O R I G I N A L A R T I C L E
Clinical evaluation of an antero-medial approach for plate fixation
of the proximal humeral shaft
Burak Akan•Mehmet Armangil•Kerem Basarir•
Halil Acar•Sinan Sirri Bilgin•Mehmet Demirtas
Received: 5 May 2011 / Accepted: 3 July 2011 / Published online: 17 July 2011 Ó Springer-Verlag 2011
Abstract
Objective Surgical approach of fractures of the proximal humeral shaft should protect the muscular insertions and the vascularisation of fragments, improving bone union and functional recovery. The aim of this study is to review cases operated with an original anteromedial approach, in cases of specific fractures of the proximal humeral shaft. Materials and methods Prior to clinical application, a cadaveric study was accomplished. Based on the results, six clinical cases had surgery using an approach medial to the biceps and brachialis. The osteosynthesis was per-formed with locked plates and 4.5 screws. The approach was indicated in fractures presenting with a large lateral wedge including the deltoid muscle insertion. Stable oste-osynthesis achieved with this approach allowed early postoperative mobilization of the arm in all cases. Results The case-series consisted of three women and three men with a mean age of 52.1 years (range 38–68). The minimal follow-up was 1 year. Bone union was observed at an average time of 11.2 weeks. There were no intra- or postoperative complications.
Discussion Open reduction and internal fixation with compression plating is a standardized and successful
procedure in the treatment of humeral fractures. Internal fixation with lateral plating is difficult in the proximal third of the humeral shaft, where the positioning of the implant may hurt the long biceps tendon and the deltoid insertion. This approach was successful and safe in the presented cases.
Conclusion The antero-medial approach with metaphy-seal locking plate protects the muscular insertions and the vascularisation of the wedge fragment, leading to good results in all the cases in this series.
Keywords Antero-medial approach Humerus fracture Lateral wedge humerus fracture Osteosynthesis Plate 4.5 screws
Introduction
Fractures of the proximal and middle thirds of the humerus may be treated with plate fixation [5,15,16]. Traditionally, plate fixation is performed on the lateral side of the proximal humerus due to its flat surface and the frequently fractured segments of the tuberculum majus and humeral head. However, in the middle third of the humerus, the deltoid insertion limits the placement of the plate on the external cortical [15,16]. Additionally, the large lateral wedge frag-ment containing the point of deltoid insertion should be stripped of its soft tissue attachments, eventually disturbing its vascular supply and delaying the bone healing.
Due to the anatomical difficulties, the surgeons have sometimes to choose between inserting the plate into a lateral position with more soft tissue stripping or into a weaker eccentric position with preservation of vasculari-sation. The use of a pre-contoured helical plate fitting the greater tuberosity proximally and the antero-medial surface B. Akan
Department of Orthopedics and Traumatology, Ufuk University Faculty of Medicine, Ankara, Turkey M. Armangil (&) K. Basarir S. S. Bilgin M. Demirtas A.U¨ .T.F. I˙bn’i Sina Hospital, Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, 06100 Samanpazarı, Ankara, Turkey
e-mail: mehmetarmangil@yahoo.com H. Acar
Department of Anatomy, Ankara University Faculty of Medicine, Ankara, Turkey
distally was proposed in order to preserve the deltoid insertion [3, 4, 16]. Although suitable for most proximal humeral fractures, this technique still requires extensive dissection proximally and on the wedge fragment.
The purpose of this study was to evaluate the use of the open reduction and internal fixation through an antero-medial approach that preserves the vascularisation of the wedge fragment and of the humeral head in cases of fractures of the proximal humerus presenting with a large proximal fragment. Our hypothesis was that this technique could be used in selected cases with high union and low complication rates.
Patients and methods
In the cadaver work prior to the clinical application, an approximately 15-cm long anteromedial incision was per-formed. The biceps brachii and brachialis muscles were identified and distracted laterally, allowing access to the humerus. The neurovascular structures exposed during this approach included the cephalic vein and musculocutaneous nerve. The plate can be implanted from the pectoralis major tendon. If necessary, the plate can also be inserted under the long biceps tendon by lifting the insertion of the pectoralis major muscle (Fig.1). This surgical approach was utilized in all the cases in this series.
The Institutional Review Board (IRB) of our institution approved this study that included in a prospective manner a total of 6 patients with fractures of the proximal and middle thirds of the humerus. Indications for use of antero-medial approach specifically were the presence of a fracture in the proximal and middle thirds of the humeral shaft, uninjured humeral head fragment, and the presence of a lateral wedge
fragment at deltoid muscle insertion (Fig.2). All patients were treated by a senior surgeon (D.M.) between May 2007 and March 2009. Indications for surgical intervention in acute fractures were polytrauma cases and inability to obtain or maintain an acceptable closed reduction. Three patients were injured in road traffic or pedestrian accidents and 3 patients fell from a height. The fractures were clas-sified using the Orthopaedic Trauma Association (OTA) classification system. All patients were operated in supine position with the head of the table tilted 20° forward. The antero-medial approach was used to expose the proximal and middle humerus without a tourniquet. After identifi-cation of the biceps brachii and brachialis muscle, dissec-tion was performed medially. The humeral shaft was identified; Hohmann retractors were used subperiosteally to approach the fracture site. Fractures were reduced and temporarily fixed with Kirschner wires and lag screws if possible. Locking plates with 4.5-mm non-locking and 5.0-mm locking screws (Synthes, Warsaw, Indiana, USA) were used for definitive fixation. The musculocutaneous nerve was identified and protected during the operation.
All patients received perioperative antibiotics for pro-phylaxis. After 2 days of sling immobilization, passive shoulder and elbow mobilization was initiated within an arm neck sling. The shoulder and elbow mobilization and strengthening were progressively increased based on the patient’s tolerance.
Patients were followed postoperatively by the surgeon until consolidation occurred, and they were reviewed for the study. The charts and radiographs were revisited for demographic and clinical data. The type of injury, fracture classification, adequacy of reduction, and bone consolida-tion were reviewed. The medical outcome was carefully recorded.
Fig. 1 Cadaveric study. Note the relationship of the musculocutaneous nerve and muscles
Results
Six patients who constituted the basis of this report had a mean follow-up of 18.8 months (range 12–26 months). There were three men and three women with a mean age of 52.1 years (range 38–68 years). Three fractures were OTA type 12-B1, 2 fractures were OTA type 12-B2, and the other was 12-B3. No intra-operative problems such as neurovascular injury were associated with the use of this approach. The average operative time was 62 min (range 50–100 min). The mean intra-operative blood loss was 400 ml (range 300–650 ml). All fractures healed unevent-fully. The mean time for bone consolidation was 11.2 weeks (range 8–15 weeks). No postoperative com-plications were observed in this group including wound
infection, fixation failure, or nerve palsy. None of the patients reported symptoms due to irritation caused by the plate; therefore no removal of the fixation material was noted (Fig.3).
Discussion
The majority of humeral shaft fractures can be satisfacto-rily treated with nonoperative methods. However, opera-tive treatment is indicated when unacceptable reduction is observed, in case of multiple injuries or nonunion [1,2,5,
6, 16]. Open reduction and internal fixation with com-pression plating has been accepted as a standard and suc-cessful model for the surgical treatment of humerus Fig. 2 55-year-old male. X-ray views before and 8 weeks after surgery
fractures [2,9,11,14]. Compression plating is reported to have several advantages over intramedullary nailing including superior fixation in both osteopenic and normal bones, less shoulder pain, greater shoulder mobility, and fewer secondary procedures [10, 12, 14]. Compression plating has become widely accepted as the ‘‘definitive method’’ of treating fractures of the upper extremity [2,7,
12, 13]. Successful results are reported also with intra-medullary nailing or with locking plates.
Internal fixation with conventional lateral plating tech-nique has some limitations in certain anatomic areas, such as fractures located in the proximal one-third of the hum-eral shaft, where the long head of the biceps muscle and the deltoid muscle insertion limit placement of the plate [3,14,
16]. Deltoid detachment may lead to delayed rehabilitation and inferior migration of the humeral head [14]. Addi-tionally, the large lateral wedge fragment needs to be stripped in order to place a plate on its surface, which may potentially lead to delayed or non-union. The ultimate goal is to preserve both muscle insertions and vascular supply of the wedge fragment. Spiral plates and minimally invasive techniques were the suggested methods for the two prob-lems, respectively.
Helical or spiral plate usage was performed in a case of humeral nonunion more than a decade ago [4]. Since then, several reports were published considering the use of this type of plates. Fernandez used a helical plate for minimally invasive plate osteosynthesis (MIPO) of the humerus starting at the sub-deltoid space and turning 90° anteriorly to the sub-brachialis space. The axillary nerve is at risk at the insertion site, and the long head of the biceps may be injured with this technique [1, 3]. For comminuted frac-tures of the proximal and middle thirds of the humerus, Yang used a twisted long plate from the lateral aspect of the greater tuberosity to the anterior or antero-medial aspect of the mid or the distal shaft of the humerus, pre-serving the deltoid muscle insertion, in n patients [16].
Considering the vascularisation of the fracture and MIPO of the humerus, a cadaveric study investigated plating on the lateral side of the biceps and medial to the deltoid with two separate small incisions. Although no radial nerve entrapment was noted, the anatomical land-marks and tissue planes may be usually abnormal and distorted in cases of comminuted fractures [1].
Among the several techniques defined over a period of more than a decade, none had gained wide acceptance [8]. There may be several explanations for this. First, it is difficult to correctly bend a regular plate intraoperatively or to have a pre-contoured plate. Secondly, minimally inva-sive techniques still carry a serious risk of neurovascular injury in the humeral shaft, the radial nerve being in proximity and presenting eventually a distorted anatomy.
Our approach may be accepted as an alternative tech-nique, with an open approach minimizing the risk of neu-rovascular damage compared with the MIPO technique and lessening the need for bending the plate. The small number of the cases and lack of randomized trials remain a limi-tation for this study. However, bone union was obtained in all cases within 11.2 weeks in this series, which is com-parable to other techniques.
Conclusion
In certain fracture types of the meta-diaphyseal humeral shaft, the antero-medial approach with metaphyseal lock-ing plate appears to be a promislock-ing alternative. This approach preserves the vascularisation of the wedge frag-ment attached to the deltoid insertion and proximal humerus, avoiding unnecessary dissection. We recommend the anatomic study for the surgeons who would like to perform this approach in practice.
Conflict of interest No benefits in any form have been or will be received from a commercial party related directly or in directly to the subject of this manuscript.
References
1. Apivatthakakul T, Arpornchayanon O, Bavornratanavech S (2005) Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? a cadaveric study and preliminary report. Injury 36:530–538
2. Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY (1985) The results of plating humeral shaft fractures in patients with multiple injuries. The sunnybrook experience. J Bone Joint Surg Br 67: 293–296
3. Fernandez Dell’Oca AA (2002) The principle of helical implants: unusual ideas worth considering. Case studies. Injury 33:29–40 4. Gill DRJ, Torchia ME (1999) The spiral compression plate for
proximal humeral shaft nonunion: a case report and description of a new technique. J Orthop Trauma 13:141–144
5. Heim D, Herkett F, Hess P, Reggazoni P (1993) Surgical treat-ment of humeral shaft fractures–—the basel experience. J Trauma 35:226–232
6. Hunter SG (1982) The closed treatment of fractures of the humeral shaft. Clin Orthop 164:192–198
7. Jiang R, Luo CF, Zeng BF, Mei GH (2007) Minimally invasive plating for complex humeral shaft fractures. Arch Orthop Trauma Surg 127:531–535
8. Levy O, Pritsch M, Oran A, Greental A (1999) A wide and versatile combined surgical approch to the shoulder. J Should Elb Surg 8:658–659
9. Lever JP, Aksenov SA, Zdero R, Ahn H, McKee MD, Schemitsch EH (2008) Biomechanical analysis of plate osteosynthesis sys-tems for proximal humerus fractures. J Orthop Trauma 22:23–29 10. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH (2000) Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br 82:336–339
11. McKee MD, Seiler JG, Jupiter JB (1995) The application of the limited contact dynamic compression plate in the upper extrem-ity: an analysis of 114 consecutive cases. Injury 26:661–666 12. Modabber MR, Jupiter JB (1998) Operative management of
diaphyseal fractures of the humerus. Plate versus nail. Clin Ort-hop Relat Res 347:93–104
13. Rose PS, Adams CR, Torchia ME, Jacofsky DJ, Haidukewych GG, Steinmann SP (2007) Locking plate fixation for proximal humeral fractures: initial results with a new implant. J Should Elb Surg 16:202–207
14. Spitzer AB, Davidovitch RI, Egol KA (2009) Use of a hybrid locking plate for complex metaphyseal and nonunions about the humerus. Injury 40:240–244
15. Szyszkowitz R. (2000): Humerus proximal. In: Rudi TP, Murphy WM (eds) AO principles of fracture management. Thieme, Stuttgart, pp 271–89
16. Yang KY (2005) Helical plate fixation for treatment of commi-nuted fractures of the proximal and middle one-third of the humerus. Injury 36:75–80
