20(5):764–70.PubMedCrossRefGoogle Scholar
  106. 106.
    Hoxie SC, Sperling JW, Cofield RH. Pulmonary embolism after operative treatment of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16(6):782–3.PubMedCrossRefGoogle Scholar
  107. 107.
    Klatte TO, Sabihi R, Guenther D, Kamath AF, Rueger JM, Gehrke T, et al. High rates of occult infection after shoulder fracture fixation: considerations for conversion shoulder arthroplasty. HSS J. 2015;11(3):198–203.PubMedPubMedCentralCrossRefGoogle Scholar
  108. 108.
    Gottschalk MB, Carpenter W, Hiza E, Reisman W, Roberson J. Humeral shaft fracture fixation: incidence rates and complications as reported by American Board of Orthopaedic Surgery Part II Candidates. J Bone Joint Surg Am. 2016;98(17):e71.PubMedCrossRefGoogle Scholar
  109. 109.
    Athwal GS, Sperling JW, Rispoli DM, Cofield RH. Acute deep infection after surgical fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16(4):408–12.PubMedCrossRefGoogle Scholar
  110. 110.
    Blonna D, Barbasetti N, Banche G, Cuffini AM, Bellato E, Masse A, et al. Incidence and risk factors for acute infection after proximal humeral fractures: a multicenter study. J Shoulder Elbow Surg. 2014;23(4):528–35.PubMedCrossRefGoogle Scholar
  111. 111.
    Marecek GS, Weatherford BM, Fuller EB, Saltzman MD. The effect of axillary hair on surgical antisepsis around the shoulder. J Shoulder Elbow Surg. 2015;24(5):804–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Luca La Verde
    • 1
    • 2
  • Edoardo Franceschetti
    • 2
  • Filippo Familiari
    • 3
  • Francesco Franceschi
    • 2
  1. 1.UOC di Ortopedia e Traumatologia, Policlinico Universitario “G. Martino”MessinaItaly
  2. 2.UOS di Chirurgia dell’Arto Superiore ed Inferiore, Policlinico Universitario “Campus Bio-Medico”RomeItaly
  3. 3.Casa di Cura “Villa del Sole”CatanzaroItaly

Personalised recommendations