What is the step-by-step procedure for treating a fracture of the surgical neck of the humerus using a Proximal Humerus Interlocking System (PHILOS) locking plate?

From the Guidelines

The surgical treatment of a fracture of the surgical neck of the humerus using a PHILOS locking plate involves several key steps, prioritizing stable fixation and early mobilization to minimize morbidity and mortality, and improve quality of life. The procedure begins with positioning the patient in either the beach chair position or supine with a bump under the scapula, administering general anesthesia with or without regional block.

Key Steps in the Procedure

• The deltopectoral approach is utilized, making an incision from the coracoid process extending distally along the deltopectoral groove for about 10-15 cm.
• The cephalic vein is identified and protected, and the deltopectoral interval is developed, retracting the deltoid laterally and the pectoralis major medially.
• The long head of the biceps tendon is identified as a landmark, and the fracture site is exposed.
• Reduction of the fracture is performed under fluoroscopic guidance, using K-wires for temporary fixation, as recommended by recent studies such as 1.

Placement of the PHILOS Plate

• The PHILOS plate is then positioned on the lateral aspect of the proximal humerus, about 5-8 mm distal to the greater tuberosity and 2-4 mm posterior to the bicipital groove.
• Initial fixation is achieved with a non-locking screw in the slotted hole.
• Multiple locking screws are then placed in the humeral head, ensuring they don't penetrate the articular surface.
• Additional shaft screws are inserted distally to secure the plate to the humeral shaft.

Postoperative Care

• Fluoroscopy confirms proper reduction and hardware placement.
• The wound is irrigated, and layered closure is performed.
• Postoperatively, the arm is immobilized in a sling for 2-3 weeks, followed by progressive rehabilitation with passive motion exercises initially, advancing to active motion and strengthening as healing progresses, which is crucial for minimizing complications and improving quality of life, as noted in studies such as 1. This approach provides stable fixation through multiple angular-stable locking screws, allowing for early mobilization while maintaining fracture reduction, particularly beneficial in osteoporotic bone where traditional screws may have poor purchase.

From the Research

Procedure Overview

The procedure for treating a fracture of the surgical neck of the humerus using a Proximal Humerus Interlocking System (PHILOS) locking plate involves several steps:

• Preoperative planning: This includes assessing the fracture pattern, patient's overall health, and selecting the appropriate surgical approach 2, 3.
• Surgical approach: The deltopectoral approach or deltoid split approach can be used, depending on the fracture pattern and surgeon's preference 4, 5.
• Reduction and fixation: The fracture is reduced, and the PHILOS plate is applied to stabilize the fracture. The plate is fixed to the bone using locking screws 2, 3.
• Tuberosity repair: If the fracture involves displacement of the tuberosities, they are repaired using high-strength sutures 5.
• Calcium sulphate augmentation: This can be used to augment the fixation in comminuted fractures or osteopenic bone 5.
• Wound closure: The wound is closed in layers, and the patient is immobilized in a sling 2, 3.

Key Considerations

• Anatomical reduction and stable fixation are crucial for achieving good clinical outcomes 2, 3.
• The PHILOS plate should be contoured to fit the proximal humerus, and the screws should be inserted carefully to avoid damaging the surrounding tissues 4.
• The use of calcium sulphate augmentation and tuberosity repair can help to improve the stability of the fixation and reduce the risk of complications 5.
• The patient should be followed up regularly to monitor the progress of healing and to address any complications that may arise 2, 3.

Potential Complications

• Complications such as avascular necrosis, varus positioning of the head, impingement syndrome, secondary screw perforation, non-union of the fracture, and infection can occur 3, 4.
• The risk of complications can be minimized by using proper surgical technique, careful patient selection, and regular follow-up 2, 3.
• Implant removal may be required in some cases, and this can be done arthroscopically to minimize the risk of complications 6.