Cadaveric study of the anatomical reference points for proximal humeral plate positioning

  • Kittikun Thienthong
  • Manusak Boonard
  • Artit BoonrodEmail author
  • Kowit Chaisiwamongkol
  • Suwitcha Sripadungkul
Original Article • SHOULDER - FRACTURES



Complications following locking plate fixation in proximal humeral fractures often related to malposition plates and inadequate screw fixation. However, literature did not define the best anatomical reference point for plate positioning. We conducted a study to assess the occurrence of subacromial impingement and screw perforation with two anatomical reference points for proximal humeral plate positioning.


Sixty shoulders of 30 cadavers were dissected, and proximal humeral locking plate was placed in two different levels in the coronal plane of the upper tip of plate: (1) the proximal portion of bicipital groove group and (2) the most prominent of lesser tuberosity group. Subacromial impingement during passive forward elevation and screw perforation were assessed in relation to the plate positioning.


No subacromial impingement during passive motion contacted to the plate in both groups. The calcar screw perforation rate was significantly lower in the proximal portion of the bicipital groove group (2 of 60 specimens, 3.33%) than the most prominent of lesser tuberosity group (52 of 60 specimens, 86.67%). The most proximal screws of the plate were no humeral head perforation in all specimens.


Our study would suggest that two anatomical reference points could be used to be the landmark to avoid the subacromial impingement and the most proximal screw perforation. However, the placement of the locking plate using the proximal portion of bicipital groove reference is better for calcar screw insertion.


Proximal humeral fracture Proximal humeral locking plate Cadaveric study Screw perforation 



All authors declare no funding source or sponsor involvement in the study design, collection, analysis, and interpretation of the data, in writing the manuscript, and in submission of the manuscript for publication.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests regarding the publication of this paper.


  1. 1.
    Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson AN (2011) Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Jt Surg Am 93(2):121–131CrossRefGoogle Scholar
  2. 2.
    Hirschmann MT, Fallegger B, Amsler F, Regazzoni P, Gross T (2011) Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS). J Orthop Trauma 25(5):286–293. CrossRefPubMedGoogle Scholar
  3. 3.
    Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS (2011) Predicting failure after surgical fixation of proximal humerus fractures. Injury 42(11):1283–1288CrossRefPubMedGoogle Scholar
  4. 4.
    Lee CW, Shin SJ (2009) Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Shoulder Elbow Surg 18(1):83–88CrossRefPubMedGoogle Scholar
  5. 5.
    Sproul RC, Iyengar JJ, Devcic Z, Feeley BT (2011) A systematic review of locking plate fixation of proximal humerus fractures. Injury 42(4):408–413CrossRefPubMedGoogle Scholar
  6. 6.
    Schliemann B, Siemoneit J, Theisen C, Kösters C, Weimann A, Raschke MJ (2012) Complex fracture of proximal humerus in elderly outcome and complications after locking plate fixation. Musculoskelet Surg 96(Suppl 1):S3–S11CrossRefPubMedGoogle Scholar
  7. 7.
    Faraj D, Kooistra BW, Vd Stappen WA, Werre AJ (2011) Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. Eur J Orthop Surg Traumatol 21(1):7–12CrossRefPubMedGoogle Scholar
  8. 8.
    Sun JC, Li YL, Ning GZ, Wu Q, Feng SQ (2013) Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate. Eur J Orthop Surg Traumatol 23(6):699–704. CrossRefPubMedGoogle Scholar
  9. 9.
    Erasmo R, Guerra G, Guerra L (2014) Fractures and fracture-dislocations of the proximal humerus: a retrospective analysis of 82 cases treated with the Philos locking plate. Injury 45(Suppl 6):S43–S48CrossRefPubMedGoogle Scholar
  10. 10.
    Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20(5):747–755CrossRefPubMedGoogle Scholar
  11. 11.
    Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G (2009) Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Jt Surg Am 91(6):1320–1328CrossRefGoogle Scholar
  12. 12.
    Maddah M, Prall WC, Geyer L, Wirth S, Mutschler W, Ockert B (2014) Is loss of fixation following locked plating of proximal humeral fractures related to the number of screws and their positions in the humeral head? Orthop Rev (Pavia) 6(2):5336. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedics, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
  2. 2.Orthopedics CenterBangkok Hospital UdonUdon ThaniThailand
  3. 3.Department of Anatomy, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand

Personalised recommendations