Review Article

Complications Associated with Locking Plate of Proximal Humerus

Fractures

Abstract Venkat Kavuri,

Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing Blake Bowden,
use of locking plate has helped treat this problem, but at the same time has brought about Neil Kumar,
complications. Past systematic reviews have documented these complications, however a large
number of recent studies have been published since, reporting their own complication rates with Doug Cerynik
different techniques. This study reviews the current complications associated with locking plate Department of Orthopaedic
of proximal humerus fractures as well as methods to reduce them. A systematic review, following Surgery, Drexel University
College of Medicine,
the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using Hahnemann University Hospital,
PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of Philadelphia, PA, USA
traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of
12-month postoperative followup, articles within the last 5 years, and studies with >10 participants.
Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible
studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were
included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery
and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from
multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting
of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal
humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported
complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular
necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation
occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-
related complications, which in turn were the main reasons for reoperation. The authors of these
studies discussed different techniques that could be used to address these issues. Expanding use of
locking plate in the proximal humerus fractures leads to improvements and advancements in surgical
technique. Further research is necessary to outline indications to decrease complications, further.

Keywords: Fracture, proximal humerus, locking plate,complications

MeSH terms: Bone plates, humeral fractures, proximal, surgical complications

Introduction hemiarthroplasty, proximal humeral nailing,

and reverse total shoulder arthroplasty.4,5
Proximal humerus fractures represent
a steadily growing problem within the Locking plate represents a relatively new
health-care system. Proximal humerus technology that theoretically supports
fractures are the third-most common type fixation in the setting of osteoporotic Address for correspondence:
Dr. Venkat Kavuri,
of fragility fracture, accounting for nearly bone.6 Its biomechanical properties made
Department of Orthopaedic
6% of all adult fractures.1,2 In addition, it promising in the setting of proximal Surgery, Drexel University
as the world’s population has aged, the humerus fractures, where purchase in the College of Medicine,
incidence of this fracture type has increased humeral head is difficult to obtain, due Hahnemann University Hospital,
245 N. 15th St. M.S. 420,
as well.3 Surgical intervention for this to large variations in bone density and
Philadelphia, PA 19103, USA.
fracture type is around 20%, due to the strength.7 Understandably, complications E-mail: [email protected]
increase in complications as patients age.3,4 were highly variable as locking plates
Surgical fixation with locking plates is first began to be used in the proximal
the most common type of intervention humerus fractures. The first systematic Access this article online
for displaced proximal humerus fractures, review in this setting noted the importance Website: www.ijoonline.com
though other options exist, such as closed of medial calcar support and the need for DOI:
reduction with percutaneous pinning, more attention to technical aspects of the 10.4103/ortho.IJOrtho_243_17
procedure.8 Sproul et al. performed another Quick Response Code:

This is an open access article distributed under the terms of the

review with a focus on length of followup,
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the How to cite this article: Kavuri V, Bowden B,
work non-commercially, as long as the author is credited and the Kumar N, Cerynik D. Complications associated with
new creations are licensed under the identical terms. locking plate of proximal humerus fractures. Indian J
For reprints contact: [email protected] Orthop 2018;52:108-16.

108 © 2018 Indian Journal of Orthopaedics | Published by Wolters Kluwer ‑ Medknow

 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

to more accurately capture the time frame necessary for the Table 1: Search terms used in the PubMed, Cochrane,
development of avascular necrosis (AVN) of the humeral and Scopus databases
head. The study confirmed factors for screw cutout and had Proximal humerus AND Screw
similar rates of complications.9 Humerus fracture Plate
Since the publication of these two reviews, there has been Shoulder Locking plate
an increase in the literature, regarding locking plate fixation LCP
for proximal humerus fractures. In addition, studies have PHILOS
attempted to curtail the complication rates mentioned
S3
earlier with augmentation strategies such as fibular strut
Fracture fixation
allograft, autograft, cancellous chips, suture fixation of the
rotator cuff, and defined technical steps, regarding plate and Fracture healing
screw placement. Recent years have shown an increase in Open reduction internal fixation
the indications for the use of locking plates, as well as Osteosynthesis
reverse total shoulder arthroplasty versus hemiarthroplasty LCP=Locking compression plate
in the setting of proximal humerus fractures.10,11 Given
the relative infancy of locking plate fixation at the time of studies were graded in accordance with the Journal of Bone
prior systematic reviews, and the small number of studies and Joint Surgery and Centre for Evidence-Based Medicine
included within each review, a more recent systematic guidelines, to universally assess the level of evidence of
review of the literature is warranted. This study examines each study. Statistics were performed by authors with
the current literature to evaluate complications experienced training in biostatistics. Complication rates were analyzed
with locking plate in light of changes to operative technique in a simple manner, first divided by the total number of
as familiarity with this implant has increased. fractures treated and followed by stratification by level of
evidence. There were no comparative analyses performed
Materials and Methods due to the heterogeneity of each study.
Following preregistration with PROSPERO
(CRD42015019038), a comprehensive search of the
Results
literature was performed in November 2013 and repeated The initial query conducted through the PubMed, Scopus,
in February 2015, to capture recent publications, utilizing and Cochrane databases identified 51,206 citations. After
the PubMed, Cochrane, and Scopus databases.12 Database removing duplicates and articles with irrelevant titles and
queries were performed using modifiers, limiting results to abstracts, a total of 191 full-text articles were assessed
publications in the English language of the past 10 years, for eligibility. From these 191 articles, 57 articles were
in studies involving human subjects. Search terms were included to be a part of this systematic review. The results
intentionally broad to identify all relevant articles [Table 1]. of screening and application of inclusion/exclusion criteria
are outlined in Figure 1.14-70
The study design was conducted strictly in accordance with
the PRISMA guidelines.12 The results were subsequently There were seven Level 1, three Level 2, 10 Level 3, and
filtered for duplicates, and titles and abstracts were 37 Level 4 studies. Level 1 and 2 studies included control
manually screened for relevance and potential adherence groups in regard to surgical approaches, nonoperative
to our inclusion criteria. To be included, eligible studies treatment, various treatment modalities, or deferring
must have been conducted in the past 5 years (modifier in operative techniques. Some Level 3 studies had a basis for
initial query was 10 years to ensure broadness of search), comparison when evaluating different surgical approaches
involving 10 or more subjects, adults aged 18 years or or operative techniques. Finally, Level 4 studies were
older, and a minimum average followup of 12 months. case series without a basis for comparison. Some of these
International studies with the English translation were series investigated techniques such as strut allografts,
included. Studies involving pathologic fractures, nonhuman suture fixation, bone grafting, and minimally invasive
subjects (in vitro studies), and cadavers were excluded. surgery.
Publications with overlapping or duplicate patient
There were a total of 3422 proximal humerus fractures that
populations were excluded.
were treated with locking plate. Certain studies failed to
Next, articles were assigned a quality score using a mention or report the presence or absence of complications that
previously published quality scoring system, which was were specifically being investigated. If this occurred, the study
also used by Sproul et al.9,13 The scoring system took into was not included in the complication’s analysis. The most
account the quality of the study design, as well as the quality common complication was intraarticular screw penetration
of its information. Two reviewers scored the articles and (9.5%), followed by varus collapse (6.8%), subacromial
only studies with a minimum score of 7/10 were included. impingement (5.0%), AVN (4.6%), adhesive capsulitis (4.0%),
Disagreements were resolved by consensus. Finally, the nonunion (1.5%), and deep infection (1.4%). Reoperation

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 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

PubMed Cochrane Scopus Table 2: Rate of intraarticular screw penetration

8,776 records 1,012 records 41,418 records
Level Percentage of Percentage Rate (%)
occurrences of fractures
1 40 192 20.8
2 71 360 19.7
51,206 records 3 57 639 8.9
4 129 1951 6.6
39,756 duplicates
Total 297 3142 9.5

11,450 records

11,259 titles/abstracts
Table 3: Rate of varus collapse
excluded Level Percentage of Percentage Rate (%)
occurrences of fractures
1 11 116 9.5
191 full-text articles
2 4 23 17.4
3 19 316 6.0
134 articles excluded
4 50 788 6.3
Total 84 1243 6.8
57 articles included

Figure 1: Flowchart showing selection of studies Table 4: Rate of subacromial impingement

Level Percentage of Percentage Rate (%)
occurred at a rate of 13.8%. Tables 2-9 display these rates of occurrences of fractures
complications broken down by levels of evidence. 1 1 27 3.7
2 5 270 1.8
Discussion 3 12 217 5.5
Intraarticular screw penetration (9.5%) 4 88 1616 5.5
Total 106 2130 5.0
Intraarticular screw penetration through the humeral head
has been noted as a problematic complication and may lead
to additional surgery to revise or remove the screw(s). Two Table 5: Rate of avascular necrosis
different screw penetrations have been discussed: primary Level Percentage of Percentage of Rate
and secondary. Primary screw penetration refers to the occurrences fractures
intraoperative placement of screws into the glenohumeral 1 18 283 6.4
joint. Secondary screw penetration refers to the screws that 2 4 113 3.5
have violated the articular surface as a result of collapse of 3 21 489 4.3
the humeral head due to varus collapse, AVN, or failure of 4 88 1956 4.5
fixation. Reports from the earlier literature show the prevalence Total 131 2841 4.6
of this complication to range from 0% to 23%.71 Sproul et al.
demonstrated this complication to be at a rate of 7.5%.9 Table 6: Rate of adhesive capsulitis
Level 1 Level Percentage of Percentage Rate (%)
occurrences of fractures
Fjalestad et al. reported that the majority of these 1 7 75 9.3
complications occurred in patients with Orthopaedic 2 Not reported Not reported -
Trauma Association (OTA) Type C fractures, with evidence 3 6 150 4.0
of AVN.27 Another study noted that attempts to obtain 4 36 1015 3.5
maximal purchase into the humeral head led to higher rates Total 49 1240 4.0
of primary screw penetrations. The authors adjusted their
surgical technique by placing screws 2 mm–3 mm away
from the subchondral bone, as was done in another level 1 Table 7: Rate of nonunion
study.48,70 In comparing different plates, Voigt et al. found Level Percentage of Percentage Rate (%)
that polyaxial locking screws with blunted ends could be occurrences of fractures
advantageous if screw penetration were to occur.65 1 3 272 1.1
2 Not reported Not reported -
Level 2 3 6 389 1.5
Buecking et al. observed that complications pertaining 4 24 1544 1.6
to the humeral head were higher in their deltoid-splitting Total 33 2205 1.5

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 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

Table 8: Rate of deep infection Varus collapse (6.8%)

Level Percentage of Percentage Rate (%) Varus collapse represents one of the more important
occurrences of fractures complications in the setting of locking plate in proximal
1 1 124 0.8 humerus fractures. Varus collapse is responsible for
2 5 360 1.4 secondary subacromial impingement and screw penetration
3 6 439 1.4
into the articular surface of the glenohumeral joint. Sproul
4 26 1790 1.5
et al. reported this as the most common complication in
Total 38 2713 1.4
their review, at a rate of 16.3%.9 The authors recommended
that special attention should be paid to the medial column,
Table 9: Rate of reoperation which has led some surgeons to place inferomedial
Level Percentage of Percentage Rate (%) support screws, cement, or graft in hopes of lowering this
occurrences of fractures complication rate.
1 34 227 15.0
Level 1
2 25 113 22.1
3 62 529 11.7 In comparing polyaxial versus monoaxial locking screws,
4 228 1658 13.8 Voigt et al. noted an increase in the rate of varus deformity
Total 349 2527 13.8 in the group treated with monoaxial screws. The authors
felt that polyaxial screws gave more options for screw
approach group, while complications pertaining to the placement inferomedially.65 Zhang et al. postulated that
humeral shaft were higher in their deltopectoral approach inferomedially placed support screws would resist varus
group.19 Konrad et al. reported screw penetration, not varus stress to the humeral head, therefore maintaining neck shaft
collapse or loosening, as the most common complication angle in three- and four-part fractures.69
with locking plate in their large multicenter study of Level 2
270 patients.34
Evaluating a new carbon fiber–reinforced-
Level 3 polyetheretherketone (CFR-PEEK) locking plate,
In a study comparing locking plate fixation with calcium Schliemann et al. showed a lower rate of varus deformity
phosphate cement augmentation versus cancellous bone in comparison to the control titanium locking plate. They
chips versus no augmentation, Egol et al. demonstrated believed that this was due to CFR-PEEK being less rigid
a significant decrease in intraarticular screw penetration and having a similar elastic modulus to bone.58
with calcium phosphate cement augmentation. In Level 3
addition, there was no association between the number
of screws in the humeral head and screw penetration. Lin et al. reported low rates of varus collapse in both their
However, age was associated with screw penetration minimally invasive and deltopectoral approach groups.
as elderly patients sustained this complication more However, they attributed a slightly higher rate within the
frequently.26 minimally invasive group due to a false sense of security
with progression through weight-bearing exercises because
Level 4 of faster wound healing and smaller scars.37
Little et al. described five incidences of asymptomatic Level 4
screw penetration in their series evaluating 72 cases, for
which endosteal augmentation was used. The authors Ricchetti et al. discussed additional contouring of the
believed that this intramedullary graft decreased the locking plate as a method to reduce the incidence of
working length of the locking screws.38 Ricchetti et al. varus malunion as it aids in obtaining an anatomic
reported no cases of screw penetration in their series neck–shaft angle. In addition, they placed bone graft for
of 54 fractures followed for 13 months. The authors complicated three- and four-part fractures.52 Kim et al.
described using screws 5 mm–10 mm away from the performed a study using autologous iliac bone impaction
subchondral bone to decrease the risk of screw perforation graft with locking plate of four-part fractures and
both primarily and secondarily, should collapse occur. reported 0 incidences of varus collapse in 21 cases over
This technique has also been reported in a review article a 27.5-month followup period. The authors believed that
by Ricchetti et al.52,71 Spross et al. noted that, by placing their meticulous attention to restoring the medial calcar,
screws 4 mm–5 mm away from the subchondral bone, obtaining sufficient screw purchase in the inferomedial
complications regarding intraarticular screw penetration aspect of the humeral head, and suturing the rotator cuff
decreased significantly. They also advocated the use of to the plate led to such positive results.32 Badman et al.
fluoroscopy in three planes in an attempt to avoid missing reported on 81 proximal humerus fractures, a majority of
primary screw penetrations.62 which were three-part fractures. The authors focused on

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 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

supplemental suture fixation of the rotator cuff in the five discover predictors of necrosis, following a proximal
cases of varus collapse and also used structural allograft in humerus fracture. Hertel et al. determined that the most
the setting of severe osteopenia.16 relevant factors included integrity of the medial hinge,
length of the dorsomedial metaphyseal extension, and
Subacromial impingement (5.0%)
different fracture types.72 Furthermore, growing indications
Subacromial impingement can be the result of poor for reverse total shoulder arthroplasty and recent favorable
intraoperative plate positioning or the sequelae of humeral studies in comparison to hemiarthroplasty may have
head collapse. Impingement is frequently symptomatic artificially decreased the rate of AVN currently being
and may require plate removal. Sproul et al. reported this reported.73 In addition, AVN may present later in followup
complication at a rate of 4.8%.9 Increased attention to plate and inadequate lengths of followup would, in turn, under
placement and preventing varus collapse are the methods report this complication. Recent studies have attempted to
surgeons are using to decrease this complication. use deltoid-splitting or minimally invasive approaches with
the belief that less soft tissue disruption in proximity to the
Level 1
humeral head would preserve its blood supply. Finally,
Only one study mentioned a case of subacromial there is growing belief that asymptomatic cases of AVN can
impingement. Olerud et al. reported one patient in their potentially over-report this serious complication.
treatment group of 27 cases with three-part fractures,
Level 1
who subsequently required plate removal. The authors
recommended averting humeral head collapse to prevent Comparing the minimally invasive approach to the
this complication.48 deltopectoral approach, Liu et al. reported one case of
AVN in the latter group and zero in the former. The authors
Level 2
believed that the minimally invasive approach decreased
Konrad et al. attributed their cases of impingement to soft tissue stripping and preserved the blood supply around
placing the plate too superiorly, leading to five cases in the proximal humerus.39 Zhang et al. reported only one
their study population of 270.34 case of AVN in their study that focused on medial support
Level 3 screws using a deltopectoral approach. In their opinion,
preventing medial collapse also aided in preventing AVN.69
Lin et al. attributed their cases of impingement to varus Interestingly, the findings from Fjalestad et al. showed that
collapse, while Jung et al. attributed their one case to nonoperatively treated patients had a higher rate of AVN
intraoperative error.31,37 Jung et al. described their operative than those in the operative group. All patients had displaced
positioning of the plate following reduction as caudal to three- and four-part fractures.27
the superior end of the greater tuberosity and lateral to the
bicipital groove.31 Bachelier et al. instead specified plate Level 2
position 1 cm caudal to the superior aspect of the greater Buecking et al. reported no case of AVN and no difference
tuberosity.15 between deltoid-splitting and deltopectoral approaches.
Followup, however, was only for 1 year.19 Schliemann et al.
Level 4
reported a lower incidence of AVN in patients treated with
Sahu reported no case of impingement, taking the shoulder their CFR-PEEK implant compared to conventional locking
through a range of motion arc before closure of the wound plate. Their followup was for a minimum of 2 years.58
to detect any symptoms of impingement.55 Osterhoff et al.
Level 3
described the majority of their 10 cases of impingement to
be strongly associated with medial calcar comminution.49 Martetschlager et al. reported higher rates of AVN in
Ricchetti et al. positioned the locking plate 5 mm–10 mm patients treated with a deltopectoral approach compared
lateral to the bicipital groove and 15 mm–20 mm caudal to to a minimally invasive deltoid-splitting approach. With a
the tip of the greater tuberosity. Two patients in their series mean followup of nearly 4 years, AVN was diagnosed in
of 54 cases had postoperative subacromial impingement six of 33 patients in the deltopectoral approach group and
symptoms.52 Finally, Aggarwal et al. described one of 37 patients in the deltoid-splitting approach group.41
provisionally fixing the plate with K-wires and placing the Wu et al. reported similar findings over a mean followup
shoulder through a range of motion arc under fluoroscopy. of 2.5 years in comparing a minimally invasive approach to
This technique resulted in five cases of impingement in a deltopectoral approach.67
their series of 47.14
Level 4
Avascular necrosis (4.4%)
Using a minimally invasive plating technique and a mean
AVN has been a historic concern with proximal humerus followup of nearly 3 years, Chen et al. reported only one
fractures. Sproul et al. reported this rate to affect 10.8% case of AVN in their series of 64 cases.21 Little et al.
of patients.9 This has even led to studies attempting to reported low rates of AVN as well by using a deltoid

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 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

splitting approach and a medial strut allograft.38 On the Level 4

other hand, Spross et al. reported 20 cases of AVN in their
Ockert et al. noted an unplanned reoperation rate of 14%
large case series of 294 followed for 1 year. The patients
and a planned reoperation rate (due to impingement, patient
were treated using a deltopectoral approach. The authors
request, or range of motion deficit) of 40% in its series of
determined, however, that fracture type influenced whether
43 patients followed for 10 years.46 Kim et al. reported
AVN occurred or not, with fracture dislocations having the
2 implant removals for cultural reasons in their case
highest rate.62
series of 21 four-part fractures followed for 27.5 months.32
Reoperations (13.8%) Finally, Schliemann et al. reported impingement and screw
penetration as the primary reason their revision rate was
Reoperations are a very important measure of how
close to 30%.57
successful the index operation was and also highlight the
most significant complications. Reoperations also highlight The data presented in this systematic review not only
possible improvements in surgical decision-making or support data from past reviews but also present potential
technique to avoid certain complications. Even in regard solutions proposed by investigators, in the hopes of
to AVN, more meticulous soft tissue management, attempts decreasing the complication rate associated with locking
at minimally invasive techniques, and consideration of plate of proximal humerus fractures. Recent reviews have
arthroplasty as primary surgery have led to a decrease emphasized the importance of AVN and fracture dislocation
in reoperation. It is also important to make a distinction patterns negatively impacting outcome. Complex,
between “planned” versus “unplanned” operations as many intraarticular fracture patterns have high complication rates
patients do request to have hardware removed. Hardware when treated with locking plate. Brorson et al. also noted
removal has been associated with a very low complication that the methodological quality of studies is lacking.75
rate and high patient satisfaction as indicated in a recent Tepass et al. noted that three- and four-part fractures
case series.74 This should be differentiated from the need actually had better outcomes when treated with head
to undergo an arthroplasty procedure due to failed primary preserving surgery compared to a hemiarthroplasty and that
open reduction and internal fixation (ORIF). there were an increase in the number of complications as
the fracture complexity increased.76 Finally, in a review
Level 1
specifically looking at referrals for complications, Jost
Cai et al. reoperated on three of 12 patients following et al. discussed the importance of making the primary
locking plate. The patients originally had four-part fractures surgery the definitive surgery. A majority of the patients
and reoperations were during the 2nd year of followup. received arthroplasty as a revision surgery, secondary to
Plates were removed for fixation failure and revision complications from locking plate. In these patients, primary
internal fixation for nonunion.20 Zhu et al. performed five reduction was not achieved, indicating that the more
screw revisions due to primary screw penetration.70 Voigt complex fracture patterns may not necessarily be amenable
et al. attributed the majority of reoperations in their study to locking plate.77
due to secondary displacement of the greater tuberosity.65
None of the articles presented in this review were in
Level 2 the most recent comprehensive systematic review, as
Sproul et al. completed their literature search in 2009.
Buecking et al. reported a large number of reoperations:
In addition, none of the articles from the previous
three screw revisions, 18 plate removals, four revision
systematic reviews are in this review as we only included
ORIF, and seven arthroplasties in their study population of
the most recent articles. We repeated our queries to
90.19 Seventeen of the plate removals were at the request
capture the most recent literature and data, noting
of the patient and the rest were due to screw perforation,
that there were quite a few articles we would not have
implant loosening, or infection. Schliemann et al.
been able to include. More experience with locking
performed seven plate removals with arthrolysis in two of
plate in treating proximal humerus fractures and the
those cases.58
application of newer techniques has definitely adjusted
Level 3 complication rates. Moreover, the complication rates may
not have been entirely accurate in the previous reviews
Kralinger et al. reported mechanical failure as a strong
as they were analyzing a smaller number of total cases.
predictor of reoperation in their study consisting of majority
Thus, one of the aims of this review was to encompass
three- and four-part fractures. Two revision arthroplasties,
as many recent articles without sacrificing quality, which
six capsular releases, six revisions of internal fixation,
we accomplished by including only high scoring articles
14 plate removals, and one hematoma evacuation were
into this study.
performed.35 Sanders et al. discussed screw revisions and
plate removals secondary to intraarticular screw penetration It is also worthwhile to discuss the fact that there is
and impingement, respectively, as a major reason for their a large amount of literature describing nonoperative
50% reoperation rate.56 treatment of proximal humerus fractures. Concerning

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 Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures

the number of complications as well as costs associated Subacromial impingement

with surgical treatment, there have also been studies
Ensure the plate does not sit too proximally, AVN, Consider
comparing operative versus nonoperative treatment of
fracture type to stratify risk of AVN, Careful soft-tissue
these fractures. Handoll et al. found in their Proximal
dissection, Consider minimally invasive techniques.
Fracture of the Humerus: Evaluation by Randomization
trial that surgical treatment does not result in Financial support and sponsorship
improved outcomes in most patients and that it is not Nil.
cost effective.78 This lends support to the argument that
every fracture should be treated on a case-by-case basis. Conflicts of interest
The osteoporotic nature of some of these fractures leaves There are no conflicts of interest.
it incredibly difficult to treat, and though locking plate
has been promising in theory, not every plate is the same References
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