title: Proximal humeral fractures: the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates.
abstract: The aim of our study is to analyse the results of our surgical technique for the treatment of proximal humeral fractures and fracture dislocations using locking plates in conjunction with calcium sulphate bone-substitute augmentation and tuberosity repair using high-strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Optimal surgical management of proximal humeral fractures remains controversial. Locking plates have become a popular method of fixation. However, failure of fixation may occur if they are used as the sole method of fixation in comminuted fractures, especially in osteopenic bone.
  
  
  METHODS
  We retrospectively analysed 22 proximal humeral fractures in 21 patients; 10 were male and 11 female with an average age of 64.6 years (range 37-77). Average follow-up was 24 months. Eleven of these fractures were exposed by the extended deltoid-splitting approach. Fractures were classified according to Neer and Hertel systems. Preoperative radiographs and computed tomography (CT) scans in three- and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were five two-part, six three-part, five four-part fractures and six fracture-dislocations (two anterior and four posterior). Results were assessed clinically with disabilities of the arm, shoulder and hand (DASH) scores, modified Constant and Murley scores and serial postoperative radiographs.
  
  
  RESULTS
  The mean DASH score was 16.18 and the modified Constant and Murley score was 64.04 at the last follow-up. Eighteen out of twenty-two cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. Four patients had a longer recovery period due to stiffness, associated wrist fracture and elbow dislocation. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients.
  
  
  CONCLUSIONS
  In our experience, we have found the use of locking plates, calcium sulphate bone substitute and tuberosity repair with high-strength sutures to be a safe and reliable method of internal fixation for complex proximal humeral fractures and fracture-dislocations. Furthermore, we have also found the use of the extended deltoid-splitting approach to be safe and to provide excellent exposure facilitating accurate reduction for fixation of the fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations.
authors.affiliation: West Middlesex University Hospital NHS Trust, Department of Orthopaedics, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK. Karthick.Somasundaram@wmuh.nhs.uk
authors.forename: K
authors.initials: K
authors.lastname: Somasundaram
authors.forename: C P
authors.initials: CP
authors.lastname: Huber
authors.forename: V
authors.initials: V
authors.lastname: Babu
authors.forename: H
authors.initials: H
authors.lastname: Zadeh
mesh_terms: D000328:Adult; D000368:Aged; D001365:Axilla / Q000000981:diagnostic imaging* / Q000294:innervation; D001860:Bone Plates; D018786:Bone Substitutes / Q000627:therapeutic use*; D002133:Calcium Sulfate / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D010147:Pain Measurement; D056888:Patient Positioning; D011859:Radiography; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D018786:Bone Substitutes; D002133:Calcium Sulfate