ORIGINAL ARTICLE

Open Reduction and Internal Fixation of Proximal

Humerus Fractures Using a Proximal Humeral Locked
Plate: A Prospective Multicenter Analysis
Felix Brunner, MD,* Christoph Sommer, MD,† Christian Bahrs, MD,‡ Rainer Heuwinkel, MD,§
Christian Hafner, MD,¶ Paavo Rillmann, MD,k Georges Kohut, MD,** Anders Ekelund, MD, PhD,††
Mathias Muller, MD,‡‡ Laurent Audigé, DVM, PhD,‡‡ and Reto Babst, MD*

primary and secondary screw perforations into the glenohumeral

Objectives: The goal of this study is to evaluate the incidence of joint, with an overall complication rate of 35%. More accurate length
complications and the functional outcome after open reduction and measurement and shorter screw selection should prevent primary
internal fixation with the proximal humeral locking plate (Philos). screw perforation. Awareness of obtaining anatomic reduction of the
tubercles and restoring the medial support should reduce the
Design: Prospective case series.
incidence of secondary screw perforations, even in osteopenic bone.
Setting: Multicenter study in 8 trauma units (levels I, II, and III) Key Words: proximal humerus fracture, Philos, ORIF, fixation,
with recruitment between September 12, 2002, and January 9, 2005.
angular stable, form plate, complication, screw perforation, avascular
Patients: One hundred fifty-seven patients with 158 fractures. head necrosis

Intervention: Open reduction and internal fixation with a (J Orthop Trauma 2009;23:163–172)
Philos plate.
Main Outcome Measurements: Occurrence of postoperative
complications up to 1 year and active follow-up for 1 year with INTRODUCTION
radiologic assessment to observe fracture healing, alignment, The incidence of proximal humerus fractures is increas-
reduction, avascular necrosis, and functional outcome measurements ing, especially in the elderly population.1–5 Various treatment
including Constant, Disabilities of the Arm, Shoulder, and Hand, and options of displaced fractures are known but are still asso-
Neer scores. ciated with high complication rates.6–37
Open reduction and internal fixation (ORIF) of proximal
Results: One-year follow-up rate was 84%. The incidence of humerus fractures with conventional plates has been associ-
experiencing any implant-related complication was 9% and 35% for ated with loss of reduction, screw loosening, and osteonec-
nonimplant-related complications. Primary screw perforation was the rosis.18–27 Consequently, angular stable plates33–44 have been
most frequent problem (14%) followed by secondary screw developed in recent years to preserve anatomic reduction with
perforation (8%) and avascular necrosis (8%). After 1 year, a mean stronger anchorage, especially in osteoporotic bone. Among
Constant score of 72 points (87% of the contralateral noninjured them, the 3-dimensional anatomically adjusted Philos plate
side), a mean Neer score of 76 points, and a mean Disabilities of the (Synthes, Oberdorf, Switzerland) provides a locking system
Arm, Shoulder, and Hand score of 16 points were achieved. for its proximal part contacting the humeral head. To our
Conclusions: Fixation with Philos plates preserves achieved knowledge, limited scientific evidence from only 4 case series
reduction, and a good functional outcome can be expected. However, studies has been published on fracture and patient outcomes
complication incidence proportions are high, particularly due to after the use of this implant.38–44
The present multicenter study was conducted to evaluate
the rate of union, functional outcomes, and the complication
incidence proportions after 1 year following fixation of proxi-
Accepted for publication October 21, 2008.
From the*Department of Surgery, Cantonal Hospital, Lucerne, Switzerland; mal humerus fractures with this angular stable plate.
†Department of Surgery, Cantonal Hospital, Chur, Switzerland;
‡BG Unfallklinik, Tübingen, Germany; §Trauma Unit, Westpfalz-Klinikum,
Kaiserslautern, Germany; {Trauma Unit, Klinikum Rosenheim, Rose- PATIENTS AND METHODS
nheim, Germany; kDepartment of Surgery and Orthopedics, Spital Davos,
Davos Platz, Switzerland; **Department of Orthopedics, Cantonal Patient Recruitment
Hospital, Fribourg, Switzerland; ††Department of Orthopedics, Capio All patients with displaced proximal humerus fractures
St. Göran’s Hospital, Stockholm, Sweden; and ‡‡AO Clinical Inves- were recruited between September 12, 2002, and January 9,
tigation and Documentation, AO Center, Davos Platz, Switzerland.
Reprints: Prof Dr. med. Reto Babst, MD, Department of Surgery, Cantonal 2005, at 8 participating trauma units. Patients underwent ORIF
Hospital, 6000 Lucerne 16, Switzerland (e-mail: [Link]@[Link]). with a Philos plate and were prospectively followed according
Copyright Ó 2009 by Lippincott Williams & Wilkins to a predefined protocol. Included patients were required to be

J Orthop Trauma
Volume 23, Number 3, March 2009 163

Brunner et al J Orthop Trauma
Volume 23, Number 3, March 2009

at least 18 years of age, skeletally mature, and have a maximum emergency room. The radiographs were repeated postopera-
delay of 10 days between the date of injury and definitive tively. Computed tomography evaluation was undertaken at
ORIF. Surgeons involved in the care of these patients had to the discretion of the treating surgeon.
have prior experience in at least 5 osteosyntheses with this
implant before their patients were included in the study. All Follow-up Examinations
operating or supervising surgeons were also required to be
Patients were examined immediately postoperatively
fellowship-trained trauma surgeons. Exclusion criteria in-
and after 12 weeks and 6 and 12 months. At each follow-up,
cluded pseudarthrosis, pathologic fractures and refractures,
patients received shoulder radiographs in 2 planes (anterior–
open fractures, or concomitant fractures of the ipsilateral
posterior and Neer view) to survey fracture healing. Antic-
elbow or distal radius. In addition, patients with existing
ipated postoperative complications included loss of reduction,
disorders having an effect on the healing process and function
fragment displacement, major varus or valgus deformation,
such as multiple sclerosis, paraplegia, or other relevant
head necrosis or implant-related problems (‘‘screw perfora-
neurologic disorders, patients with polytrauma with an Injury
tion,’’ screw loosening or backing out, plate pullout, or break-
Severity Score greater than 16, and patients with posttraumatic
age), and surgical and other general complications such as
brachial plexus injury or peripheral nerve palsy were excluded.
wound infection or soft-tissue problems (rotator cuff lesions,
Operative Technique adhesions, frozen shoulders, impingement, and nerve lesions).
Complications and radiographic findings were jointly reviewed
Surgery was performed in a beach chair position or
by the primary and senior authors to define if complications
prone on a radiolucent table, with side placement of an image
were implant or nonimplant related; the primary author was not
intensifier to allow viewing of the humeral head in 2 planes.
involved in the care of any study patient, and the senior author
Depending on the particular need for exposure, an anterior
was only involved with a small proportion of patients due to the
deltopectoral or transdeltoid lateral approach was chosen. The
multicenter nature of the study. A complication was considered
latter approach was only appropriate for limited operations
as implant related if screws perforated secondary to angular
with exposure of the greater tuberosity or the most proximal
stability or if implant breakage, secondary loss of reduction, or
part of the humeral head. After reduction, mostly with the aid
screw pullout due to insufficient purchase occurred.
of sutures, the plates were positioned using a mounted aiming
Patients were further interviewed concerning pain and
device. Plates with 3 or 5 holes at shaft level were chosen
shoulder mobility and underwent shoulder examination using
based on fracture extension. Plates were placed at least 5–8
a spring balance (Isobex; Curson AG, Bern, Switzerland) at
mm inferior to the upper end of the greater tuberosity to avoid
90-degree abduction. The average of these power measure-
subacromial impingement and 2–4 mm lateral to the bicipital
ments was used to assess individual Constant scores47 of
groove, ensuring that a sufficient gap was maintained between
injured and contralateral shoulders. Additionally, DASH and
the plate and the tendon of the long head of the biceps muscle.
Neer scores8 were determined at the 1-year follow-up.
The achieved reduction was temporarily fixed with 1.6-mm
Humeral head-to-shaft angle was measured in all
K-wires through the proximal holes and checked with an
anterior–posterior postoperative x-ray projections, and those
image intensifier. When reduction was satisfactory, the
specifically taken at the last follow-up were measured using
K-wires were replaced by locked screws. Locked or standard
the viewing software, IcoView Light (Icoserve Information
cortical screws were inserted into the remaining holes of the
Technologies, Innsbruck, Austria). The angle between shaft
humeral shaft at the discretion of the treating surgeon.
axis and head axis was measured and approximated to the next
Baseline Evaluations 5 degrees, whereby head axis was taken as perpendicular to
a line between the nearest lateral and medial visible points of
During hospitalization, patient demographics (ie, sex,
the anatomic neck through the apex of the head. Head-to-shaft
age, dexterity, smoking, concomitant diseases, and medi-
angle measurements were further categorized as major varus
cation) and baseline characteristics (ie, accident type, energy
(,115 degrees), minor varus (115–124 degrees), normal
level of trauma, concomitant injuries, fracture classification,
(125–145 degrees), minor valgus (146–155 degrees), and
delay between accident and surgery, operation time, C-arm
major valgus (.155 degrees) and compared between the
time, use of plates with 3 or 5 holes at shaft level, distribution
postoperative and latest follow-up examination. No anatomic
of used standard and locking screws, additional implants and
measurements could be performed using Neer view as only
sutures, additional medication, type and duration of immo-
40% of the x-rays performed at the latest follow-up were
bilization, and beginning of active assisted and unrestricted
adequate.
mobilization) were documented. At the immediate post-
operative period, patients were asked to rate their upper limb
function during the week before the accident to determine their Data Management and Analysis
preinjury Disabilities of the Arm, Shoulder, and Hand (DASH) Study monitoring, database management, and statistics
score using the extended 3 modular questionnaire.45 Fractures were performed by a central monitoring organization. Data
were classified according to the AO/OTA and Neer classifi- were entered in a Qualicare 5.1 database (Qualidoc, Trimbach,
cation8,46 by the treating surgeons. Intraoperative complica- Switzerland) and exported into Excel (Microsoft Corporation,
tions such as bleeding, hematoma, and nerve injury were Washington, DC). Statistical analyses were conducted with
documented. Patients received anterior-posterior projection Intercooled Stata Version 9 (Stata Corporation, College
and Neer view shoulder radiographs upon admission to the Station, TX).

164 q 2009 Lippincott Williams & Wilkins

J Orthop Trauma
Volume 23, Number 3, March 2009 ORIF of Proximal Humerus Fractures

Complications were tabulated according to their most

likely causative factor as evaluated by the primary and senior
authors. Associated events were considered carefully during
the occurrence of complications when estimating cumulative
complication incidence proportions over the follow-up period.
For instance, ‘‘secondary impaction’’ and screw perforation
were often associated events in the clinical expression of
a complication. Complication incidence proportions were
estimated by the cumulative number of reported complications
during the follow-up period divided by the number of fractures
at the start of this period. Cause-specific complication
incidence proportions were calculated and reported with their
binomial exact 95% confidence interval (CI). The latter
estimations were then used to explore the effect of potential
influencing factors, for example, fracture types (A, B, and C)
and age categories.
The mean of all Constant scores of the contralateral FIGURE 1. Distribution of fracture types according to the AO/
healthy side measured at any follow-up time was taken as OTA classification.
a reference for each patient. The Constant scores of the injured
side at each follow-up were then compared with the mean
healthy Constant score and expressed in percentages.
Whereas continuous variables were described using Treatment Details
means, standard deviations, and ranges, categorical variables Each surgeon (from a total of 53 involved in the study)
were tabulated with absolute and relative frequencies. For operated on an average of 3 study patients (SD: 3.6; median: 2;
comparison of paired categorical variables, the McNemar range: 1–17). The mean delay between accident and ORIF was
test (dichotomous variables) and the symmetry and marginal 2.9 (SD: 2.6; range: 0–10) days. Mean operation time was 87
homogeneity tests (variables with more than 2 categories) (SD: 31; range: 25–208) minutes. In 86%, the shorter plate
were applied. For comparison of unpaired categorical and with 3 holes at shaft level was applied. Implants employed in
continuous variables, the Fisher exact and Kruskal–Wallis addition to the Philos plate were used for 19 fractures and
rank tests were applied, respectively. The log-rank test was included mostly plate-independent screws (n = 14). Additional
applied for comparison of the return-to-work curves between sutures were widely used either to fix a displaced tuberosity
fracture types. (n = 52) or to regain rotator cuff integrity (n = 39).
Perioperatively, 75% received prophylactic antibiotics for
a maximum of 3 days, whereas 1 patient required longer
treatment. Postoperatively, the shoulders of 101 patients (64%)
RESULTS were immobilized during the initial 16 (SD: 14; median: 10;
Patient Demographics and Baseline range: 1–45) days, with assisted active movements starting on
Characteristics the second day (SD: 2; median: 1; range: 0–15) followed by
One hundred fifty-seven patients with 158 proximal unrestricted mobilization after 24 (SD: 17; median: 28; range:
humerus fractures were recruited between September 12, 0–84) days.
2002, and January 9, 2005, 1 patient had bilateral proximal
humerus fractures. Patient mean age was 65 (SD: 16.4; range:
19–94) years and 111 of them were women (71%). Only 29% Complication Incidence Proportions
were employed before their accident (9% blue-collar and 20% Before discharge, all patients were seen at the acute
white-collar workers), where 41% were retirees, 28% were postoperative period and after a mean of 3.0 (SD: 0.46; range:
housewives, and the remaining 2% were students. The median 2–4) months at the planned 3-month follow-up visit and 6.3
preinjury DASH score was 0 (95th percentile: 25; range: 0–76) (SD: 0.74; range: 5–9) and 12.9 (SD: 3.1; range: 10–33)
points. months at the scheduled 6- and 12-month follow-up visits,
The majority of patients (73%) sustained a low-energy respectively. Follow-up rates were 88% at 3 months, 82% at
trauma, mostly obtained from falls in a domestic setting. In 6 months, and 84% at the 1-year follow-up; 24 patients were
49%, the dominant arm was injured. According to the lost at the 1-year follow-up and included 6 patients who had
AO/OTA classification, 25%, 39%, and 37% of the fractures died of unrelated causes and 18 who could not be contacted or
were classified as type A, B, and C, respectively (Fig. 1). refused to frequent the treating clinic for further examination.
According to the Neer classification, 29% 2-part fractures, For the estimation of complication incidence proportions and
42% 3-part fractures, 22% 4-part fractures, 5% fracture their 95% CI, the total number of fractures at risk of expe-
dislocations, and 3% head-splitting fractures were found. The riencing complications was 158. Overall, 53 patients had
most common fracture type was 3-part fractures, with at least 1 complication, often a combination of associated
displacement of the greater tuberosity (39%). Other fracture events, which led to 39 unplanned reoperations (Table 1). The
types were rarely seen. incidence of obtaining any implant-related complication was

q 2009 Lippincott Williams & Wilkins 165

Brunner et al J Orthop Trauma
Volume 23, Number 3, March 2009

TABLE 1. Detailed Listing of Complications With Indication of Underlying Cause

Complications Implant Nonimplant All Reoperation*
Hematoma and bleeding
Hematoma — 1 1 1
Wound infections
Superficial — 1 1 1
Deep — 1 1 1
Soft tissue
Impingement — 4 4 4
Adhesion, frozen shoulder — 4 4 3
Rotator cuff lesion — 3 3 0
Neurologic complication — 4 4 1
Reduction
Secondary loss of reduction 5 — 5 5
Secondary dislocation of greater tuberosity — 4 4 1
Secondary impaction — 11 11 —
Plate and screws
Primary screw perforation — 22 22 10
Secondary screw perforation 13 — 13 4
Loosening — 1 1 1
Screw backing out 1 1 2 1
Breakage 1 — 1 —
Proximal screw and plate pullout 2 — 2 1
Distal screw and plate pullout — 2 2 1
Head necrosis
Partial head necrosis — 7 7 2
Complete head necrosis — 6 6 1
General
Abdominal wall hematoma — 1 1 1
Posttraumatic cervicobrachial — 1 1 —
pain syndrome
Total number of complications† 15 56 71 39
Complication risk (%) (95% CI) 9 (5–15) 35 (28–43) 25 (18–32)
*Reoperations are indicated by the event that led most likely to the intervention because an associated complication may also lead to a reoperation.
†The total number of complications takes into account associated events, for example, secondary impaction with screw perforation.

9% (95% CI: 5%–15%), whereas the incidence for a nonim- Complications related to a surgical technique problem
plant-related complication was 35% (95% CI: 28%–43%). were relatively frequent mainly because 22 primary screw
Patients older than 60 years were at a significant 1.9 times perforations through the articular surface were observed. They
higher incidence of experiencing any complication (P = 0.02) occurred because proximal screws were placed too close to
compared with younger patients. Complex fractures were the articular surface. In all cases, intraoperative C-arm control
also more likely to have a higher incidence of developing a was performed and there was no initial suspicion of screw
complication because the incidence of complication for type perforation. Within 1 year, plates had to be removed from 9
B and C fractures was 1.8 times higher than for type A patients, and in another patient, 1 related screw was removed.
fractures. Twenty-one primary screw perforations occurred in patients
The incidence of obtaining an implant-related com- older than 60 years. This particular complication can be
plication in patients older than 70 years was significantly illustrated by a case shown in Figure 2.
increased by a factor of 3.3 compared with younger patients An important postoperative problem involved secondary
(P = 0.04), and fracture types did not significantly influence screw perforations through the articular surface (n = 13)
the incidence of implant-related complications. For nonimplant- combined with secondary subsidence of the humeral head
related complications, patients with type B or type C fractures (n = 9), secondary loss of reduction (n = 2), or both (n = 1);
were at a significant 2.6 times higher incidence of experiencing 1 secondary subsidence and 1 loss of reduction were each
at least one of these complications (95% CI: 1.1–6.0; P = 0.02) associated with a proximal plate and screw pullout. Eight of
compared with patients with a type A fracture. On the contrary, these patients had to undergo a reoperation, which included
no significant effect of patient age on the occurrence of 3 simple plate removals, 2 plate removals with additional
nonimplant-related complications was observed (Tables 2 and 3). arthroscopic mobilization of the shoulder, 1 replacement of

166 q 2009 Lippincott Williams & Wilkins

J Orthop Trauma
Volume 23, Number 3, March 2009 ORIF of Proximal Humerus Fractures

end of the plate was observed at the 6-month follow-up, when

TABLE 2. Cumulative Incidences for Experiencing at Least 1
the head showed a secondary impaction and 5 of 6 proximal
Complication Per Age Class
screws had penetrated the articular surface. After the implant
N* n* Risk (%) Exact 95% CI Risk Ratio (P)†
was removed, shoulder function improved. In the last patient,
Implant related the proximal plate pulled out and shifted proximally, although
Age classes (yrs) 5 of 7 screws had perforated into the joint, and the head
#50 31 0 0.0 0–11.2 migrated to a major valgus position 3 weeks after osteosyn-
.50–60 25 2 8.0 1.0–26.0 thesis. This plate was replaced by tension banding of the
.60–70 46 3 6.5 1.4–17.9 3.3 (0.036) greater tuberosity. During the follow-up, humeral head
.70 56 9 16.1 7.6–28.3 necrosis developed but no further operative intervention was
Nonimplant related undertaken.
Age classes (yrs) Plate breakage occurred in 1 patient with a 2-part
#50 31 7 22.6 9.6–41.1 fracture with metaphyseal comminution due to implant fatigue
.50–60 25 4 16.0 4.5–36.1 1.6 (0.10) caused by the missing medial support after 6 months. After
.60–70 46 15 32.6 19.5–48 plate breakage occurred, medial contact was restored and the
.70 56 18 32.1 20.3–46 fracture healed in a minor varus deviation with good functional
*N = number of fractures at risk, n = number of fractures with at least 1 complication outcome (Constant score = 80). Medial support is important to
related to a particular cause. prevent any implant fatigue. In another patient, an additional
†Risk ratio and corresponding P values between age categories are separated by
lines, for example, patients older than 70 years are at a 3.3 times higher risk of
compression screw fixing the greater tuberosity loosened 6
experiencing at least 1 implant-related complication compared with younger patients. weeks after surgery and was removed, whereby the greater
tuberosity displaced again; the fracture healed without further
intervention.
Secondary loss of reduction occurred in 5 patients and
2 screws, and replacement of the plate with hemiarthroplasty
was associated with secondary impaction, secondary screw
in 2 patients, who additionally suffered from severe humeral
perforation, proximal screw backing out, or proximal plate
head necrosis. Notably, only in 4 of these particular patients
pullout and always led to a reoperation. Fixation was con-
was secondary screw perforation the main reason for the
sidered as ‘‘failed’’ when the plate had to be removed and
reoperation. An example of secondary screw perforation is
ORIF with any implant had to be performed again to ensure
presented in Figure 3.
fracture healing. Six (3.8%) cases of fixation failure were
Postoperatively, 4 Philos plates pulled out either
observed; 3 cases were due to secondary loss of reduction,
proximally or distally. A distal pullout occurred in an 80-
another resulted from proximal plate pullout and secondary
year-old patient after a strenuous physiotherapy session, 9 days
loss of reduction, 1 failure occurred because of distal
after surgery (Fig. 4). The sum of missing medial support, poor
plate pullout, and the last case involved a screw backing
bone stock, and strenuous physiotherapy seems to have caused
out. Incidences of both complete and partial osteonecroses
the fixation failure in the shaft area. The plate was replaced
were 4%.
by a longer plate with 5 holes. A similar mechanism was
Three patients (2%) developed wound complications.
observed in another case, but because the fracture healed
For 1 case, a deep wound infection was treated operatively, and
without axis deviation, no further action was undertaken. In
after this fracture healed at 3 months, the plate was removed.
the third patient, although the fracture was adequately reduced
In addition, 1 superficial wound infection and 1 hematoma
and the plate correctly placed, a slight liftoff of the proximal
healed, after the wounds were also operatively revised. Soft-
tissue complications consisted mainly of impingement (n = 4),
adhesions leading to a frozen shoulder (n = 4), rotator cuff
TABLE 3. Cumulative Incidences for Experiencing at Least 1 lesions (n = 4), and neurologic complications (n = 4). In 2
Complication Per Fracture Type patients showing signs of impingement, the plate was placed
N* n* Risk (%) Exact 95% CI P† too high. One ulnar nerve irritation was reported in a patient
Implant related
with too long screws at the shaft level; recovery was attained
Fracture type
after the screws were replaced. Two lesions of the axillary
A 39 3 7.8 1.6–20.9 0.095
plexus with deltoid atrophy were observed for the first time at
B 61 9 14.8 7.0–26.2
the 1-year follow-up examinations, whereupon one was seen
C 58 2 3.4 0.4–11.9
in a patient with a severely dislocated type C3 fracture. In
Nonimplant related
addition, hypesthesia of the axillary nerve was reported in
Fracture type
1 patient at the 3-month follow-up.
A 39 5 12.8 4.3–27.4 0.022
Only 4 patients (3%) had to undergo secondary
B 61 19 31.1 19.9–44.3
hemiarthroplasty: 2 because of partial head necrosis after 6
C 58 20 34.5 22.5–48.1
months and 1 year, another because of complete head necrosis
after 8 months, and the last patient due to a secondary
*N = number of fractures at risk, n = number of fractures with at least 1 complication impacted fracture that led to perforation of 4 screws into the
related to a particular cause.
†Difference among fracture types (Fisher exact test). joint after 7 weeks. These patients were initially diagnosed
with type C1, C2, C3, and B2 fractures, respectively.

q 2009 Lippincott Williams & Wilkins 167

Brunner et al J Orthop Trauma
Volume 23, Number 3, March 2009

FIGURE 2. Immediate postoperative

AP x-ray of a 62-year-old patient
(left). Anterior-posterior x-ray at 3
months showing screw perforation
through the articular surface due to
placement of screws that were too
long (middle). After 1 year, the
patient reported no pain and dem-
onstrated good shoulder function
(Constant = 82, DASH = 0) (right).

Anatomic Restoration and delayed union was reported; however, at the 1-year follow-up,
Functional Outcomes this fracture was healed. Sixty-six percent of the fractures were
No nonunions occurred during the 1-year follow-up healed with a normal head to shaft axis at 1 year. However,
period, although the proportion of united fractures increased 5 fractures had changed from a normal head to shaft axis
from 66% at 3 months to 99% at the 6-month follow-up. One postoperatively to major varus deformation at the latest follow-
up; these 5 patients had a mean age of 73 (range: 66–86) years
and sustained the following fracture types: 2 A3, 1 B1, 1 B2,
and 1 B3. Major varus led to the worst functional outcome
with a Constant score of 60 points at the 1-year follow-up, but
differences in Constant scores among the head shaft axis
deviation categories were not statistically significant (P = 0.16)
(Table 4).
Overall, the mean Constant score improved significantly
(P , 0.001) during the follow-up periods and reached 72 (SD:
15; range: 23–99) points after 1 year (Table 5 and Fig. 5). In
relation to respective contralateral healthy shoulders, a mean
relative Constant score of 87% (SD: 16.6%; median: 92%;
5%–95% percentile: 53%–103%) was achieved. Patients
without any complication reached a significantly higher
Constant score compared with patients suffering from at least
1 complication (75 versus 64 points, respectively, P , 0.001).
The mean Neer score observed at the 1-year follow-up
was 76 (SD: 18.4; range: 18–100), where 35 patients (27%)
showed an excellent score, 37 (28%) obtained a satisfactory
score, and 27 (20%) and 33 patients (25%) were reported with
unsatisfactory and failed scores, respectively. The mean DASH
score, after 1 year, of 16 (SD: 21; median: 5.8; range: 0–85)
points was significantly worse than the mean preinjury score
(P , 0.001). However, patients reported significantly improved
range of motion for their injured shoulders (P . 0.001),
reaching between 79% and 94% of contralateral healthy
FIGURE 3. Immediate postoperative anterior-posterior x-ray of
a 74-year-old patient (left). The proximal screws cut through shoulders after 1 year depending on the direction of movement
the humeral head during the follow-up period perforating the (Table 5). At the last follow-up, 45 patients (34%) indicated
articular surface (right). Besides concomitant impaction of the incidental shoulder pain, mostly during functional use.
humeral head, the greater tuberosity fragment (initially fixed Thirty-five (88%) patients could return to work within
with sutures) dislocated. 1 year. Only 5 patients (ie, 3 blue-collar and 2 white-collar

168 q 2009 Lippincott Williams & Wilkins

J Orthop Trauma
Volume 23, Number 3, March 2009 ORIF of Proximal Humerus Fractures

FIGURE 4. Anterior-posterior x-rays of the fracture (left) and initial fixation with a 3-hole plate in an 80-year-old patient (second
from left). Distal plate pullout and replacement with a 5-hole plate occurred 9 days after surgery (second from right). Radiographic
follow-up of the same patient at 3 months (right).

workers) were unable to return to their jobs, where one of the complications was relatively low compared with previously
white-collar workers had retired by the 1-year follow-up. The performed studies concerning the treatment of proximal
various fracture types had no influence on convalescence time humerus fractures. All fractures healed within 1 year and
(P = 0.36). rates of osteonecrosis and secondary loss of reduction were
only 8% and 3%, respectively. In comparison, secondary
displacement occurring due to the loosening of screws after
DISCUSSION conventional plating (particularly in patients with osteopenic
To our knowledge, the presented study is the first bone) achieved rates between 4% and 27%,21,26,27 where
multicenter study evaluating an angular stable implant in the secondary displacement rates after ORIF with angular stable
treatment of proximal humerus fractures. This prospective implants (including Philos) ranged between 1% and 5%.35–41
study design with active follow-up examinations allowed for After conventional plating, osteonecrosis and pseudarthrosis
an accurate recording of anticipated and unanticipated com- rates ranged between 0%–45% and 0%–3%, respec-
plications and measurement of functional outcome parameters. tively.9,18,23,25–27 For ORIF trials using angular stable implants
More than 50 surgeons in 8 trauma units participated in the (including Philos), observed rates of osteonecrosis were
study, which highlights the wide use of this implant among between 0%–5% and 0%–6% for pseudarthrosis.35–39,41 Only
clinics that provide different levels of care. 1 small retrospective study (including 17 acute fractures treated
Although our study population consisted of elderly with Philos) showed poorer results compared with the
patients with mostly complex fracture patterns, the incidence previously cited studies: osteonecrosis and pseudarthrosis rates
of secondary displacement, pseudarthrosis, or osteonecrosis were both 6% and the secondary displacement rate was 12%.40

TABLE 4. Comparison of Head Shaft Axis Deviation Categories With Mean Constant Scores After 1 Year
No. Fractures* Mean Constant Score After 1 Year
Category Postoperative 1-Year Follow-up Injured Shoulder† Ratio of Injured/Healthy Shoulder (%)
Major varus 0 8 60 73
Minor varus 7 10 70 83
Normal 86 86 73 88
Minor valgus 29 19 73 86
Major valgus 17 16 71 87
*Fractures with x-rays available at both postoperative and 1-year follow-up periods.
†Kruskal–Wallis test; P = 0.16.

q 2009 Lippincott Williams & Wilkins 169

Brunner et al J Orthop Trauma
Volume 23, Number 3, March 2009

TABLE 5. Mean Range of Motion and Constant Score of Injured and Contralateral Shoulders at the Various Follow-up Visits
n Forward Flexion* Abduction* External Rotation* Internal Rotation* Constant Score*
Healthy contralateral shoulder (degrees)† 149 160 6 25.8 136 6 35.9 63 6 17.7 89 6 11.8 82 6 9.4
Injured shoulder (degrees)
3 months 139 106 6 37.6 88 6 34.9 34 6 23.0 76 6 22.2 56 6 15.4
6 months 129 125 6 38.4 108 6 38.8 43 6 22.4 82 6 20.0 64 6 15.7
1 year 133 137 6 39.6 119 6 40.8 50 6 24.1 84 6 18.7 72 6 15.2
Ratio injured/healthy shoulder (%)
3 months 139 67 6 23.0 66 6 24.5 54 6 32.8 86 6 22.3 67 6 18.3
6 months 129 79 6 24.8 80 6 23.1 68 6 30.2 92 6 20.0 78 6 17.8
1 year 132 86 6 22.9 86 6 20.5 79 6 35.6 94 6 19.3 87 6 16.6
Differences between follow-ups were significant for all parameters (P , 0.001).
*Mean 6 SD indicated.
†Mean of contralateral values at any follow-up.

In our study, 4 patients (3%) required hemiarthroplasty, including short calcar segments, a disrupted medial hinge, and
3 of whom experienced osteonecrosis after being initially the basic fracture pattern were found to be relevant predictors
diagnosed with type C fractures. In primary arthroplasty, for humeral head ischemia when perfusion was intraoper-
necrosis of fixed tubercles may lead to unpredictable clinical atively assessed.48,49
results32; therefore, primary plating is preferred by our group. The working groups of Kettler et al41 and Charalambous
40
However, there remains a limited indication for primary joint et al detected 24/176 and 2/17 primary screw perforations,
replacement in low-demand patients with poor bone respectively, in their series of Philos plate patients. Inter-
stock.28,31,32 estingly, in our study, all primary screw perforations were
The complexity of fractures influenced the incidence of observed in patients older than 60 years. Despite intraoperative
sustaining a nonimplant-related complication. Primary screw C-arm control, primary screw perforations through the
perforations were mainly found in type B (50%) and type C articular surface can be overlooked at the time of surgery.
fractures (46%). Complications related to a sustained injury or Using measuring notations on drill bits and K-wires seems
poor bone quality consisted mainly of osteonecrosis or soft- inadequate for achieving reliable screw length in osteopenic
tissue complications. Eight of 13 osteonecrosis cases were bone. Therefore, the authors recommend drilling the lateral
associated with type C2 or type C3 fractures, whereas only 1 half of the track, followed by the use of a depth gauge to
osteonecrosis case was associated with a type A fracture. This feel the resistance of the subchondral bone in these patients;
suggests that severe destruction or dislocation of the humeral the final screw length should be 2–3 mm shorter than
head interferes with the arterial blood supply of the humeral the measured length. With this recommended surgical tech-
head. There are no prospective studies available, which nique, primary screw perforations could be avoided and
examine predictive values (eg, fracture patterns and implants) the complication incidence proportion could be reduced by
for the development of osteonecrosis. Only various factors about 30%.

FIGURE 5. Absolute mean Constant score of the injured shoulder at the various follow-up visits (left) and the scores relative to the
mean Constant score of the contralateral shoulder (right).

170 q 2009 Lippincott Williams & Wilkins

J Orthop Trauma
Volume 23, Number 3, March 2009 ORIF of Proximal Humerus Fractures

Another frequent problem—secondary screw perforation— study plan did not provide standard procedures concerning
has already been described for Philos and for other locking antibiotic prophylaxis, surgical approach, and time of
proximal humerus plates.34,38,41 The rigidity of these angular immobilization and periods for starting active assisted and
stable implants is responsible for screws cutting through unrestricted mobilization. As a result, the participating clinics
osteoporotic bone, where humeral heads in older patients may had the freedom to apply their own standards regarding these
subside due to a missing medial bone buttress or osteonec- parameters. In addition, x-rays in Neer view were often not
rosis, while the screws remain locked. Secondary varus performed in a reproducible projection, which made reliable
angulation was observed in 5 patients, where screws were measurement of the head shaft axis impossible. Assessment of
placed in 3 of these patients to support the medial buttress. the preinjury DASH score after trauma can also be biased
However, none of the 5 patients received tension band sutures because patients might overestimate their preinjury function of
between the rotator cuff and the plate to neutralize traction the upper extremity. Finally, our case series can only be used to
forces. The authors therefore suggest that traction forces from generate hypotheses regarding treatment effectiveness com-
the rotator cuff should be neutralized using tension band pared with other devices or treatment options. Prospective
sutures combined with screws supporting the medial calcar, in comparative studies are required to develop treatment
cases where medial support is insufficient. In a recent study by recommendations, although this may present some problems
Gardner et al,50 a missing medial support led to 30% screw due to the low interobserver and intraobserver reliabilities
perforations compared with 6% for fractures with an intact occurring for classifying proximal humerus fractures (ie,
medial support. This observation may however be considered AO/OTA and Neer classifications).53,54
biased, particularly, because the patients in the former group
were significantly older.
Incidence of impingement due to high positioning of the CONCLUSIONS
plate was rarely observed (n = 2, 1%). Nevertheless, special The Philos plate is effective in maintaining fracture
attention must be paid to correct plate placement, and the use reduction in proximal humerus fractures. Due to stable
of aiming devices and positioning K-wires is recommended.51 restoration, early functional aftercare is possible and allows
The mean Constant score of 72 points at the 1-year the patient to regain good shoulder function and return to work
follow-up is comparable to values observed in a number of earlier. Loss of reduction was rarely seen compared with other
published articles.15,16,19,23,34,41,43 Because many elderly pa- implants. Importantly, with the use of this implant, observed
tients sustaining proximal humerus fractures also have screw perforations led to relatively high reoperation rates.
concomitant diseases, the Constant score is of little value in Complication incidence proportions increased in older patients
expressing the functional outcome for those patients who are due to higher rates of secondary impaction, screw perforations,
frail before the accident. The Constant score is therefore more and humeral head necrosis, with an overall nonimplant-related
relevant when considered in relation to the contralateral complication rate of 35%. Patients older than 60 years had a 2-
healthy side. Consequently, the Constant score in relation to fold higher incidence of developing any type of complication,
the contralateral side (87%) obtained in this study was slightly and those older than 70 years had a 3-fold greater incidence of
better when compared with those scores achieved with angle experiencing plate-related complications. Osteonecrosis was
blade plates (82%) and the Targon nail (86%),16,19 the only mostly seen in severe fracture types.
2 trials using similar patient groups with respect to age and
fracture type. REFERENCES
1. Palvanen M, Kannus P, Niemi S, et al. Update in the epidemiology of
Satisfactory to excellent Neer scores were achieved in proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92.
55% of the patients at the 1-year follow-up, where 28% had 2. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal
type A, 36% had type B, and 36% had type C fractures. With humeral fractures. Acta Orthop Scand. 2001;72:365–371.
respect to elderly patients, the Neer score does not adequately 3. Lind T, Kroner K, Jensen J. The epidemiology of fractures of the proximal
account for any age-related degeneration that is often humerus. Arch Orthop Trauma Surg. 1989;108:285–287.
4. Nguyen TV, Center JR, Sambrook PN, et al. Risk factors for proximal
associated with the ability to perform overhead movements, humerus, forearm, and wrist fractures in elderly men and women: the
for example, touching the top of one’s head. The integrated Dubbo Osteoporosis Epidemiology Study. Am J Epidemiol. 2001;153:
pain questions of this nonvalidated score are also not based on 587–595.
established pain measurements. This suggests its low value for 5. Jones G, Nguyen T, Sambrook PN, et al. Symptomatic fracture incidence
in elderly men and women: the Dubbo Osteoporosis Epidemiology Study
estimating shoulder function in this patient population, (DOES). Osteoporos Int. 1994;4:277–282.
particularly, because the range of motion is also generally 6. Rommens PM, Heyvaert G. Conservative treatment of subcapital humerus
decreased in noninjured shoulders and widely varies among fractures. A comparative study of the classical Desault bandage and the
these patients.52 new Gilchrist bandage. Unfallchirurgie. 1993;19:114–118.
Some limitations in this study should be mentioned. The 7. Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced
proximal humeral fractures: epidemiology and outcome in 507 cases. Acta
multicenter design included surgeons who had previous Orthop Scand. 2003;74:580–585.
experience in at least 5 interventions with this implant, which 8. Neer CS. Displaced proximal humeral fractures. I. Classification and
might reflect a lower level of competency using Philos and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.
some difference in the surgical techniques employed. 9. Misra A, Kapur R, Maffulli N. Complex proximal humeral fractures in
adults—a systematic review of management. Injury. 2001;32:363–372.
However, this study design may also disclose the clinical 10. Tingart M, Bathis H, Bouillon B, et al. The displaced proximal humeral
reality when a new implant is introduced. A 1-year follow-up fracture: is there evidence for therapeutic concepts? Chirurg. 2001;72:
period is too short to detect all humeral head necroses. The 1284–1291.

q 2009 Lippincott Williams & Wilkins 171

Brunner et al J Orthop Trauma
Volume 23, Number 3, March 2009

11. Zyto K. Non-operative treatment of comminuted fractures of the proximal 34. Fankhauser F, Boldin C, Schippinger G, et al. A new locking plate for
humerus in elderly patients. Injury. 1998;29:349–352. unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005;
12. Zyto K, Ahrengart L, Sperber A, et al. Treatment of displaced proximal 430:176–181.
humeral fractures in elderly patients. J Bone Joint Surg Br. 1997;79: 35. Mückter H, Herzog L, Becker M, et al. Angle and rotation-stable internal
412–417. fixation of proximal humerus fractures with the humerus fixator plate.
13. Resch H, Povacz P, Frohlich R, et al. Percutaneous fixation of three- and Early clinical experience with a newly developed implant. Chirurg. 2001;
four-part fractures of the proximal humerus. J Bone Joint Surg Br. 1997; 72:1327–1335.
79:295–300. 36. Lungershausen W, Bach O, Lorenz CO. Locking plate osteosynthesis for
14. Resch H, Hubner C, Schwaiger R. Minimally invasive reduction and fractures of the proximal humerus. Zentralbl Chir. 2003;128:28–33.
osteosynthesis of articular fractures of the humeral head. Injury. 2001; 37. Lill H, Hepp P, Rose T, et al. The angle stable locking-proximal-humeral-
32(Suppl 1):SA25–SA32. plate (LPHP) for proximal humeral fractures using a small anterior-lateral-
15. Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral deltoid-splitting-approach—technique and first results. Zentralbl Chir.
fractures with the Polarus nail. J Shoulder Elbow Surg. 2001;10:7–10. 2004;129:43–48.
16. Mittlmeier TW, Stedtfeld HW, Ewert A, et al. Stabilization of proximal 38. Koukakis A, Apostolou CD, Taneja T, et al. Fixation of proximal humerus
humeral fractures with an angular and sliding stable antegrade locking nail fractures using the PHILOS plate: early experience. Clin Orthop Relat
(Targon PH). J Bone Joint Surg Am. 2003;85-A(Suppl 4):136–146. Res. 2006;442:115–120.
17. Mathews J, Lobenhoffer P. Results of the provision of unstable proximal 39. Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal
humeral fractures in geriatric patients with a new angle stabilizing humeral fractures with a locking compression plate: a retrospective
antegrade nail system. Unfallchirurgie. 2004;107:372–380. evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop
18. Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal Scand. 2004;75:741–745.
fixation of three and four-part fractures of the proximal part of the 40. Charalambous CP, Siddique I, Valluripalli K, et al. Proximal humeral
humerus. J Bone Joint Surg Am. 2002;84-A:1919–1925. internal locking system (PHILOS) for the treatment of proximal humeral
19. Meier RA, Messmer P, Regazzoni P, et al. Unexpected high complication fractures. Arch Orthop Trauma Surg. 2007;127:205–210.
rate following internal fixation of unstable proximal humerus fractures 41. Kettler M, Biberthaler P, Braunstein V, et al. Treatment of proximal
with an angled blade plate. J Orthop Trauma. 2006;20:253–260. humeral fractures with the PHILOS angular stable plate: presentation of
20. Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures 225 cases of dislocated fractures. Unfallchirurgie. 2006;109:1032–1040.
of the proximal humerus. J Bone Joint Surg Br. 2004;86-B:848–855. 42. Hanschin AE, Cardell M, Contaldo C, et al. Functional results of angular-
21. Hessmann M, Baumgaertel F, Gehling H, et al. Plate fixation of proximal stable plate fixation in displaced proximal humeral fractures. Injury. 2008;
humeral fractures with indirect reduction: surgical technique and results 39:306–313.
utilizing three shoulder scores. Injury. 1999;30:453–462. 43. Moonot P, Ashwood N, Hamlet M. Early results for treatment of three- and
22. Wanner GA, Wanner-Schmid E, Romero J, et al. Internal fixation of four-part fractures of the proximal humerus using the PHILOS plate
displaced proximal humeral fractures with two one-third tubular plates. system. J Bone Joint Surg Br. 2007;89:1206–1209.
J Trauma. 2003;54:536–544. 44. Strohm PC, Helwig P, Konrad G, et al. Locking plates in proximal
23. Hintermann B, Trouillier HH, Schafer D. Rigid internal fixation of humerus fractures. Acta Chir Orthop Traumatol Cech. 2007;74:410–415.
fractures of the proximal humerus in older patients. J Bone Joint Surg Br. 45. Hudak PL, Amadio PC, Bombardier C. Development of an upper
2000;82:1107–1112. extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder
24. Szyszkowitz R, Schippinger G. Fractures of the proximal humerus. and Hand). The Upper Extremity Collaborative Group (UECG). Am J Ind
Unfallchirurgie. 1999;102:422–428. Med. 1996;29:602–608.
25. Kuner EH, Siebler G. Dislocation fractures of the proximal humerus— 46. Müller ME, Nazarian S, Koch P, et al. The Comprehensive Classification
results following surgical treatment. A follow-up study of 167 cases. of Fractures of Long Bones. Berlin, Germany: Springer-Verlag; 1990.
Unfallchirurgie. 1987;13:64–71. 47. Constant CR, Murley AH. A clinical method of functional assessment of
26. Speck M, Lang FJ, Regazzoni P. Proximal humeral multiple fragment the shoulder. Clin Orthop Relat Res. 1987;214:160–164.
fractures—failures after T-plate osteosynthesis. Swiss Surg. 1996;2:51–56. 48. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head
27. Esser RD. Open reduction and internal fixation of three- and four-part ischemia after intracapsular fracture of the proximal humerus. J Shoulder
fractures of the proximal humerus. Clin Orthop Relat Res. 1994;299:244–251. Elbow Surg. 2004;13:427–433.
28. Robinson CM, Page RS. Severely impacted valgus proximal humeral 49. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the
fractures. J Bone Joint Surg Am. 2004;86-A(Suppl, pt 2):143–155. humeral head. An anatomical study. J Bone Joint Surg Am. 1990;72:
29. Zyto K, Wallace WA, Frostick SP, et al. Outcome after hemiarthroplasty 1486–1494.
for three- and four-part fractures of the proximal humerus. J Shoulder 50. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in
Elbow Surg. 1998;7:85–89. locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21:
30. Bosch U, Skutek M, Fremerey RW, et al. Outcome after primary and 185–191.
secondary hemiarthroplasty in elderly patients with fractures of the 51. De Boer P, Rüedi T. AO Surgery Reference. May1, 2006. Available at:
proximal humerus. J Shoulder Elbow Surg. 1998;7:479–484. [Link] Accessed June 20,
31. Demirhan M, Kilicoglu O, Altinel L, et al. Prognostic factors in prosthetic 2006.
replacement for acute proximal humerus fractures. J Orthop Trauma. 52. Suk M, Hanson BP, Norvell DC, et al. AO Handbook. Musculoskeletal
2003;17:181–188. Outcomes Measures and Instruments. New York, NY: Thieme; 2005.
32. Kralinger F, Schwaiger R, Warnbacher M, et al. Outcome after primary 53. Siebenrock KA, Gerber C. The reproducibility of classification of
hemiarthroplasty for fracture of the head of the humerus. A retrospective fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;
multicentre study of 167 patients. J Bone Joint Surg Br. 2004;86:217–219. 75:1751–1755.
33. Plecko M, Kraus A. Internal fixation of proximal humerus fractures using 54. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for
the locking proximal humerus plate. Oper Orthop Traumatol. 2005;17: proximal humeral fractures. An assessment of interobserver reliability and
25–50. intraobserver reproducibility. J Bone Joint Surg Am. 1993;75:1745–1750.

172 q 2009 Lippincott Williams & Wilkins