PHILOS Plate: Is it the Panacea for all Proximal Humerus Fractures?

Proximal humerus fractures are common and have a bimodal age distribution. Fracture-dislocations in younger patients result from highenergy trauma and most surgeons attempt open reduction and internal fixation, if at all possible. Osteoporotic fractures in elderly patients are commonly associated with low-energy trauma such as groundlevel falls and most are minimally displaced, impacted fractures that can be treated successfully with non-operative means. However, the optimal surgical management of three and four-part proximal humeral fractures in elderly osteoporotic patients remains controversial, with many advocating prosthetic replacement of the humeral head [1]. Recent developments in plating with the use of locking screws offer mechanical advantages for the treatment of displaced fractures of the proximal humerus [2]. Biomechanical data suggest that these implants can resist physiological loads in osteoporotic bone and may provide an alternative to hemi-arthroplasty [3]. Theoretically, these plates provide more secure fixation of proximal humeral fractures, especially in weak or osteoporotic bones [4]. Nevertheless, the associated complication rate remains high (over 10%) [5]. The rate of avascular necrosis of humeral head after 3or 4-part fractures ranges between 12-25% and 41-59% respectively [6]. Furthermore, the increased number of screws in the humeral head may affect fracture-healing and perfusion of humeral head, thus contributing towards further osteonecrosis of humeral head [2]. Complications, including loss of fixation, humeral head perforation, and mechanical impingement, have been reported [1]. We present a case of failed PHILOS plate in a middle aged woman where osteoporosis and comminuted fracture pattern resulted in migration of locking screws into the shoulder joint, causing further damage to humeral head.