- Research article
- Open Access
- Open Peer Review
The bicipital groove as a landmark for reconstruction of complex proximal humeral fractures with hybrid double plate osteosynthesis
© Theopold et al. 2016
- Received: 6 August 2015
- Accepted: 8 March 2016
- Published: 12 March 2016
Complex proximal humerus fractures with metaphyseal comminution remain challenging regarding reduction and stability. In most fracture patterns the hard bone of the bicipital groove remains intact. In this case series, we describe a novel technique of hybrid double plate osteosynthesis of complex proximal humerus fractures with metaphyseal comminution.
In randomly chosen shoulder specimens and synthetic bones, pilot studies for evaluation of the feasibility of the technique were performed. Between 4/2010 and 1/2012 10 patients underwent hybrid double plate osteosynthesis. Seven patients (4 male, 3 female, mean age was 50 years (range 27–73)) were available for retrospective analysis. Based on plain radiographs (anterior-posterior and axial view), the fractures were classified according to the Orthopaedic Trauma Association classification (OTA) and by descriptive means (head-split variant (HS), diaphyseal extension or comminution (DE)).
Follow-up radiographs demonstrated complete fracture healing in six patients and one incomplete avascular necrosis. None of the patients sustained loss of reduction. Three patients where reoperated. The medium, not adapted, Constant score was 80 Points (58–94). Patients subjective satisfaction was graded mean 3 (range: 0–6) in the visual analog scoring system (VAS).
The technique of hybrid double plate osteosynthesis using the bicipital groove as anatomic landmark may re-establish shoulder function after complex proximal humerus fractures in two dimensions. Firstly the anatomy is restored due to a proper reduction based on intraoperative landmarks. Secondly additional support by the second plate may provide a higher stability in complex fractures with metaphyseal comminution.
- Proximal humerus fracture
- Metaphyseal comminution
- Double plate
- Locked plate
Complex proximal humerus fractures with metaphyseal extension or comminution are challenging regarding reduction and stability of the osteosynthesis [1, 2]. The metaphysis may be broken into several fragments and anatomical landmarks for reduction may be absent. In addition there will not be a sufficient metaphyseal substance to provide support for fixation. The missing restoration of the medial cortical support has been identified being responsible for an increased failure rate [1, 2] and nonunions  of the proximal Humerus. The initial calcar comminution is an independent prognostic factor for bad clinical outcome [1, 2]. This may lead to secondary varus dislocation with biomechanical alteration due to decreased supraspinatus efficiency . Whereas locking plates with placement of calcar screws [2, 5] and locking plates in combination with fibular bone grafts [6, 7] have been described to increase the medial support, hybrid double-plating has not been considered for improving stability, yet.
In this report, we describe a technique of double plate osteosynthesis of complex proximal humerus fractures with metaphyseal comminution. In the first step the bicipital groove is used as an anatomical landmark for reduction of the anterior column and a one-third tubular plate is placed into the groove in an inverted fashion. Secondly the reduction is completed and the fracture is fixed by a laterally placed locking plate.
After surgery patients had individual patient-related postoperative management. For better comfort, the patient’s arm was placed in a sling for a maximum of 2 weeks. Passive and active range of motion exercises were started after surgery, depending on pain and activity level.
Overall characteristics and results of the seven patients with minimum 12 months follow-up
OTA proximal segment classification
Constant score (affected/unaffected side)
Shoulder range of motion
Cause of injury
Material removal after 12 months
AVN, Screw perforation, frozen shoulder, 2 reoperations
Material removal after 13 months
Table 1 summarizes the demographic, injury and follow up data for each patient in our series. Follow-up radiographs demonstrated complete fracture healing in six patients and one incomplete avascular necrosis. None of the patients sustained loss of reduction. Three patients where reoperated: Two elective material removal after one year (Fig. 3) and one removal of perforating screws after 9 months and complete material removal with arthrolysis of the shoulder joint after 21 months. The medium, not adapted, Constant score is 80 Points (58–94). The medium Constant score of the non-affected side was 91 Points (84–96). Functional results revealed a mean range of motion (flexion/extension/adduction/abduction/internal rotation, external rotation) of 150 (110–170)/40 (30–50)/40 (30–50)/140 (90–180)/60 (50–90)/and 80 (40–90)°. Patients subjective satisfaction was graded mean 3 (range: 0–6) in the visual analog scoring system (VAS).
Taking into account that adequate reduction and stable conditions in osteosynthesis of proximal humerus fractures may be crucial for preservation and revascularization of the humeral head , the double plate osteosynthesis with consideration of the bicipital groove as anatomical landmark has been developed to restore the anatomy and optimize the stability after complex proximal humerus fractures.
Double plating with two one-third tubular plates in 90° configuration has previously been described in clinical studies providing high stability and allowing early mobilization . On the other hand biomechanical studies pointed out superior biomechanical properties of locking plates when compared to double plate with one-third tubular plates . Whereas hybrid plating – the combination of locking and nonlocking screws in the same plate – has been shown to provide an attractive alternative to an all-locked construct , to our knowledge the combination of a locking plate with nonlocking tubular plate has not been described, yet. This hybrid configuration of the one-third tubular plate anatomically fitting in the bicipital groove and the advantages of the locking plate in osteoporotic bone may lead to higher strength of the construct.
Whereas the bicipital groove is used as an anatomical landmark to restore humeral head retroversion when treating complex proximal humeral fractures with arthroplasty [12, 13], it has not been taken into account as landmark for the reconstruction with plate osteosynthesis. In most fracture patterns the hard bone of the bicipital groove remains intact . The inverted one-third tubular plate fits into this sulcus. Nevertheless anatomical variations have to be taken into account  and the tubular plate may not always optimally fit. One may criticize the tenotomy of the biceps tendon for exposure of the sulcus. On the other hand the tendon has recently been identified as potential source for pain in complex proximal humerus fractures  and is routinely performed in hemiarthroplasty. In a series of arthroscopic material removal 30 % tenotomies were performed due to biceps tendon pathologies after proximal humerus fractures . In our experience the biceps tendon tenotomy provides a greater exposure of the metaphyseal comminution zone, enables a distinct visualisation and palpation of the joint surface through the rotator interval and this may potentially reveal hidden head-split variants.
In our series, the patients treated with double plate technique sustained complex proximal humerus fracture. Retrospectively, 57 % (n = 4) showed a head-split variant in combination with the metaphyseal comminution. In the literature this kind of fracture are often treated with arthroplasty [18, 19]. Except of one patient with persisting pain and functional impairment, the overall Constant score was predominately excellent and good. The functional results were comparable with current literature [8, 20].
One further limitation of the presented case series is the lack of a reliable algorithm for the use of double plate osteosynthesis. The decision making was individual in each case and was performed, when reduction or stability was subjectively unsatisfying.
In conclusion, the technique of hybrid double plate osteosynthesis using the bicipital groove as anatomic landmark may re-establish shoulder function after complex proximal humerus fractures in two dimensions. Firstly the anatomy is restored due to a proper reduction based on intraoperative landmarks. Secondly additional support by the second plate may provide a higher stability in complex fractures with metaphyseal comminution. Ultimately, comparative biomechanical evaluations and long term follow-up studies in vivo are required to delineate the advantages.
We acknowledge support from the German Research Foundation (DFG) and Universität Leipzig within the program of Open Access Publishing.
All authors state that they have no conflict of interest and disclose all restrictions on full access for all authors to all raw data.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Krappinger D, Bizzotto N, Riedmann S, et al. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011;42:1283–8.View ArticlePubMedGoogle Scholar
- Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21:185–91.View ArticlePubMedGoogle Scholar
- Court-Brown CM, McQueen MM. Nonunions of the proximal humerus: their prevalence and functional outcome. J Trauma. 2008;64:1517–21.View ArticlePubMedGoogle Scholar
- Voigt C, Kreienborg S, Megatli O, et al. How does a varus deformity of the humeral head affect elevation forces and shoulder function? A biomechanical study with human shoulder specimens. J Orthop Trauma. 2011;25:399–405.View ArticlePubMedGoogle Scholar
- Osterhoff G, Ossendorf C, Wanner GA, et al. The calcar screw in angular stable plate fixation of proximal humeral fractures--a case study. J Orthop Surg Res. 2011;6:50.View ArticlePubMedPubMed CentralGoogle Scholar
- Osterhoff G, Baumgartner D, Favre P, et al. Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Shoulder Elbow Surg. 2011;20:740–6.View ArticlePubMedGoogle Scholar
- Gardner MJ, Boraiah S, Helfet DL, et al. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22:195–200.View ArticlePubMedGoogle Scholar
- Bastian JD, Hertel R. Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: outcomes in a consecutive case series. J Shoulder Elbow Surg. 2009;18:216–9.View ArticlePubMedGoogle Scholar
- Wanner GA, Wanner-Schmid E, Romero J, et al. Internal fixation of displaced proximal humeral fractures with two one-third tubular plates. J Trauma. 2003;54:536–44.View ArticlePubMedGoogle Scholar
- Hessmann MH, Korner J, Hofmann A, et al. Angle-fixed plate fixation or double-plate osteosynthesis in fractures of the proximal humerus: a biomechanical study. Biomedizinische Technik Biomedical Engineering. 2008;53:130–7.View ArticlePubMedGoogle Scholar
- Doornink J, Fitzpatrick DC, Boldhaus S, et al. Effects of hybrid plating with locked and nonlocked screws on the strength of locked plating constructs in the osteoporotic diaphysis. J Trauma. 2010;69:411–7.View ArticlePubMedGoogle Scholar
- Angibaud L, Zuckerman JD, Flurin PH, et al. Reconstructing proximal humeral fractures using the bicipital groove as a landmark. Clin Orthop Relat Res. 2007;458:168–74.PubMedGoogle Scholar
- Kontakis GM, Damilakis J, Christoforakis J, et al. The bicipital groove as a landmark for orientation of the humeral prosthesis in cases of fracture. J Shoulder Elbow Surg. 2001;10:136–9.View ArticlePubMedGoogle Scholar
- Edelson G, Kelly I, Vigder F, et al. A three-dimensional classification for fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86:413–25.View ArticlePubMedGoogle Scholar
- Wafae N, Atencio Santamaria LE, Vitor L, et al. Morphometry of the human bicipital groove (sulcus intertubercularis). J Shoulder Elbow Surg. 2010;19:65–8.View ArticlePubMedGoogle Scholar
- Tosounidis T, Hadjileontis C, Georgiadis M, et al. The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective. Injury. 2010;41:273–8.View ArticlePubMedGoogle Scholar
- Lill H, Katthagen C, Voigt C. Technique and value of arthroscopic implant removal in the shoulder. Orthopade. 2011;40:79–84.View ArticlePubMedGoogle Scholar
- Ockert B, Biermann N, Haasters F, Mutschler W, Braunstein V. Reverse shoulder arthroplasty for primary fracture treatment. Displaced three and four part fractures of the proximal humerus in the elderly patient. Unfallchirurg. 2013;116:684–90.View ArticlePubMedGoogle Scholar
- Reuther F, Kohut G, Nijs S. Newly developed modular reverse fracture endoprosthesis in non-reconstructable humeral head fracture in old people. Oper Orthop Traumatol. 2014;26:369–82. quiz 382–384.View ArticlePubMedGoogle Scholar
- Ockert B, Siebenbürger G, Kettler M, Braunstein V, Mutschler W. Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2014;23:1223–31.View ArticlePubMedGoogle Scholar