Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide

Objectives

The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted in a locked position with the external guide.

Methods

Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve.

Results

The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide.

Conclusions

This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.     

Sub-muscular plating of the humerus: An emerging technique

Objective

The purpose of the present study was to evaluate percutaneous sub-muscular internal fixation using a locked screw methodology for treatment of diaphyseal humeral fractures.

Methods

Inclusion criteria were multiple extremity fractures, open fractures, neurovascular injuries, additional ipsilateral upper extremity fractures, the inability to obtain a satisfactory closed reduction and isolated fractures with circumstances that prevented effective bracing. Exclusion criteria were immaturity, neoplasm, infection and intra-articular extensions in the same bone. Outcome measures included clinical and radiographic healing, complications, elbow and shoulder symptoms, range of motion (ROM) and Constant-Murley (CM) scores.

Results

Thirty-one patients with 32 fractures were evaluated with a mean follow-up of 16 months (3-38 months). There was radiographic healing in 31 out of the 32 fractures; the non-union was revised to open plating at 6 months and healed uneventfully. Hardware complications included two construct disengagements; one patient was revised and healed, and the other achieved union with bracing. Neurovascular complications included one preoperative nerve palsy that recovered by 3 months, two partial to complete postoperative nerve palsies that recovered by 6 months, and one intact-to-complete nerve palsy due to a bone fragment that required decompression with full recovery by 3 weeks. All patients had functional ROM with a mean CM score of 88. There were no elbow complaints and minor shoulder dysfunction occurred in two patients with ipsilateral shoulder injuries. The rate of neurovascular complications was comparable to open plating techniques and all patients had full recovery.

Conclusion

We feel sub-muscular anterior plating of the humerus using locking screw technology is a viable and useful method for diaphyseal humeral fractures.     

A new nail with a locking blade for complex proximal humeral fractures

Introduction

The objective of this study was to assess the clinical outcome of displaced proximal humerus fracture treated with a new locking blade nail.

Materials and methods

This prospective study included a series of 92 patients with acute fracture of the proximal humerus treated in one hospital level I trauma centre with locking blade nail between December 2010 and December 2013. According to the Neer classification, all fractures were two- to four-part fractures. Age adopted Constant score, DASH and visual analogue scores were used as outcome measures.

Results

A total of 92 patients were enrolled in the study. However, 29 patients were excluded due to loss to follow-up and death. Ultimately, 63 patients were available for final follow-up and data analysis. The mean duration of follow-up was 22 months (range 16–48 months). On average at 1 year, all fractures had united. The mean weighted Constant score was 84.2 % and the median disabilities of the arm, shoulder and hand (DASH) score was 26, the range of elevation was 115 and range of abduction was 97. The head shaft angle was 130, and pain visual analogue was 1.6. We found that 5 of the 63 patients (8 %) demonstrated complications. Two patients (3 %) displayed secondary displacement and require device removal. Two patients (3 %) had impingement due to prominent metal work, and one patient had a superficial wound infection which was treated with a course of antibiotics.

Conclusion

Our study shows excellent results with new locking blade nail for displaced proximal humerus fractures. We think the locking blade nail offers stiff triangular fixation of the head fragment and support of the medial calcar region to prevent secondary varus collapse.

Level of evidence

III.

     

Effect of the Initial Deformity in the Coronal Plane on Postoperative Outcome of Proximal Humeral Fractures

Objective

There is currently no consensus on proximal humerus fractures with an initial deformity in the coronal plane who are better off with plates or nails, so we designed this study. To compare the effect of the initial deformity in the coronal plane of proximal humerus fractures on postoperative outcomes, we compare the maintenance of reduction in procedures utilizing plates and nails, and analyzed the subsequent occurrence of complications to explore whether the initial deformity should dictate the fixation approach.

Methods

The clinical data of patients with proximal humerus fractures who were hospitalized and underwent surgical treatment in our hospital from January 2016 to December 2020 were reviewed. Postoperative functional scores (American Shoulder and Elbow Surgeons, ASES; Constant-Murley Score, CMS), Neck-shaft angle (NSA), Quality of fracture reduction, Deltoid Tuberosity Index (DTI), and complications were compared among cases with initial varus, normal, or valgus deformities.

Results

We included 131 patients, 56 males and 75 females, with a mean age of 60.89 ± 5.53 years (range 50–76) and a mean follow-up duration of 16.63 ± 6.78 months (range 12–48). Of these, 29 cases had initial varus displacement, 71 had a normal NSA, and 31 had initial valgus displacement. Seventy-five were treated with a locking plate and 56 with a nail. After open reduction and internal fixation, the NSA was restored to normal (−135°) in all patients in all groups (P > 0.05). There was a significant difference in NSA changes at the last follow-up; 2.93° ± 2.12° in the varus group, 1.77° ± 1.18° in the normal group, and 2.32° ± 1.64° in the valgus group, with the highest change occurring in the varus group. There was no significant difference in the range of motion or functional scores including ASES and CMS among the three groups (P > 0.05). The complication rate of 20.7% in the varus group was significantly higher than the complication rates of 12.7% in the normal and 12.9% in the valgus groups (P < 0.05).

Conclusions

While proximal humerus fractures with initial coronal displacement (varus, normal, and valgus) show similar postoperative functional outcomes, varus fractures have a higher rate of complications. The nail provides better maintenance of reduction than the locking plate, especially in varus fractures.     

Evidence for Success with Locking Plates for Fragility Fractures

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.     

Shoulder hemiarthroplasty for complex humeral fractures: a 5 to 10-year follow-up retrospective study

Purpose

The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, strength recovery and predictors of successful treatment.

Methods

Seventy unstable proximal humeral fractures were treated with open reduction internal fixation (ORIF) with the use of locking proximal humerus plate. At an average follow-up of 31 months, the clinical and subjective outcomes were evaluated, and complication was analysed.

Results

The average Constant score was 72. The mean disabilities of the arm, shoulder and hand score was 23. The average range of motion was as follows: mean range of anterior elevation and abduction 120°–150°; external rotation in abduction 64° and in adduction 44°; and internal rotation T12.

Conclusion

On the basis of the overall functional and clinical outcome obtained, it is possible to suggest that the ORIF of the proximal humerus fractures using locking plate represents a helpful option that can lead to a good clinical and functional outcome even in the most complex fractures. Level of evidence, Case Series, Treatment Study, Level IV.     

Posterior multifragmentation of the femoral neck: Does it portend a poor outcome in internally fixed intracapsular hip fractures?

Aim

To establish whether posterior multifragmentation of intracapsular proximal femoral fractures leads to an increased incidence of non-union and avascular necrosis following internal fixation by contemporary methods.

Methods

After preoperative radiography which was evaluated for posterior fragmentation, 1042 intracapsular hip fractures (471 undisplaced and 571 displaced) were treated with reduction and internal fixation. The rates of non-union and avascular necrosis in the presence or absence of fragmentation were compared in both undisplaced and displaced groups.

Results

The undisplaced cases comprised 460 non-fragmented and 11 fragmented fractures. The complication rates were 14% and 18%, respectively. Displaced fractures consisted of 489 non-fragmented and 82 fragmented cases. In this group, complication rates were 43% and 40%, respectively. No difference was statistically significant.

Conclusions

Using current methods of internal fixation of intracapsular hip fractures, there is no significant association between the posterior multifragmentation of the femoral neck observed on preoperative radiography and the later development of fracture healing complications.     

Surgical treatment of two-part fractures of the proximal humerus: Comparison of fixed-angle plate osteosynthesis and Zifko nails

Introduction

Closed reduction and percutaneous pinning using Zifko nails offer the advantage of a minimal soft-tissue dissection but have been criticised for limited stability and secondary fracture dislocation. Angular stable plate osteosynthesis enables anatomic reduction, but carries the risk of soft-tissue traumatisation and consecutive humeral head necrosis. The present study compares the clinical and radiological outcome of patients with dislocated two-part fractures of the proximal humerus, who were treated with either Zifko nails or angular stable plate fixation.

Material and methods

A matched-pair analysis was performed and patient groups were matched according to age (±3 years), sex and fracture type. As many as 11 pairs of patients with a minimum follow-up of 3 years were formed and investigated radiographically and clinically using the Constant score (CS) and the visual analogue scale (VAS) for the patients’ satisfaction.

Results

At the time of follow-up, the absolute CS was 83 points in the PHP group and 78 points in the Zifko group (n.s.). Neither in the age and gender-corrected CS was found a significant difference between the study groups (PHP 104 ± 29, Zifko 95 ± 17, n.s.) nor in terms of subjective patient satisfaction (PHP 6.54; Zifko 7.8, n.s.). The complication rate was also comparable in both groups.

Conclusion

In conclusion, Zifko nailing represents a cost-effective minimally invasive surgical method with a complication rate and clinical outcome comparable to that after angular stable osteosynthesis by angular stable plate fixation in the treatment of two-part fractures of the proximal humerus.     

Locking plate fixation for proximal humerus fractures

Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.     

锁定钢板治疗肱骨近端骨折术后并发症的相关因素分析

目的探讨应用锁定钢板治疗肱骨近端骨折发生术后并发症的相关因素。方法回顾性分析80例(并发症组29例,无并发症组51例)行锁定钢板(LPHP或PHILOS)治疗肱骨近端骨折患者资料,应用Logistic回归分析研究各因素与术后并发症的关系。结果单因素分析示,并发症组在年龄、术后内侧皮质缺损、肱骨颈干角复位不佳等方面与无并发症组比较,差异有统计学意义(P<0.05);Logistic回归分析发现术后内侧皮质缺损和肱骨颈干角复位不佳是发生术后并发症的独立预测因素。结论影响锁定钢板治疗肱骨近端骨折术后并发症的相关因素较多,其中术后内侧皮质缺损及肱骨颈干角复位不佳是主要因素。     

Pseudarthrosis of the surgical neck of humerus treated by buttressing with a medial cortico-cancellous graft

Background:

Pseudarthrosis of surgical neck of humerus is uncommon condition. Different methods of improving the stability of fixation have been described, including impaling the shaft into the head, placing a tension suture through the rotator cuff, or using an intramedullary cortical graft. We report our results of cortico-cancellous strut graft medially to counter the varus force, in conjunction with a fixed-angle implant on the lateral side.

Materials and Methods:

We used this technique in seven cases of pseudarthrosis of surgical neck of the humerus. There were four women and three men, ranging in age from 22 to 65 years. All were treated with a tricortical medial buttress bone graft and fixed-angle fixation device on the lateral side. A locking proximal humerus plate (Synthes) was used in six cases, and a bent reconstruction plate (Synthes) was applied in one case. The one in which reconstruction plate was applied was operated before the advent of locking plates. The limb was immobilized in 30° of abduction over a cushion for 6 weeks, followed by a sling for another 6 weeks.

Results:

The followup varied from 18 to 96 months. All our cases healed within mean 5.1 months (range 4–6 months). There was one case of avascular necrosis. All cases had useful function of shoulder.

Conclusion:

The medial buttressing by strut graft with external fixation by laterally placed fixed angle plate is successful to achieve fracture union in pseudarthrosis of surgical neck of humerus.     

The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail

Introduction:

Non-union following fracture of the proximal humerus is not uncommon, particularly in the elderly. This can be associated with significant morbidity due to pain, instability and functional impairment. The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. We report our experience with the Polarus nail for the treatment of established non-union of the proximal humerus.

Materials and Methods:

A total of 7 Polarus nails were inserted for the treatment of non-union of the proximal humerus between June 2000 and July 2007. Each fracture site was opened, debrided, stabilized with a Polarus nail and then grafted with autologous cancellous iliac crest bone. The time between injury and surgery ranged from 6 to 102 months. One patient had undergone previous fixation of her fracture using Rush intramedullary rods. All patients were females, and mean age at surgery was 63.6 years (range, 49-78 years). A retrospective review of notes and radiographs was carried out. Patients were reviewed at varying intervals postoperatively (range, 13-68 months) and assessed using the Constant shoulder-scoring system.

Results:

All un-united fractures progressed to union. There were no wound complications and no postoperative nerve palsies. Functional outcome was good, even in those cases with a long interval between injury and surgery. The mean Constant score was 63 (range, 54-81). Migration of a single proximal locking screw was seen in 2 patients, and these screws required removal at 5 and 12 months, respectively, postoperatively.

Conclusion:

In our experience, a locked proximal humeral nail used in conjunction with autologous bone grafting is an excellent device for the treatment of proximal humerus non-unions.     

Intramedullary nailing of proximal tibia fractures—An anatomical study comparing three lateral starting points for nail insertion

Introduction

Intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. To date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures.

Materials and methods

18 fresh-frozen cadaver lower extremities were used to simulate an AO/OTA 41-A3 fracture. Six nails (Expert Tibial Nailing System, Synthes, Salzburg, Austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. After nail insertion, alignment in the coronal plane was recorded.

Results

Mean varus malalignment was dependent on the entry point at the lateral tibia plateau. Mean varus malalignment was 16° if nails were inserted at the lateral third, 10° at the middle third and 4° after nail insertion at the medial third. If nails were inserted from the medial third, valgus malalignment was recorded in two specimens.

Discussion

The effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. Primary valgus deformation up to 20° can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. Surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion.     

成人肱骨近端骨折锁定钢板固定术中重建肱骨颈干角的临床意义

 目的 测量肱骨颈干角的正常值,探讨成人肱骨近端骨折锁定钢板固定术中重建肱骨颈干角的临床意义。方法 测量382名正常成人的肱骨颈干角。回顾性分析2006年6月至2011年2月采用锁定钢板治疗的128例肱骨近端骨折患者的病历资料。测量术后患侧肱骨颈干角,并以测得的正常成人肱骨颈干角双侧95%参考值范围作为参考值,将患者分为内翻复位组(颈干角双侧95%参考值范围上限)。随访指标包括患侧肱骨颈干角的变化、肩关节Constant评分、疼痛视觉模拟评分(visual analog scale,VAS)及并发症等。结果　国人肱骨颈干角的正常值为136.1°±4.5°,双侧95%参考值范围127.2°～144.9°。所有患者获得6～32个月的随访,平均13.8个月。内翻复位组29例、正常重建组90例、外翻复位组9例。末次随访,Constant评分分别平均为70.3分、77.2分和73.2分, VAS评分分别平均为2.8分、1.8分和2.1分,肱骨头内翻角度分别平均为4.2°、1.6°和3.1°,并发症发生率分别为34.5%、14.4%和22.2%。正常重建组在功能恢复、VAS评分、术后肱骨头内翻情况及并发症发生率等方面均优于内翻复位组。结论　术中重建良好的肱骨颈干角是内固定稳定、预防术后肱骨头内翻、内固定失败和取得良好临床疗效的关键。肱骨头内翻复位易导致肱骨头进行性内翻及其相关并发症。     

Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures

Introduction

Short-term follow-up of angular stable fixation for proximal humeral fractures has been well documented in the literature. Longer follow-up series are difficult to find. However, especially regarding the risk of avascular humeral head necrosis longer follow-up series are high of clinical relevance.

Methods

Forty-eight patients with a mean age of 66 years and treated with open reduction and angular stable internal fixation for proximal humeral fractures were followed up for a mean of 45 months. The clinical and radiographic follow-up (Constant Score (CS), age and gender related Constant Score (agCS), Constant Score in comparison to the contralateral side (%CS) and shoulder anterior-posterior and lateral view and axial view X-rays) was performed postoperatively.

Results

Clinical results after 45 months showed a mean CS of 66.2 ± 15.4 points with a mean agCS of 90.0 ± 23.1%. Evaluation of the %CS showed 77.7 ± 17.8%. %CS results showed no significant differences after 45 months in comparison to those obtained after 12 months. However, incidence of avascular necrosis of the humeral head doubled over the follow-up period from 4 cases at 12 months follow-up to 9 cases at final follow-up.

Conclusion

Results of open reduction and internal fixation with angular stable implants for proximal humeral fractures are reliable, however long-term complications such as avascular necrosis of the humeral head need to be evaluated further on since its incidence increases over the time.     

Practice variation in common fracture presentations: a survey of orthopaedic surgeons

Background

Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation.

Materials and methods

A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored.

Results

358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures).

Conclusions

Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.     

Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach

Background and purpose

The extended deltoid-splitting approach was developed as an alternative to the deltopectoral approach in the treatment of three- and four-part proximal humeral fractures. The aim of our prospective study was to determine whether this approach was associated with evidence of nerve injury, functional deficits or other complications in these cases, during the first year following reconstruction.

Methods

Over a 1-year-period, we treated 14 people (median age 59 years) with open reduction and plate fixation using the extended deltoid-splitting approach. All were prospectively reviewed clinically and radiologically during the first year after surgery. Functional testing involved three scoring systems, spring balance testing of deltoid power, dynamic muscle function testing and, at 1 year, electrophysiological assessment of axillary nerve function.

Results

Of the 14 fractures, 13 united without complications and with comparatively minor residual functional deficits. Of these 13 cases, 1 showed slight neurogenic change in the anterior deltoid but no evidence of anterior deltoid paralysis. In the remaining case, osteonecrosis of the humeral head developed 9 months after surgery and functional scores were poor, but without evidence of nerve injury on electrophysiological testing.

Conclusions

This technique is a useful alternative in the treatment of complex proximal humeral fractures, providing good access for reduction and implant placement without adverse effects.     

解剖锁定钢板结合注射式人工骨植骨治疗老年肱骨近端外展嵌插四部分骨折

目的探讨解剖锁定钢板结合注射式人工骨植骨治疗老年肱骨近端外展嵌插四部分骨折的疗效。 方法回顾性分析2014年7月至2018年5月复旦大学附属浦东医院采用解剖锁定钢板结合注射式人工骨植骨治疗的11例老年肱骨近端外展嵌插四部分骨折患者的病例资料,其中男性4例、女性7例;平均年龄72岁。评估术后情况、肩关节功能及术后并发症。 结果末次随访时,患者视觉模拟评分平均1.6分;多数患者肩关节功能恢复良好,肩关节活动范围：平均前屈角度166°,平均外展角度166°;平均Constant-Murley评分为86.2分;前臂、肩及手快速残疾调查评分平均18.9分。随访过程中无病例出现肱骨头缺血性坏死、螺钉切出或其他内固定失败。 结论注射式人工骨植骨一方面填塞外展嵌插复位后造成的骨缺损,另一方面提高螺钉的把持力,可有效解决近端螺钉切出的问题,解剖锁定钢板结合注射式人工骨植骨是治疗老年肱骨近端外展嵌插四部分骨折的有效选择。     

Use of a “hybrid” locking plate for complex metaphyseal fractures and nonunions about the humerus

Purpose

To review one surgeon's experience with a novel type of “hybrid” locking plate (which has both 3.5 mm and 4.5 mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft.

Methods

Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A “hybrid” locking plate containing 3.5 mm locking holes on one end and 4.5 mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5 mm screws on one side of the fracture and three 3.5 mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion.

Results

Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the “hybrid” nature of the plate design was felt to be advantageous.

Conclusion

This “second generation” metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant.