Proximal humerus fractures constitute a significant portion of upper limb injuries, accounting for nearly 4–5% of all fractures, particularly among elderly individuals due to osteoporotic bone and low-energy mechanisms such as falls [1]. Managing these fractures, especially when displaced or involving multiple fragments, remains a clinical challenge due to complex shoulder anatomy and the potential for complications like nonunion, malunion, and avascular necrosis [2,3].

Surgical fixation using locking compression plates (LCPs), including the Proximal Humerus Internal Locking System (PHILOS), has emerged as a widely accepted treatment option. These implants provide angular stability, particularly beneficial in osteoporotic bone, and allow for early mobilization due to their biomechanical advantages [4,5]. The fixed-angle construct of locking plates ensures stable fixation, reduces the risk of screw loosening, and minimizes further soft tissue damage compared to conventional plates.

Several recent studies have reported promising clinical and functional outcomes following ORIF with LCPs in proximal humerus fractures. Improvements in standardized shoulder function scores, such as the Constant-Murley and DASH scores, have been consistently noted postoperatively [6,7]. Shah et al. [7] observed a high union rate and functional recovery in a prospective study involving 95 patients, while Khatib et al. [6] also reported substantial improvements in range of motion and pain relief using LCPs. Likewise, Singh et al. [8] and Kumar et al. [9] highlighted early radiological union and favorable rehabilitation outcomes.

While some complications such as varus collapse or screw perforation have been noted, overall complication rates remain low when proper surgical techniques and patient selection are employed [10]. As the elderly population increases and surgical techniques continue to evolve, evaluating and refining treatment strategies for proximal humerus fractures becomes increasingly important.

This study aims to assess the clinical and functional outcomes of proximal humerus fractures treated with locking compression plates at our institution and to compare our findings with existing literature.

Study Design and Setting

This was a retrospective observational study conducted at the Department of Orthopaedics, Dr Moopens medical college wayanad, between 1/8/2023 and 1/2/2024. The study was approved by the Institutional Ethics Committee, and informed consent was obtained from all participants.

Inclusion Criteria

Patients were eligible for inclusion if they:

Were aged 18 years or older

Had acute proximal humerus fractures classified as Neer's two-part, three-part, or four-part fractures

Were treated surgically with a locking compression plate (LCP) within 10 days of injury

Exclusion Criteria

Patients were excluded if they:

Had pathological fractures or open fractures

Had pre-existing shoulder pathology or previous surgery on the affected side

Were medically unfit for surgery

Sample Size

A total of 54 patients who met the eligibility criteria were included in the study.

Surgical Technique

All surgeries were performed under general or regional anesthesia using the standard deltopectoral approach. After achieving fracture reduction under fluoroscopic guidance, fixation was performed using a proximal humerus locking compression plate (typically PHILOS). The number and positioning of screws were determined based on fracture configuration and bone quality. Care was taken to avoid screw penetration into the joint.

Postoperative Protocol

All patients were given intravenous antibiotics for 48 hours postoperatively. The arm was supported in a sling, and pendulum exercises were initiated on postoperative day 2, followed by gradual progression to passive and active-assisted range-of-motion exercises. Strengthening exercises were started around 6 weeks postoperatively depending on clinical and radiological healing.

Outcome Measures

Clinical and functional outcomes were assessed using

DASH (Disabilities of the Arm, Shoulder and Hand) Score for disability evaluation

Radiological union was evaluated using standard anteroposterior and axillary views at each follow-up

Patients were followed up at 2, 6, 12, and 24 weeks postoperatively.

Data Analysis

All collected data were entered into Microsoft Excel and analyzed using SPSS version [XX]. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. A p-value of <0.05 was considered statistically significant.

Age Distribution

A total of 54 patients with proximal humerus fractures treated using locking compression plates were included in the study. The age of the patients ranged from 18 to over 75 years, with a mean age of approximately 52.6 years. The distribution of patients by age group is shown in Table 1.

The majority of the patients (37%) were in the age group of 56–75 years, followed by 25.9% in the 18–35 years group and Patients aged 36–55, while those above 75 years accounted for the remaining 11%.

This distribution reflects the bimodal pattern often seen in proximal humerus fractures—affecting both younger individuals involved in high-energy trauma and elderly patients with osteoporotic bone following low-energy falls.

Table 1: Age Group Distribution of Patients

Sex Distribution

Of the 54 patients included in the study, 36 (66.7%) were male and 18 (33.3%) were female, as detailed in Table 2. This indicates a higher prevalence of proximal humerus fractures among males in the present cohort.

The male predominance may be attributed to increased exposure to high-energy trauma, such as road traffic accidents and occupational injuries, which are more commonly observed in younger and middle-aged men.

Table 2: Sex Distribution of Patients

Side Involvement

Out of the 54 cases studied, the right side was involved in 40 patients (74%), whereas the left side was affected in 14 patients (25%), as presented in Table 3. This significant right-side predominance may be related to hand dominance, making the dominant arm more prone to injury during falls or trauma.

Table 3: Side Involvement

Fracture types

According to Neer's classification, the most common fracture pattern observed in this study was the 3-part fracture, affecting 32 patients (59.3%). This was followed by 2-part fractures in 12 patients (22.2%) and 4-part fractures in 10 patients (18.5%), as detailed in Table 4.

Table 4: Fracture types

DASH Score at follow up

The functional recovery of patients was assessed using the DASH (Disabilities of the Arm, Shoulder and Hand) score at regular postoperative intervals. A clear trend of improvement was observed over time.

At 2 weeks, the mean DASH score was relatively high at 68.5, indicating significant disability and functional limitation in the early postoperative period. By 6 weeks, the score had improved to 48.2, suggesting noticeable progress in mobility and reduction in discomfort.

Further improvements were evident at 12 weeks, with the mean score decreasing to 29.7, reflecting moderate disability with better tolerance of daily activities. By 24 weeks, the mean DASH score had significantly dropped to 15.4, indicating only mild disability and substantial recovery of upper limb function. Lost of followup of 4 patients during the study.

This progressive decline in DASH scores over time demonstrates the effectiveness of surgical fixation and rehabilitation in restoring shoulder function following proximal humerus fractures.

Table 5: DASH Score at follow up

Proximal humerus fractures remain a significant clinical challenge, particularly among elderly patients with osteoporotic bone and in younger individuals involved in high-energy trauma. Our study aimed to explore how well locking compression plates (LCPs), especially PHILOS plates, perform in treating these fractures—and our findings have been encouraging.

We noticed a bimodal age distribution, with a considerable number of patients at both ends of the spectrum: younger adults with high-impact injuries and older patients with fragility fractures due to falls. This pattern has been consistently reported in literature, such as the work by Court-Brown and Caesar [1], and Roux et al. [2], highlighting the dual nature of this injury population.

Interestingly, most of our patients were male, and injuries were far more common on the right side. This may be linked to hand dominance and occupational exposure—men are often more likely to be involved in physically demanding tasks or road accidents. Similar trends have been observed in studies by Fjalestad et al. [3] and Kim et al.[4].

When we looked at the types of fractures, Neer’s 3-part fractures were the most common in our cohort, which is consistent with findings from other large studies like those by Khatib et al. [6] and Südkamp et al. [7]. These fractures often require surgical stabilization due to fragment displacement and instability.

Using locking compression plates, we aimed for stable fixation to allow early rehabilitation. The PHILOS system, in particular, provided a good balance between stability and minimal soft tissue disruption. Multiple studies—including those by Agudelo et al. [10] and Björkenheim et al. [11]—have shown that these plates work well even in osteoporotic bone, reducing the risk of fixation failure.

In our patients, functional outcomes steadily improved over time. The average DASH score dropped from 68.5 at two weeks post-op to just 15.4 at six months. This steady decline reflects substantial recovery of upper limb function and mirrors improvements seen in similar studies by Schliemann et al.[12] and Zhang et al.[13]. Early physiotherapy likely played a key role here, and we found that encouraging patients to begin passive and active-assisted movements early made a noticeable difference.

Complication rates in our study were low, which was reassuring. Careful preoperative planning, correct implant positioning, and adherence to rehabilitation protocols were likely contributing factors. However, it’s important to remember that even with locking plates, complications such as varus collapse or screw penetration can occur—as noted in studies by Owsley et al.[14] and Clavert et al. [15]. We believe that meticulous surgical technique, especially attention to calcar screws and medial column support, helped us avoid these issues.

That said, surgical treatment isn’t always the best choice for every patient. In elderly individuals with severely comminuted fractures or very poor bone quality, primary reverse shoulder arthroplasty may be more appropriate. Authors like Sebastia-Forcada[17] and Cuff[18] have shown excellent functional outcomes in such cases, and it’s something to consider in future treatment algorithms.

Our study shows that using locking compression plates, particularly PHILOS plates, is a reliable and effective method for treating proximal humerus fractures. Most patients showed steady improvement in shoulder function, with DASH scores improving significantly over time. Complication rates were low, and outcomes were especially favorable when proper surgical technique and early rehabilitation were followed.

These results highlight the value of internal fixation with LCPs in both younger trauma patients and elderly individuals with osteoporotic fractures. With careful patient selection and structured postoperative care, this approach can help restore function and improve quality of life after proximal humerus fractures.

1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–697.
2. Roux A, Decroocq L, El Batti S, et al. Epidemiology of proximal humerus fractures managed in a trauma center. Orthop Traumatol Surg Res. 2012;98(6):715–719.
3. Fjalestad T, Hole MO, Jørgensen JJ, et al. Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients. J Orthop Trauma. 2012;26(2):98–103.
4. Kim SH, Szabo RM, Marder RA. Epidemiology of proximal humerus fractures in the United States: An analysis of the National Trauma Data Bank (NTDB). J Orthop Trauma. 2007;21(3):187–190.
5. Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: A systematic review. J Orthop Trauma. 2011;25(10):612–617.
6. Khatib O, Onyekwelu I, Zuckerman JD. The incidence of complications associated with operative treatment of proximal humerus fractures in the elderly. Bull NYU Hosp Jt Dis. 2011;69(2):111–117.
7. Südkamp N, Bayer J, Hepp P, et al. 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 Joint Surg Am. 2009;91(6):1320–1328.
8. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21(3):185–191.
9. Liew AS, Johnson JA, Patterson SD, King GJ. Effect of screw placement on fixation in the humeral head. Clin Orthop Relat Res. 2000;381:241–249.
10. Agudelo J, Schürmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676–681.
11. Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: A retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004;75(6):741–745.
12. Schliemann B, Wähnert D, Theisen C, et al. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury. 2015;46(7):1207–1214.
13. Zhang L, Zheng J, Wang W, et al. The clinical benefit of PHILOS plate for the treatment of proximal humeral fractures: A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2014;100(6):591–597.
14. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg Am. 2008;90(2):233–240.
15. Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg. 2010;19(4):489–494.
16. Hirschmann MT, Fallegger B, Amsler F, Regazzoni P. Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS). J Orthop Trauma. 2011;25(5):286–293.
17. Sebastia-Forcada E, Muñoz-Mahamud E, Lizaur-Utrilla A, Gil-Guillen V. Reverse shoulder arthroplasty in acute complex fractures of the proximal humerus in elderly patients: A prospective evaluation. J Shoulder Elbow Surg. 2014;23(10):1491–1498.
18. Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95(22):2050–2055.