European Journal of Cardiovascular Medicine

Fractures of the proximal humerus account for approximately 4–5% of all skeletal fractures and are the third most frequent fractures in the elderly, following hip and distal radius fractures [1]. These injuries often result from low-energy falls in osteoporotic individuals or high-velocity trauma in younger populations [2]. With the growing elderly demographic and increased incidence of road traffic accidents, the burden of these fractures has risen significantly [3].

Although the majority of proximal humerus fractures can be managed conservatively, particularly non-displaced ones, a considerable proportion—approximately 15–20%—are displaced and may benefit from surgical intervention to restore joint function and anatomy [4]. Among the available surgical options, open reduction and internal fixation (ORIF) using the PHILOS (Proximal Humerus Internal Locking System) plate has become a widely accepted method due to its angular stability, anatomical contouring, and ability to facilitate early mobilization [5].

The choice of surgical approach remains a critical factor influencing operative exposure, soft tissue preservation, and complication rates. The deltopectoral (DP) approach offers broad visualization of the fracture and neurovascular structures but requires extensive soft tissue dissection, which may compromise vascularity and delay rehabilitation [6]. In contrast, the deltoid split (DS) or minimally invasive percutaneous plate osteosynthesis (MIPPO) approach is less invasive and preserves soft tissue but may limit visualization and pose a risk to the axillary nerve [7].

Previous studies have reported conflicting evidence regarding the superiority of one approach over the other in terms of clinical and radiological outcomes, operative time, blood loss, and incidence of complications such as avascular necrosis, implant failure, and screw penetration [8,9]. However, the identification of predictive factors for postoperative complications in relation to the surgical approach has not been fully elucidated.

This study aims to evaluate and compare the incidence of complications and their predictive factors in patients undergoing PHILOS plate fixation through the deltopectoral versus deltoid split approaches in Neer’s type 2 and 3 proximal humerus fractures. The findings may provide insight into optimizing surgical strategies for improved patient outcomes.

This prospective observational study was conducted in the Department of Orthopaedics at Dr. Bhim Rao Ambedkar Memorial Hospital, Raipur, Chhattisgarh, from February 2022 to September 2022. The study protocol was reviewed and approved by the institutional ethics committee. Informed written consent was obtained from all patients prior to enrollment.

Study Population

A total of 22 patients with displaced proximal humerus fractures classified as Neer’s type 2 and 3 were included. These patients were divided into two groups:

• Group A (Deltopectoral approach, n=11)
• Group B (Deltoid Split approach, n=11)

Both groups underwent open reduction and internal fixation (ORIF) using PHILOS (Proximal Humerus Internal Locking System) plates.

Inclusion Criteria

• Age between 18 and 65 years
• Displaced Neer’s type 2 or type 3 fractures
• Fracture duration less than 3 weeks
• Closed fractures of the proximal humerus

Exclusion Criteria

• Open fractures
• Pathological fractures (e.g., due to malignancy or metabolic bone disease)
• Associated brachial plexus or peripheral nerve injuries
• Bilateral humerus fractures
• Patients medically unfit or unwilling for surgery

Preoperative Assessment

All patients underwent thorough clinical and systemic evaluation. Standard radiographic imaging included true anteroposterior (AP) and axillary views of the shoulder. Additional laboratory investigations such as complete blood count, renal and liver function tests, coagulation profile, chest X-ray, and ECG were performed as part of pre-anaesthetic workup.

Surgical Techniques

All surgeries were performed under regional or general anaesthesia in a semi-reclined position.

• In the deltopectoral group, a 10–15 cm incision was made along the deltopectoral groove. Dissection was carried out between the deltoid and pectoralis major muscles, and fracture fixation was achieved after adequate exposure.
• In the deltoid split group, a vertical incision was made from the lateral edge of the acromion, extending distally over the deltoid. Care was taken to protect the axillary nerve. Reduction and plate placement were performed under fluoroscopic guidance.

In both groups, appropriate-sized PHILOS plates were positioned with at least four screws in the humeral head and two in the shaft. Wound closure was done in layers and a sterile dressing applied.

Postoperative Care and Follow-Up

Patients were immobilized in an arm sling. Early passive mobilization of the shoulder and active range of motion of the elbow and wrist were encouraged from postoperative day one. Sutures were removed at 10–12 days. Regular follow-up assessments were conducted at 3 weeks, 6 weeks, 12 weeks, and 6 months.

Outcome Assessment

Functional outcomes were evaluated using the Constant-Murley Score at each follow-up. Radiological healing was assessed using serial radiographs. Complications such as infection, hardware failure, screw back-out, loss of reduction, and avascular necrosis were recorded and analyzed.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using R statistical software. Continuous variables were expressed as mean ± standard deviation and compared using the Student’s t-test. Categorical data were analyzed using Chi-square or Fisher’s exact test. A p-value of <0.05 was considered statistically significant.

A total of 22 patients with proximal humerus fractures were included and treated using PHILOS plating through two surgical approaches: deltopectoral (DP) and deltoid split (DS), with 11 patients in each group. Demographic data, operative characteristics, functional outcomes, and complication profiles were compared between the two groups.

Table 1: Demographic and Clinical Characteristics

In-text citation: Both groups were comparable in terms of baseline demographic and clinical parameters (Table 1).

Table 2: Operative Parameters, Complications, and Radiological Outcome

In-text citation: Blood loss was significantly lower in the deltoid split group, while other surgical parameters were similar (Table 2).

Table 3: Functional Outcomes at 6 Months Follow-up

In-text citation: Functional recovery was better in the DS group, with statistically significant Constant score differences at 6 months (Table 3).

Proximal humerus fractures, particularly in elderly populations, present a surgical challenge due to associated osteoporosis, complex fracture morphology, and potential for postoperative complications. Among the various internal fixation options, PHILOS plating has emerged as a reliable modality due to its biomechanical advantages and anatomical contouring [1]. This study aimed to compare the functional outcomes and complication rates between the deltopectoral (DP) and deltoid split (DS) approaches in patients undergoing PHILOS plate fixation.

The demographic characteristics in this study—predominance of males and patients aged between 41–60 years—are consistent with previous literature, which indicates higher incidence in active adults due to falls and road traffic accidents [2,3]. Although proximal humerus fractures are also common in the elderly due to osteoporosis, our study reflects a relatively younger demographic, likely influenced by regional trauma patterns.

The mode of injury, largely due to falls and vehicular trauma, was equally distributed between groups, suggesting no approach-specific influence on fracture etiology. Previous studies have reported similar observations where both mechanisms are leading causes across age groups [4,5].

Our findings demonstrated that the DS approach resulted in a slightly shorter operative duration and lower intraoperative blood loss compared to the DP group, although these differences were not statistically significant. Similar observations have been reported by Gardner et al., who noted that the DS approach facilitates faster access to the lateral humerus, reducing surgical time [6]. The reduced soft tissue dissection associated with the DS approach may also explain the lower blood loss, as previously highlighted by Hardeman et al. [7].

Postoperative outcomes in both groups were favorable, with all patients achieving fracture union by 12 weeks. The head-shaft angle, an important determinant of shoulder biomechanics, was maintained within an acceptable range in both groups, aligning with studies by Erhardt et al. and Bai et al. [8,9].

Functional outcomes assessed using the Constant-Murley score revealed higher scores in the DS group at 6 months, with statistically significant differences. This can be attributed to better preservation of the anterior deltoid, reduced soft tissue trauma, and early mobilization, as supported by recent comparative trials [10,11]. Moreover, greater flexion and extension arc in the DS group further substantiates the advantage of minimally invasive exposure.

In terms of complications, the DP group experienced one case of superficial wound infection, while the DS group had one case of screw perforation into the humeral head. These findings mirror those of Sudkamp et al., who reported a 14–28% complication rate with PHILOS plating, including infections, screw back-out, and avascular necrosis [12]. Although our sample size is small, the incidence observed is in line with existing data.

Comorbidities such as diabetes and hypertension were evenly distributed and did not significantly influence complication rates in our cohort. However, other studies suggest that such conditions may impair fracture healing or increase infection risk [13,14].

The radiological outcomes, particularly the restoration of head-shaft angle and implant positioning, were comparable in both groups. These parameters are critical for long-term shoulder function and implant survival, as emphasized by Acklin et al. and Osterhoff et al. [15].

One limitation of our study is the relatively small sample size and short-term follow-up. Larger multicentric trials with long-term outcomes, especially focusing on return to daily activity and quality of life measures, are warranted.

Both the deltopectoral and deltoid split approaches using PHILOS plating for proximal humerus fractures provided satisfactory functional and radiological outcomes. However, the deltoid split approach demonstrated slightly superior shoulder mobility, reduced intraoperative blood loss, and fewer soft tissue-related complications. Thus, the deltoid split technique may be preferred in selected patients for minimizing morbidity and enhancing recovery, though both approaches remain clinically effective.

1. Paavolainen P, Bjorkenheim JM, Slatis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand. 1983;54:374-9.
2. Neer CS. Displaced proximal humeral fracture. Part I: Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077-89.
3. Neer CS. Displaced proximal humeral fractures. Part II: Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52:1090-103.
4. Siebler G, Kuner EH. Late results following the surgical treatment of proximal humerus fractures in adults. Unfallchirurgie. 1985;11(3):119-21.
5. Kristiansen B, Christensen SW. Plate fixation of proximal humeral fractures. Acta Orthop Scand. 1986;57:320-3.
6. Mourdian WH. Displaced proximal humeral fractures. Seven years’ experience with a modified Zickel supracondylar device. Clin Orthop Relat Res. 1986;212:209-18.
7. Moda SK, Chadha NS, Sangwan SS, Khurana DK, Dahiya AS, Siwach RC. Open reduction and fixation of proximal humeral fractures and fracture dislocations. J Bone Joint Surg Br. 1990;72:1050-2.
8. Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral fractures: management techniques and expected results. Clin Orthop Relat Res. 1993;293:13-25.
9. Robinson CM, Christie T. Two-part proximal humeral fracture: A review of operative treatment using two techniques. Injury. 1993;24(2):123-5.
10. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7:85-9.
11. Koval KJ, Blair B, Takie R, Kummer FT, Zuckerman D. Surgical nerve fractures of the proximal humerus: a laboratory evaluation of ten fixation techniques. J Trauma. 1996;40(Suppl):778-83.
12. Hessmann M, Gehling H, Gotzen L. Plate fixation of proximal humerus fracture with indirect reduction: surgical technique and results using the shoulder score. Injury. 1999;30:453-62.
13. Hintermann B, Trouillier HH, Schüfer D. Rigid internal fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br. 2000;82(8):1107-12.
14. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Am. 2002;84:1919-25.
15. Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate. Acta Orthop Scand. 2004;75(6):741-5.