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Open Reduction and Internal fixation of proximal humeral physeal fracture using Synthes Philos plate

    Overview

    Learn the Open Reduction and Internal fixation of proximal humeral physeal fracture using Synthes Philos plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open Reduction and Internal fixation of proximal humeral physeal fracture using Synthes Philos plate surgical procedure.
    Proximal humerus physeal fractures are uncommon and account for fewer than 5% of fractures in children. They can be broadly divided into 2 types ,Salter-Harris I or Salter-Harris II.
    A Salter-Harris II is the more common injury and is typically an injury of adolescents following blunt trauma to the shoulder.
    A Salter-Harris I is more common in children under 5 years of age. Salter-Harris I injuries can occur as an overuse injury with resultant secondary fracture. Typically, a widening of the physis can be seen.
    Radiographic evaluation of the shoulder is performed with standard AP and axial or scapula Y views of the shoulder.
    Contralateral shoulder views can be requested for comparison.
    The combined views allow assessment of the severity of the displacement.
    The epiphysis tends to abduct and externally rotate due to the pull of the rotator cuff (supraspinatus and infraspinatus). The humeral shaft is usually displaced into a shortened, adducted and anterior position due to the pull of deltoid and pectoralis major.
    Anatomically, the proximal humeral physis contributes to 80% of humeral growth. It closes between the ages of 16-17 in females and at around 18 in males.
    The decision making is for type of fixation is down to a balance of providing a stable reduction without compromising growth potential. Where growth arrest is not a concern, a Philos plate would provide the most robust fixation as it provides adequate fixation in the epiphyseal and metaphyseal fragments. In descending order of stability, this is followed by cannulated screws, flexible nails and Kirshner wire pinning.

    Author : Mr Samuel Chan FRCS (Tr & Orth).
    Institution :The Queen Elizabeth Hospital, Birmingham, UK.
    Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
    In the USA contact: fda.gov
    In the UK contact: gov.uk
    In the EU contact: ema.europa.e

    Indications

    INDICATIONS
    Currently, there is very little literature with regard to how these injuries are managed in terms of their severity.
    Broadly speaking, fractures in pre-adolescent patients (<13 years of age) can be managed conservatively.
    If it is grossly displaced, surgical fixation may be considered. These are Neer-Horowitz type 3 and 4 fractures. The literature with regard to surgical fixation in this age group is weak.
    However, as age increases and remodelling potential decreases, the question of surgical fixation comes into play.
    Any decision for surgery depends on the age of the patient and their remodelling potential, the severity of injury and their functional demands. Chaus et al. suggests that in the older paediatric populations, conservatively managed proximal humerus physeal injuries have a higher chance of a less than desirable outcome.
    In addition, there is less concern with regard to potential growth arrest in a patient nearing skeletal maturity.
    SYMPTOMS & EXAMINATION
    There is usually a traumatic injury associated with these fractures.
    Clinical examination may reveal tenderness, bruising, deformity.
    When examining, it is important to exclude associated injuries which include brachial plexus injuries ,ACJ injuries and SCJ injuries
    IMAGING
    In addition to standard radiographs for determining fracture pattern and severity of displacement, a CT can be helpful in characterising the severity of the injury.
    Plain X-rays are used to classify according to the Neer-Horowitz classification , which can be used to determine treatment.
    Type 1 – minimally displaced (<5mm)
    Type 2 – displaced <1/3 width of humeral shaft Type 3 – displaced >1/3 and less than 2/3 of width of humeral shaft
    Type 4 – displaced >2/3 width of humeral shaft
    If there is concern regarding growth arrest, hand or elbow radiographs can be used to determine physiological age, as well as contralateral shoulder images.
    ALTERNATIVE OPERATIVE TREATMENT
    For patients with concern regarding growth arrest:
    Closed reduction under anaesthetic
    This method is reserved for Neer-Horowitz type 3-4 injuries and acute presentations where the fracture may still be mobile.
    The fracture is usually reduced using longitudinal traction, abduction and external rotation.
    There is a risk of redisplacement for this cohort of patients.
    Closed reduction and K-wire fixation
    Once the fracture is reduced using the method described above, 2-3 threaded pins are inserted to stabilise the fracture reduction.
    As they are passed percutaneously, there is a risk of injury to the axillary and the musculocutaneous nerve.
    Open reduction and K-wire fixation
    This is reserved for patients where the fracture is irreducible closed and require opening.
    The main structures that can block reduction and necessitate open reduction are the long head of biceps tendon , shoulder joint capsule , in-folded periosteum
    or fibres from the deltoid muscle
    Limited growth arrest concerns:
    Open reduction and other fixation
    If a more robust construct is desired, any reduction can be augmented with cannulated screws, Philos plate and retrograde flexible nails.
    Complications from intervention include axillary nerve injury, pin site infection, malunion and growth arrest (uncommon).
    The decision making is down to a balance of providing a stable reduction without compromising growth potential. Where growth arrest is not a concern, a Philos plate would provide the most robust fixation, followed by cannulated screws, flexible nails, and Kirshner wire pinning.
    NON-OPERATIVE MANAGEMENT
    The majority of these fractures can be treated in a sling. These fractures tend to heal quickly, so when the patient is comfortable, they are allowed to mobilise their shoulder as tolerated.

    Setup

    The patient undergoes a general anaesthetic and interscalene brachial plexus block.
    The patient is set up on a shoulder table inclined at around 45-60 degrees.
    Care is taken to ensure that the shoulder is positioned so that once the shoulder paddles are removed, the scapula body remains stable on the central paddle and that there is adequate exposure for intra-operative imaging.
    The whole of the shoulder, arm and hand of is prepared with chlorhexidine spirit and draped in the standard fashion. Sterile incise drapes are used to isolate the axilla.
    The operative arm is placed in a stockinette and supported on a sterile Mayo table.
    The image intensifier is set up on the contralateral side and advanced across the body when needed to image the shoulder. This allows adequate space for the surgeon to operate.

    Operation – 1

    AP and modified axial views of a 17 year old, who sustained a right displaced proximal humeral physeal fracture as a result of a fall whilst playing rugby.

    A contralateral shoulder view is help as part of the work-up.
    It shows that the proximal humeral physis has partially fused and that the patient is nearing mature skeletal growth.

    A CT scan with 3D reconstruction allows us to assess the pattern of displacement and plan for reduction +/- fixation.
    Note this patient’s displacement is unusual – the humeral shaft is displaced posteriorly , shortened and adducted, as opposed to being displaceed anteriorly, shortened and adducted.

    As described, the patient is set up on a shoulder table inclined at around 45-60 degrees.
    Care is taken to ensure that the shoulder is positioned so that once the shoulder paddles are removed, the scapula body remains stable on the central paddle and that there is adequate exposure for intra-operative imaging.

    A manipulation under anaesthetic was performed to assess the reducibility and stability of the fracture.
    This procedure was performed at day 7 post injury, and had already started to heal and was stable. It was not possible to perform an acceptable closed reduction. Therefore, the decision was made to proceed to open reduction and internal fixation.
    Note, in the majority of paediatric fractures, this amount of displacement would be acceptable as there is significant potential for remodelling in children. In this case, it was felt that this was not an acceptable position due to the patient nearing skeletal maturity, and that his career aspirations required a high functional demand and quick return to function.

    The whole of the shoulder, arm and hand of is prepared with chlorhexidine spirit and draped. Two sterile incise drapes are used to seal off the axilla.
    The operative arm is placed in a stockinette and supported on a sterile Mayo table.

    The procedure is performed using a deltopectoral approach.
    This is an extensile approach utilising the internervous plane between the deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves).
    Landmarks for incision
    – Inferior border of clavicle
    – Coracoid
    – Insertion of deltoid

    The skin and fat are incised and the deltopectoral plane is developed.
    It is usually identified by the fat stripe that lies between the 2 muscles, within which the cephalic vein can be identified.
    If there is difficulty identifying the correct plane, it is easiest to start proximally where the orientation of muscle fibres of deltoid and pec. major are more pronounced.
    The origin of deltoid attachment can be much more medial than anticipated (particularly in muscular individuals).
    If it is difficult to make progress, palpating or locating the coracoid is usually a reliable reference point for determining the deltopectoral interval.
    On deeper dissection proximally, one can also encounter the deltoid arteries running transversely at the proximal aspect of the exposure at the deltopectoral interval. These need to be identified and cauterised before proceeding with dissection.

    The cephalic vein is usually taken laterally as the tributaries of deltoid drain into the cephalic vein.
    Occasionally, when the vein sits in a more medial position, it can be mobilised accordingly. Care should be taken to ligate or cauterise its deltoid tributaries.
    The cephalic vein can be damaged from overzealous or prolonged retraction. In these cases, it should be ligated. There is no associated morbidity if this step is necessary.

    Once the interval is developed and the deltoid is retracted medially and pec. major is retracted laterally. The conjoint tendon (A) is exposed.
    The conjoint tendon attaches to the tip of the coracoid and consists of the short head of biceps and coracobrachialis tendon.
    A Hohmann retractor can be placed over the hook of the acromion and retracted to improve exposure and the field of view.

    The clavipectoral fascia is incised lateral to the conjoint tendon and developed proximally up to the coracoacromial (CA) ligament. The CA ligament runs from the tip of the coronoid to attach onto the anterior edge of the acromion.
    Note that the muscle belly of the conjoint tendon sits more laterally and deep to the conjoint tendon itself. Care is taken to mobilise the conjoint tendon and its muscle belly in its entirety.
    The CA ligament is much thicker than the condensation of clavipectoral fascia. It is a discrete structure and therefore, is easy to discern where the proximal limits of dissection lie.

    Once the clavipectoral fascia is incised, the appropriate plane between deltoid and proximal humerus is defined using sharp dissection.
    The deltoid is dissected off the proximal humerus by blunt dissection and is mobilised all the way round to the posterior aspect of the proximal humerus.
    The subdeltoid space is freed up into the subacromial space using blunt (finger) dissection.

    Once the proximal humerus is mobilised, the proximal 1-1.5cm of the attachment of pec. major (PM) can be released to further expose the proximal humerus
    Note the attachment of pec. major is broad and flat and is usually 4-5cm in diameter.

    The pec. major tendon (PM) is lifted up and held under tension and released using electrocautery.
    A cuff of tissue at the bony insertion is left. This facilitates a soft tissue long head of biceps tenodesis if requires.
    This was not performed in this patient due to their young age.

    Once the pec. major tendon is partially released, the long head of biceps tendon comes into view.
    In this case, it is important to preserve the anterior circumflex artery and its ascending branch as it runs proximally up the bicipital groove with the long head of biceps tendon.
    The long head of biceps tendon (LHB) (indicated by forceps) lies deep and medial to the insertion of the pec. major tendon.
    Note the fracture haematoma contained around the subdeltoid bursal tissue.

    The retractors can then be placed deep to the deltoid mucle laterally and the conjoint tendon medially.
    The Hohmann retractors are repositioned posterior to the humeral head and humeral shaft (HS) to retract deltoid and expose the humeral head and shaft.
    Note that the musculocutaneous nerve has a variable course but usually enters the bicep muscle 5-8cm distal to the coracoid process. Care must be taken when applying retractors to the conjoint tendon.
    The periosteum is incised longitudinally. As with all proximal fracture exposures, there is a balance between soft tissue stripping to allow adequate exposure to assess fracture pattern and configuration, as well judiciously maintaining some soft tissue envelope to allow some stability.
    The image shows the significant varus and (unusually) posterior displacement of the humeral shaft in relation to the epiphysis.

    The fracture plane is identified and developed.
    A periosteal elevator is used to disimpact the fracture to allow reduction.
    Despite the fracture being only 7 days old, it had started to heal. The anteromedial capsule and periosteum was contracted and fibrosed, and thus providing a mechanical block to anatomic reduction.
    This was judiciously elevated off the proximal humeral shaft to allow reduction.
    The periosteal elevator is also used to elevate the soft tissues distally to create an adequate ‘pocket’ for positioning of the Philos plate distally.

    Once disimpacted, the periosteal elevator can be used to lever the epiphysis back onto the metaphysis.

    Once reduced, the Hohmann retractors expose the field of view so that a Philos plate can be applied in the correct position.
    However, due to the instability, levering on the humeral head can cause it to redisplace.

    As the fracture had redisplaced, it was felt that it was not practical to use Hohmann retractors for the field of view.
    Travers retractors were used instead and were felt to offer a satisfactory compromise.

    Methods for stabilising fracture reduction include using pointed reduction clamps…
    It is important to ensure the clamps are placed onto bone, but also to avoid the inferior border of subscapularis as the axillary nerve and posterior circumflex artery is at risk.

    Kirshner wires are also required here to maintain reduction.
    Some foreplanning is required for the position of the clamps and K-wires as to allow for space for Philos plate application.
    Ultimately, in this case, these methods did not work due to inadequate reduction of the humeral epiphysis.
    This fracture was reduced in abduction and internal rotation of the humeral shaft.
    This is in keeping with the position of the humeral epiphysis (humeral shaft was adducted and posterior as opposed to anterior). It is more common to reduce the fracture in abduction and external rotation for fractures with the humeral shaft in adduction and anterior displacement.

    Please note that this is a demonstration set.
    The Synthes Philos plate set has various options and is worth familiarising yourself with:
    1. Philos plate – These are usually packed separately and different lengths are available. The most commonly use plate is the 3 hole Philos plate. Note that there are also diaphyseal Philos plate variations that come in different lengths. These are reserved for proximal shaft fractures.
    2. Smooth locking guides for use with the aiming device
    3. 2.5mm drill bit for small fragment cortical screws and 2.8mm calibrated drill for locking screws
    4. Drill sleeve for 2.5mm drill
    5. Measure
    6. Threaded locking guides for locking screws
    7. Screw caddy for cortical and locking screws
    8. Screw driver with torque limiter attachment

    The aiming device with nose is useful for applying the proximal locking screws in an efficient manner.

    This is applied to the Philos plate using a small fragment hexagonal screw driver.

    Operation – 2

    This is applied to the Philos plate using a small fragment hexagonal screw driver.
    The wire should be sited just distal to the tip of the greater tuberosity.
    Note that when checking with fluoroscopy, it is important to align the x-ray beam perpendicular to the proximal humerus to avoid misinterpretation of the plate position due to an oblique image.
    With experience, this step may be skipped as the height can be determined visually.

    The long head of biceps and the bicipital groove are used as a landmark for siting the plate.
    As mentioned, the Philos plate sits lateral to the long head of biceps tendon.

    The reduction was supported by the assistant and the Philos plate was applied in situ.
    Care is taken to ensure the plate is centred on the humeral head and the distal plate is aligned on the shaft. The long head of biceps tendon is a useful landmark for this. The plate lies lateral to this.
    The Philos plate is applied using the aiming device with nose extension.
    This allows passing a 1.4mm K-wire through the ‘nose’ extension to ensure that the plate is not applied too proximally. The K-wire should be in line or just distal to the proximal aspect of the greater tuberosity.

    The plate is aligned to the shaft and the 2.5mm drill bit is used in the centre of the elongated combi-hole to allow for adjustment of height if needed.

    The measure is used after drilling to determine the length of the cortical screw.
    Note that if the plate is note applied flush to the bone, some allowance has to be made for when the screw is applied so that the tip is not too proud when secured.
    Conversely, it should be long enough to ensure bicortical hold.

    The hole is tapped unless self-tapping screws are used.
    Once a satisfactory position is obtained, a cortical screw is applied through the elongated combi-hole in the plate shaft.
    This allows minor adjustment if the height of the plate is too proximal.

    The triple sleeve system is designed for use with the aiming device.
    The most inner centring sleeve is used to pass a 1.6mm Kirschner wire for temporary positioning (not used in this procedure).
    The middle centring sleeve is for use with the 2.8mm drill bit.
    The outer sleeve is used for guiding the 5mm locking screw once the hole has been drilled and ensures that the screws follows the drilled track.

    The smooth triple guide is applied to the aiming device in situ to allow satisfactory positioning of locking screws.
    When drilling, it is important to ensure that the sleeves remain secure in the aiming guide. This is done by manually maintaining it position in the aiming device.

    A graduated drill bit allows measurement of the screw length off the smooth guides.
    This can be checked under by using feedback from the drill bit or fluoroscopy to ensure the humeral head is not penetrated.
    The aim is to engage the locking screws with the subchondral bone.
    The proximal 2-3 locking screws are applied to stabilise the humeral epiphysis in relation to the humeral shaft.
    Only once this has been stabilised is it possible to screen the position of the fixation on image intensifier.
    Manipulation of the humerus is now possible to get adequate AP and lateral fluorscopic images of the proximal humerus.
    If in doubt, it is better to undersize the locking screws to account for any collapse of the humeral head.

    The inferior ‘calcar’ support screws are biomechanically important to support the fracture reduction and minimise the chances of the fracture falling into varus.
    Note: It is important for these screws to be of a sufficient length to be engaged in the subchondral bone and provide support.
    These screws tend to be inserted under direct fluoroscopic vision. Now that the fracture has been stabilised, it is technically easier to manipulate the proximal humerus to get appropriate images.

    Once satisfactory fixation has been undertaken (usually 5-6 proximal locking screws are required ), it is important to remove the aiming device.

    The remaining 2 distal shaft screws are applied using the threaded locking guide.
    Ideally, there should be 6 cortices of hold distally. If this is compromised, a longer plate should be considered.
    Care is taken to ensure that the threaded locking guide is applied concentrically and is not cross-threaded within the plate to allow engagement of the locking screws in the plate.

    The bone is drilled using the 2.8mm calibrated drill guide.
    The length can be measured off the threaded guide. If there is doubt as to the length of the screw, it is best to check using the measure before applying the locking screw.

    The final images show a satisfactory reduction and stable fixation.
    The shoulder is usually screened under live fluoroscopy to ensure that there is no screw penetration into the glenohumeral joint.

    Closure is in layers:
    The deltopectoral interval is closed using interrupted sutures to ensure that the metalwork is covered.
    A subcutaneous fat stitch is used to minimise the dead space.

    A running subcuticular stitch using an absorbable suture material is used for the skin.

    This is supplemented with 1/2 inch steristrips.

    Post Operative

    Initial post-op regime
    • Polysling for 4 weeks
    • Wrist/hand/finger exercises
    • Elbow flex/ext, pro/supination
    • Shoulder girdle exercises
    • Scapula setting exercises
    • Pendular exercises
    • Passive external rotation to neutral
    • Passive forward flexion to 90 degrees
    3-6 weeks
    • Gentle isometric exercises in neutral as pain allows
    • Wean off sling
    • Begin active assisted exercises ensuring glenohumeral movement, not scapulothoracic
    >6 weeks
    • Gentle isometric exercises in neutral as pain allows
    • Wean off sling
    • Begin active assisted exercises ensuring glenohumeral movement, not scapulothoracic

    Recommended Reading

    Chaus GW, Carry PM, Pishkenari AK, Hadley-Miller N. Operative versus nonoperative treatment of displaced proximal humeral physeal fractures: a matched cohort. J Pediatr Orthop. 2015 Apr-May;35(3):234-9. doi: 10.1097/BPO.0000000000000265.
    In the older paediatric populations, where remodelling potential is limited, conservatively managed proximal humerus physeal injuries have a higher chance of a less than desirable outcome.
    Sherk HH, Probst C. Fractures of the proximal humeral epiphysis. Orthop Clin North Am. 1975 Apr;6(2):401-13.
    Slight to moderately displaced proximal humerus fractures are relatively stable. In more severely displaced fractures, flexion, abduction, and slight external rotation of the distal fragment bring the metaphysis into alignment. These fractures have great potential for remodeling and can correct any residual deformity. Results from closed treatment are almost always good and open surgery is rarely indicated in patients with remodelling potential.
    In this case, the patient was reviewed at 6 weeks post surgery and had already gained almost full range of movement. There is no impingement from the plate and he was satisfied that his shoulder felt stable and ‘normal’ almost immediately after surgery.

    Reference

    • orthoracle.com

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