Comparative study of ORIF with philos plate vs CRIF with k wiring of Neers 2part and 3part proximal humerus fractures.

1. A COMPARATIVE STUDY OF ORIF WITH
PHILOS PLATEVs CRIF WITH
PERCUTANEOUS K WIRING OF NEER’S 2-
PART AND 3-PART PROXIMAL HUMERUS
FRACTURES
MODERATOR
DR.SUNDRESH K
BY,
DR BALAGANGADHAR
JUNIOR RESIDENT

2. INTRODUCTION
• Proximal humeral fractures, defined as fractures
occurring at or proximal to the surgical neck of
the humerus.
• nowadays proximal humeral fractures account for
almost 7% of all fractures.
• 80% of all Humeral fractures.
• Patients >65Yrs- Second most common fracture
of the upper Extremity
• F:M-3: 1

3. PATHOANATOMY
• The region of transition between the articular cartilage and
surrounding bone is defined as the anatomic neck
• whereas the region immediately inferior to the
tuberosities is termed the surgical neck
• Articular Segment is almost spherical, with a diameter of
curvature averaging 46 mm (Ranging from 37 to 57 mm)
• Inclination of the humeral head relative to the Shaft
averages 130°(centrum collum diaphyseal angle[CCD]
• Retroversion of the head varies from 18 to 40°

4. • Greater tuberosity has three regions into which the
Supraspinatus, infraspinatus and teres minor inserts.
• Subscapularis tendon-inserts on lesser tuberosity ,which is
Separated from greater tuberosity by the bicipital Groove.
• Muscle insertion on these 4 segments and the magnitude and
direction of the forces Causing injury, determine the pattern of
fracture lines, displacement and angulation

5. BLOOD SUPPLY
• The ascending branch of the anterior circumflex
humeral artery has been considered to provide
most of the blood flow to the articular segment.
• Several studies have shown branches from PCHA to
the posteromedial head to be equally important
• Arcuate artery of Liang-supplies Humeral head
• If the medial calcar of the humerus is spared by the
fracture,the vessel is spared .

6. MECHANISM OF INJURY
In individuals 60 years or older, over 90% of proximal humeral fractures result from a
fall from a standing height.
In younger individuals there is a higher incidence of proximal humeral fractures
occurring outside the home, as a result of higher-energy trauma, such as a fall from a
height, motor vehicle accidents (MVAs), sports, or assaults.
The proximal humerus can fracture as a consequence of three main loading modes:
• Compressive loading of the glenoid onto the humeral head,
• Bending forces at the surgical neck,
• Tension forces of the rotator cuff at the greater and lesser tuberosities

8. DEFORMING FORCES
• The greater tuberosity is pulled posteromedially by
the effect of the Supra-and infraspinatus tendons.
• The lesser tuberosity is pulled anteriorly by the
subscapularis
• The shaft segment is pulled anteromedially by the
pectoralis major tendon

10. X-RAYVIEWS

14. CT Scan-Allows more detailed understanding of fracture
configuration ,degree of osteopenia ,presence and location of
bone impaction and extent of fracture comminution

15. CLASSIFICATION OF PROXIMAL HUMERUS
FRACTURES
• In 1934,Codman described proximal humerus fractures as occurring along the
lines of epiphyseal scars and observed four possible fracture fragments:
• The articular surface
• The humeral shaft
• The greater tuberosity
• The lesser tuberosity

17. Neer classification
• In 1970, Neer introduced the concept of fracture segments
• instead of fragments. proximal humeral fractures can reproducibly yield up to
four anatomic segments with or without additional fracture lines , rather than
a single fragment.
• Displaced fractures were arbitrarily defined as those in which a segment was
translated by at least 1 cm or angulated by a minimum of 45 degrees.
• Fractures of less than 1 cm of displacment and less than 45 degrees of
angulation are considered nondisplaced and are commonly called one-part
fractures.

19. AO/OTA Classification
• The AO/OTA classification is based on fracture location and the presence of impaction,
angulation, translation, or comminution of the fracture, as well as whether a
dislocation is present.
• These fractures are classified as belonging to the 11 bone segment (1 for humerus , 1 for
proximal segment)
• and they are sub classified into types, groups, and subgroups.
• Finally each subgroup fracture is assigned a level of severity.
• Type A fractures are extra-articular unifocal fractures associated with a single fracture
line,
• type B are extra-articular bifocal fractures associated with two fracture lines,
• type C are articular fractures which involve the humeral head or anatomic neck.

21. Non-operative treatment of proximal
humeral fractures
• The majority of proximal humeral fractures are non displaced or minimally
displaced and nonoperative treatment is indicated
• Radiographically,stable fractures exibit impaction or interdigitation between
bone fragments
• Clinically , fracture stability may be assessed by palpating the proximal humerus
just distal to the acromion with one hand ,while rotating the arm at the elbow with
the other .if the proximal humerus is felt to move as a unit with the distal segment
,the fracture is considered stable.

22. NON OPERATIVETREATMENT
• Indications
1. Stable non-displaced or minimally displaced fractures
2. Patients not fit for surgery
3. Elderly patients with low functional demand
• Relative contraindications
1. Displaced fractures with loss of bony contact
Closed followup is required to confirm acceptable alignment and fracture
stability.
Weekly radiographs should be performed during the first month of treatment
,followed by biweekly radiographs until 6 weeks after injury or initial callus
formartion is visible.

23. COMPLICATIONS FOLLOWING NON-OP
TREATMENT
• Avascular necrosis
• Nonunion
• Malunion
• Stiffness
• Rotator-cuff dysfunction
• Post-traumatic arthritis

24. OPERATIVETREATMENT OF PROXIMAL HUMERUS
FRACTURES
• Many surgical techniques have been described ,but no single approach is
considered to be the standard of care
• Appropriate treatment is individualized and selected on the basis of the fracture
pattern and the underlying quality of the bone
• Surgical options
I. Open reduction and internal fixation
II. Tension band fixation
III. Closed reduction and percutaneous fixation
IV.Intramedullary nailing
V. Hemiarthroplasty
VI.Reverse total shoulder arthroplasty

25. Complications
• The most frequently reported complications after proximal humeral
fractures following operative intervention are;
• Nonunion
• Malunion
• Implant failure
• Humeral head collapse and AVN
• Infection
• Post-traumatic arthritis
• Hardware penetration
• Axillary nerve dysfunction
• Revision surgery, and mortality

26. A Comparative Study of Open Reduction and
Internal Fixation with
PHILOS Plate versus Closed Reduction and
Fixation with Percutaneous
K Wiring of Neer’s 2-Part and 3-Part Proximal
Humerus Fractures

27. INTRODUCTION
• We wanted to assess the clinical, functional, and radiological outcomes of two
surgical treatment methods (K-wire application and PHILOS plate fixation) for
proximal humerus fractures.
• A randomised prospective study of 40 cases was conducted in Sapthagiri
Institute of Medical Sciences and Hospital fromApril 2017 to June 2018.
• Group A underwent ORIF with PHILOS Plate.
• Group B underwent CRIF with percutaneous K wiring.
• Patients were evaluated clinically by Constant - Murley Score.
• Radiologically x rays were taken to evaluate the progress of union.

28. METHODS
• Inclusion Criteria
• Two part, three part proximal humeral fractures.
• Acute fracture.
• Age from 25 to 60 years.
• Exclusion Criteria
• Associated humerus shaft fracture.
• Associated neurovascular injury.
• Acute infection.
• Pathological fractures.
• Old fractures.
• Compound fracture.

29. • Conservative treatment of displaced two and three part fractures can result in non-
union or mal-union and give rise to poor functional results.
• Open reduction (OR) with internal fixation (IF) is a good method for fine reduction,
but extensive soft tissue exposure during Open Reduction impairs the vasculature
and doubles the risk of humeral head avascular necrosis (AVN).
• Closed reduction (CR) and IF with Kirschner wires (K - wires) is another method for the
treatment of proximal humeral fractures. CR with percutaneous fixation preserves
the soft tissues and prevents further soft tissue damage.

30. SurgicalTechniques
• OPEN REDUCTION INTERNAL FIXATION WITH PHILOS PLATING
• CLOSED REDUCTION AND PERCUTANEOUS FIXATION USING K-WIRES

31. Open reduction and internal fixation
with PHILOS plating
• ORIF is the most frequently used method of surgical treatment
of proximal humeral fractures
• Surgical approaches
• Deltopectoral approach
• a 12-14 cm long skin incision between the coracoid process and
the proximal humeral shaft.The shape of the skin incision can
be straight or curved depending on surgeon’s preference

32. Deltoid-splitting approach
• This incision is placed between the acromial part
(2) and the spinal part (3) of the deltoid muscle, as
illustrated.
• Depending on the fracture morphology and
foreseen osteosynthesis the extensions of the skin
incision may vary but may not extend more than 5
cm distally to the acromion, to protect the axillary
nerve.

34. • POSITION
• Beach chair: Head holder/shoulder positioner,
Waist flexed 45 degrees, knees bent 30
degrees.
Supine: Bump under ipsilateral scapula, rotating
the trunk 30 degrees toward opposite side.
• Shoulders draped free to the level of medial
scapular border.

35. Fixation using proximal humerus locking
plate[PHILOS PLATING]
• The inability of conventional plates and screws to resist varus deforming forces in the
proximal humerus,particularly if the bone is osteoporotic ,has led to locking plate fixation
being used for these fractures
• Several clinical studies have shown high rates of healing and excellent functional
recovery with proximal humerus locking plates.
• Plate designs vary in terms of the number of proximal screws and their arrangement ,as
well as the ability to place screws at different angles with regard to the plate
• A plate is selected to allow at least three screws to be placed into the distal shaft
segment .the plate position is also selected to avoid subacromial impingement and to
allow two screws to be placed into inferomedial aspect of the humeral head
• A minimum of five or six screws are routinrly placed into the proximal segment .screw
placement should be performed by drilling through the near cortex only,this avoids
perforation of the articular surface.
• Once the plate and the screws have been placed transtendinous sutures are tied onto
the plate to provide additional fixation

41. POST OP CARE
• Patients are followed at 2weeks,6weeks, and 3months after surgery
• Patients are immobilized for 6weeks in a sling while active range of motion
exercises of the elbow ,wrist, and hand are encouraged
• Depending on the fracture pattern and stability that was achieved, passive range of
movements is started between 2 and 4 weeks after surgery with forward elevation
,external rotation and pendulum exercises
• If healing has adequately progressed both clinically and radiologically at 6weeks
active assisted range of movements started .

42. CLOSED REDUCTION AND PERCUTANEOUS
FIXATION USING K-WIRES
• It has theoretical advantage of minimizing soft tissue trauma ,thereby
promoting healing and reducing the risk of AVN of the humeral head.
• It also has the advantage of decreased scarring in the scapulohumeral
interface and subsequent easier rehabilitation .
• Indications;
1. Fracture without significant communition in pt with good quality bone
2. Pt should be willing to comply with post op care plan
• Contraindications
1. Severe communition and osteopenia are absolute contraindications
2. Inability to reduce fracture fragments
3. Fracture dislocation
4. Non compliant patient

43. • Two-part, three-part, and valgus-impacted four-part fractures of the proximal
humerus can be treated with closed reduction and percutaneous fixation
(CRPF) by surgeons that have a thorough understanding of the radiographic
morphology of the proximal humerus, as assessment of fracture reduction will
rely entirely on fluoroscopic imaging.
• Bone quality plays an important role in achieving adequate fixation with CRPF
and to avoid pin migration and construct failure.
• Integrity of the medial hinge and periosteal continuity, in the absence of gross
tuberosity migration, are important forCRPF to be successful.

44. • For percutaneous K wiring CR by manual traction and mobilisation of the arm,
then confirmed the reduction using an image intensifier.
• An assistant maintained the reduction,and percutaneous pinning was performed.
Three to five 2 –2.5 - mm K - wires were used for fracture fixation, depending on
the stability. The K-wires were left protruding from the skin.

45. • To avoid injury to axillary nerve ,lateral pins
should enter the humeral cortex at a point at
least twice the distance from the upper aspect of
the head to the inferior head margin with a wire
angulated 45degree to the cortical surface
• The end point for the greater tuberosity pin
should be >2cm from the inferior most margin of
the humeral head

46. POST OPERATIVE CARE
• Patients are followed weekly both clinically and radiographically to monitor
fracture healing and detect any possible pin migration or skin problems.
• Patients are immobilized for 3 to 4 weeks in a sling, while active range-of
motion exercises of the elbow, wrist, and hand are encouraged.
• Passive range of motion is started thereafter with forward elevation, external
rotation and pendulum exercises.
• If healing has adequately progressed at 6 weeks the pins are removed under local
anesthesia and active range of motion is started.

49. • Postoperative Period and Functional Analysis
• At follow-up visits, arm pouch was applied to patients in both groups
of patients.
• Patients in the K-wire group were advised to perform passive
shoulder exercises for the first 2 weeks,active assisted exercises at 2
– 4 weeks, and active exercises after 4 weeks. K - wires were
removed after 6 weeks.
• The plate group began passive exercises from the first postoperative
day. Active assisted exercises were encouraged between 3 days and 2
weeks, and active exercises had begun by the end of 2 weeks.
• All patients were evaluated in the second, fourth, and , sixth, and
twelfth months and then once per year during outpatient visits.

50. Outcome Measures for Proximal
Humerus Fractures
Radiographic Assessment
Radiographic follow-up is usually performed at set intervals .
these frequently being 6 weeks and 3, 6, and 12 months after injury or surgery

51. CLINICAL ASSESSMENT
• Patients were assessed by Constant Murley score.
• Constant Murley score is a 100 points scale composed of
• pain (15 points), activities of daily living (20 points), strength
• (25 points), range of movements (40 points).
• Lowest being the worst outcome and highest scores means best outcome.
• <30 poor.
• 30-39 fair.
• 40-59 good.
• 60-69 very good.
• >70 excellent.

52. Pain
Pain is a key component of patient satisfaction. It is frequently quantified using a
visual analog scale (VAS) and reported as a value from 0 to 10
Range of Motion
Active and passive forward elevation, abduction, external rotation, and internal
rotation are frequently reported .The use of a standardized technique with a
goniometer is important to achieve reproducible measurements.
Strength
Strength is frequently reported as a measure of the weight that can be lifted in a
specific plane.The use of a dynamometer to assess strength in 90 degrees of
abduction is often reported.

53. RESULTS
• Group A underwent ORIF with PHILOS Plate.
• Group B underwent CRIF with percutaneous K wiring.

57. • RESULTS
• The CMS of the Kirschner wire (K - wire) and plate groups did not differ
significantly (p = 0.82671).
• . An alpha level of 5% has been taken, i.e. if any p value is less than 0.05 it has
been considered as significant. p valve we got 0.82671 so the study was
statistically insignificant and so the results were comparable.
• The mean CMS values were 58.5 ± 15.04 for the PHILOS group and
59.4 ± 12.04 for the K - wire group.
• All fractures united 100%.
• One case had stiffness and the other one had impingement in the PHILOS
group.
• In the K wire group, one case had infection.

58. DISCUSSION
• Percutaneuos fixation has its limitations of poor reduction of fracture
fragments, pin tract infection and long period of recovery.
• But it has the advantages of less soft tissue stripping with less exposure,
less blood loss and minimal invasiveness.
• ORIF with PHILOS plate for treatment of proximal humerus fractures has
the advantages of accurate reduction, early mobilization, better fixation
in osteoporotic bones and ease of reconstruction of Comminuted
irreducible fractures.
• On the other hand it has the disadvantages of excessive soft tissue
dissection and blood loss, risks of injury to the neurovascular structures
and increased risk of avascular necrosis of humeral head.

59. • In a study conducted by Fazalet al. it was seen that PHILOS plate fixation provided
stable fixation with minimal implant problems and enabled early range of motion
exercises to achieve acceptable functional results.
• In the present study it was concluded that PHILOS plate provides an excellent
stable construct even in multifragmented osteoporotic proximal humerus
fractures with the advantages of accurate reduction and early mobilization.
• Fixation with percutaneous K - wires may present an efficient treatment option for
2 or 3 part proximal humerus fractures with its advantages of minimal
invasiveness and less soft tissue dissection.
• Better functional results were seen in patients treated with PHILOS plate than
those treated with percutaneous K - wire fixation.

60. CONCLUSION
• Our study showed that in elderly population, with comminuted proximal
humerus fractures can be successfully treated with percutaneous K - wire fixation,
as well as with open reduction and internal fixation with PHILOS and both were
equally successful.
• Although the radiological results are slightly better with the PHILOS than
percutaneous K-wire fixation, there is no difference in functional outcome.
• In elderly population, both the modalities of treatments give comparable results,
K-wire fixation is preferred as it requires less intra-operative time, less blood loss,
less trauma to soft tissues, less cost but it requires C-arm control.
• As other medical comorbidities accompany the elderly patients and as fitness for
anaesthesia is sometimes in question, K-wire fixation is preferred

61. • Both modalities of treatment were associated with complications.
• They were more severe in K-wire fixation group than PHILOS group due
pin loosening in osteoporotic bones in the elderly.
• In the present study it was concluded that PHILOS plate provides an
excellent stable construct even in multifragmented osteoporotic proximal
humerus fractures with the advantages of accurate reduction and early
mobilization.

62. THANKYOU