Electronic ISSN 2287-0237




To report functional and radiological outcomes of open reduction and internal fixation of proximal humeral fracture with anatomical LCP using 6 stepwise intraoperative criteria in surgical procedures.


A total of 30 proximal humeral fractures which were treated with open reduction and internal fixation with anatomical LCP of proximal humerus at a Level 1 and a Level 2 trauma center between January 2012 to December 2015 were collected. All patients were operated using the same technique in the supine position on a radiolucent table. The surgical approach was delto- pectoral approach. The operation was strictly done following 6 stepwise intraoperative procedures, this included: Step 1) reduction and fixation of head fragments. The reference image in the true AP fluoroscopic view named “beetle car” appearance was applied in all cases; Step 2) plate positioning with the humeral head, according to recommendation of implant surgical instructions; Step 3) fix the plate to the humeral head; Step 4) plate positioning to the shaft; Step 5) fix the shaft to the plate including additional locking head screws, head and calcar fixation and; Step 6) secure the sutures of the cuff to the plate. All patients received a similar physical therapy program following internal fixation. According to the Neer’s classification, there were 13 two-part fractures, 12 three-part fractures and 5 four-part fractures. The functional outcomes, Constant scores, and radiological outcomes (head-shaft angle and complications) were analyzed. The mean follow-up time was 18 months.


At the end of the follow-up period, all fractures united with acceptable alignment. The mean Constant score for the injured side was 86 points (range 42–92). Head-shaft angle minor varus (115-124) in 5 patients, normal (125-145) 22, minor valgus (146-155) 1 and major valgus (>155) in 2 patients. 2 patients (6.6 %) had complications which was confirmed by radiologic assessment. It was also found that one case had secondary intraarticular screw penetration and another had secondary varus during follow up. Both of the cases had severe osteoporosis, but no reoperation was required.


This study reports on the functional and radiological outcomes of open reduction and fixation of displaced proximal humeral fracture with anatomical locking compression plate using these developed 6 stepwise operative procedures which showed reasonable good to excellent outcomes with low complications. This study strongly suggested that the 6 stepwise surgical procedures should be strictly followed in the correct order as a surgical strategy to prevent complications arising from the operative technique of internal fixation of the complex proximal humeral fracture. from the operative technique of internal fixation of the difficult proximal humeral fracture.


proximal humeral fracture fixation, true AP view, beetle car appear- ance, true lateral view of plate, secondary varus, screw penetration



Figure 1:
Head-Shaft angle is formed by drawing a perpendicular line of the head axis and shaft axis.
Figure 2:
Demonstrates the C-Arm setting from the other side of the operating table, opposite to the fracture side.
Figure 1A:
Shows suturing of the displaced fragments of the humeral head with non-absorbable suture material. The sutures were passed into the tendon attachment of greater tuberosity, and lesser tuberosity, as required to pull and mobilize the fragments for reduction.If necessary these sutures can be tied up together to keep the reduction before plate application.
Figure 1B:
The humeral head was reduced by pulling of sutures and tying all sutures together to form a “beetle car” appearance in true AP of fluoroscopic view.
Figure 1C:
The reduction can be facilitated by abduction of the shoulder to release the tension of deforming forces, sutures are placed to aid reduction and K-wires are fixed provisionally before plate application.
Figure 2B:
The true fluoroscopic AP view shows the beetle car appearance, and the plate has to be positioned in such a way to show the “True lateral profile the plate” while the most proximal tip of the plate is 5-8 mm inferior to the greater tuberosity tip.
Figure 2C:
In lateral view shows the plate is placed on the center of the head.
Figure 3:
The humeral head is fixed by K-wires and some locking head screws prior to reduction and fixation of the shaft.
Figure 4A:
Demonstration of measurement of Head-Shaft angle in AP view after reduction.
Figure 4B:
Shows true lateral view of proximal humerus before correction of anterior fracture angulation.In this view the distal part of the plate is not parallel to the shaft.
Figure 4C:
Shows after correction of anterior angulation of head shaft fragments by simple manipulation, the whole length of the plate is parallel to shaft.
Figure 5A:
One cortical screw is fixed to the shaft and plate after rotational alignment has been assessed and corrected. Then the screw will keep the plate in the correct position before the placement of locking head screws.
Figure 5B:
Plate fixation in AP with good head shaft axis. Plate is placed parallel and along the shaft in lateral view.
Figure 6A:
Final step of attaching the cuff sutures to the plate holes to reinforce the fixation construction.
Figure 7:
Final results after 12 months of follow up.
Figure A:
Classification of fracture type.
Figure B:
Constant score result.
Table 1:
Number of cases comparing Head-Shaft angle between immediate post-operative phase and final follow up.
Table 2:
Overall complications.