Fig. 1 Intraoperative photo showing placement of incisions for percutaneous plating of humeral fracture. The plate is inserted submuscularly along the bone and provisional proximal fixation is provided using a drill bit through a locking drill sleeve into the humeral head.
Courtesy of Jeffrey S. Staron, MD


Published 2/1/2010
Annie Hayashi

Making the transition to percutaneous plating for humeral fractures

Outcomes maintained, no increased complications

Displaced proximal humerus fractures can be surgically managed in several ways—from the traditional open deltopectoral approach to a less invasive deltoid-splitting approach. Each technique has its own distinct benefits and disadvantages.

“A standard deltopectoral approach has traditionally been used for locked-plate fixation of proximal humerus fractures,” said Jeffrey S. Staron, MD, at the 2009 annual meeting of the Orthopaedic Trauma Association. “It’s been the gold standard. But this approach disrupts vascularity—potentially causing osteonecrosis and collapse of the humeral head—and that’s a cause for concern.”

A less invasive, deltoid-splitting approach can be used to avoid these complications, allowing the locked plate to be inserted percutaneously (Fig 1). This minimally invasive approach, however, risks injury to the axillary nerve.

Dr. Staron and co-author B. Matthew Hicks, MD, compared the intraoperative and postoperative outcomes and complications of a minimally invasive, deltoid-splitting approach with those for a traditional open deltopectoral approach.

One surgeon, two patient groups
The investigators conducted a retrospective chart review of two- or three-part proximal humerus fractures with greater than 100 percent displacement. All surgical procedures were performed by the same orthopaedic traumatologist at a single institution.

The first patient group (20 patients) had been treated with a standard deltopectoral approach between 2002 and 2007. The percutaneous plating technique group consisted of the first 20 patients treated with this less invasive, deltoid-splitting approach by the surgeon. These procedures were performed between 2006 and 2008.

Table 1 shows the patient characteristics of the two groups. All 40 patients were followed for up to at least 6 months after surgery with examinations and radiographs.

All patients followed the same rehabilitation program, which included immediate initiation of pendulum exercises and physical therapy beginning 4 to 6 weeks after surgery.

The researchers also compared the following intraoperative and postoperative outcome measures: length of surgery, estimated blood loss, complications, length of hospital stay, time to radiographic healing (defined as bridging of the fracture site at three cortices), and the need for second surgeries.

Investigators attempted to contact each patient by phone to ask about outcomes, using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. They were able to reach 11 patients in the standard-approach group and 15 patients in the deltoid-splitting group.

No increased complications, less blood loss
“This study compares outcome variables of one surgeon’s transition in the treatment method for two- or three-part proximal humerus fractures,” said Dr. Staron.

“One of the main concerns regarding surgery in the proximal humerus region, specifically with the percutaneous technique, is injury to the axillary nerve. To avoid this injury, the surgeon must always be aware of the location of the nerve during surgery,” he added.

The results between the two study groups were comparable in many categories. DASH scores were comparable between the two groups; average surgical time was similar (1.6 hours for open compared to 1.4 hours for the percutaneous approach); no intraoperative complications occurred in either group; average hospital stay for both groups was 2.8 days, and the difference in time to radiographic healing was not statistically significant (21.0 weeks for open versus 17.7 weeks for percutaneous approach).

Because the percutaneous procedure was performed using an initial 2 cm to 3 cm incision with 3 additional stab incisions, intraoperative blood loss was significantly less—averaging half that experienced by the open group (57 mL percutaneous versus 114 mL for open).

Two patients in the open group and four patients in the percutaneous group required a second surgical intervention, but no post- operative infections occurred.

“During a single surgeon’s transition to a percutaneous technique, we found no increased intraoperative or postoperative complications,” said Dr. Staron. “Patient outcomes were maintained. The percutaneous plating of proximal humerus fractures can be performed safely.”

Because this was a small, retrospective study that did not investigate objective measures of postoperative functioning, the authors call for a larger-scale, randomized, prospective study to determine whether the percutaneous approach provides a true benefit compared to traditional open plating.

The authors report no conflicts.

Comparison of open versus percutaneous plating of proximal humerus fractures

Annie Hayashi is a contributing writer for AAOS Now. She can be reached at

Bottom line

  • Using the percutaneous technique to plate proximal humerus fracture requires that the surgeon pay attention to the location of the axial nerve.
  • Using the percutaneous technique results in significantly less blood loss.
  • Large-scale, randomized studies are needed to determine whether the percutaneous technique provides better outcomes than the traditional approach.