My Ssec Capstone Project INTRODUCTION Proximal humeral fractures account for approximately 5% of all fractures1

INTRODUCTION Proximal humeral fractures account for approximately 5% of all fractures1

INTRODUCTION
Proximal humeral fractures account for approximately 5% of all fractures1. It is the 3rd most common fracture among the elderly population after hip and lower end radius fractures2. More than 70% of patients with these fractures are older than sixty years of age, and 75% are women3. In the elderly population, most of these fractures are related to osteoporosis. The osseous architecture of the humeral head with poor central cancellous bone stock, particularly in elderly patients, leads to a high risk of fixation failure with classic plate and screw fixation7,8and9
Advantages of PHILOS:
PHILOS possibly provides better stability as it has more number of screws in the head area and greater variability.
Partly converging and also diverging screw placement in the humeral head provides enhanced stability.

PHILOS allows infero- medial screw placement in the best quality bone available (especially in osteoporotic heads). This results in better medial support and longer maintenance of reduction.

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The screws in the humeral head are locked into the plate and cannot back out or toggle which is of particular advantage in the osteoporotic bone.

PHILOS is anatomically precontured.

The plate has a low profile, which minimizes the risk of impingement syndrome.

PHILOS is available for long fractures also because the plate is available in longer sizes as compared to LPHP.

AIMS : This prospective study had been conducted on 35 Patients with proximal humerus fractures treated by proximal humeral locking compression plate admitted in department of orthopaedic at Dr S.N. Medical college, Jodhpur from August 2015 to December 2017 for duration of almost 2 years.

OBJECTIVES OF STUDY :
To study the role of LOCKING COMPRESSION PLATE proximal humeral fractures and evaluation of outcome with respect to stability of fixation, union of the fracture, functional return and complications of the by Constant-Murley scoring System.

MATERIAL AND METHODS : Earliest admitted 35 cases with proximal humerus fractures who completed inclusion criteria treated by PHILOS during the period of August 2015 to
December 2017.

Inclusion criteria:
1. Neer’s of 2parts,3parts and 4parts fractures of proximal humerus2. patients with fracture dislocation of the shoulder (Neer`s type5)
3. Neer’s of 2parts, 3parts and 4parts fractures of proximal humerus with extension to shaft
4. Simple, closed proximal humeral fractures in adult patients (age >18 years).
Exclusion criteria:
1. Pathologic fractures in proximal humerus.
2. Age under 18 years (immature skeleton)
3. With associated polytrauma
Follow up: Constant-Murley scoring system

The Constant–Murley scoring system , graded as
Poor (0–55 points),
Moderate (56–70),
Good (71–85), or
Excellent (86–100) .

FOLLOW UP PROTOCOL
All patients were followed up for a period of one year; the follow up visits were done at:
6 weeks
Three months
Six months
One year
The important parameters assessed were:
Clinical:
wound condition
functional score
Radiological:
Fracture Union
Amount of collapse
MalallignmentYEAR STUDY TOTAL NO OF PATIENTS(n) AVERAGE FOLLOW UP(months) AVERAGE TIME OF FRACTURE UNION(weeks) FUNCTIONAL RESULTS COMPLICATIONS(%)
2007 MOONOT .et.al 32 11 10 66.5 28
2005 PLECKO .et.al 36 31  NA 80.7  NA
2002-2003 CHIDAMBARAM .R.et al 126  NA 14 78  NA
2002-2003 HARIDAS.J.et.al 30 9 10 55  NA
2017 PRESENT STUDY 35 9 10 72.2 25
We observed ten complications in nine patients. The most common complication, observed was subacromial impingement in three patients because the Locking Proximal Humerus Plate was positioned too far cranially. In three patients, fixation of greater tuberosity in mal position was noted. Of this one patient also had primary screw perforation of the articular surface of the humeral head. One patient each had primary screw perforation of articular surface of humeral head, superficial infection, hematoma and adhesive capsulitis. Reassessment of the complications suggests that the majority (6/10) of the complications were technique related. Hence meticulous surgical discipline is pertinent.
Intraoperative screening is essential to ensure that the placement of plate is at the proper level and there is no breaching of articular surface during insertion of the screw. Despite Intraoperative C-arm control, primary screw perforations through the articular surface can be overlooked at the time of surgery. Using measuring notations on drill bits and K-wires seems inadequate for achieving reliable screw length in osteopenic bone. One of the methods to avoid this as advocated by Felix Brunner et al. is drilling the lateral half of the track, followed by the use of a depth gauge to feel the resistance of the subchondral bone; the final screw length should be 2–3 mm shorter than the measured length.
Primary malreduction with greater tuberosity improperly fixed resulted in poor functional out come in two of our patients. This type of complication may be avoided by proper reduction prior to plate fixation and use of additional fixation with lag screws and suture fixation through the appropriate holes before placing the plate against the bone.
Conclusions:
The proximal humerus fractures are seen in all age groups from 3rd decade to 8th decade. . The Road traffic accidents (high energy injury) were major cause of proximal humerus fractures in younger patients. All female patients with proximal humerus fractures are belong to 5th decade and above with Osteoporosis. PHILOS Plate allows stable fixation in all types of Neer`s fracture types of proximal humerus and fracture dislocation of proximal humerus. PHILOS Plate allows early mobilization which is essential for optimal outcome i.e. from 2nd post operative period onwards. Satisfactory reduction of the fracture and optimal positioning of the plate under image control is of paramount importance for obtaining good result. Proximal Humeral Internal Locking system (PHILOS); In this system, locking of the threaded heads of the screws in the plate itself provides for a construct with angular and axial stability, eliminating the possibility of screw toggling (windscreen wiper effect), or sliding of the screws in the plate holes. Coupled with a divergent or convergent screw orientation, this makes for much improved resistance to pull out and failure of fixation35.

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