Overview
Most fracture surgeons regard the locked proximal humeral plate as a major advance in the treatment of these fractures, and it has become the implant of choice. Whatever the device, anatomic reduction is the most important factor in outcome.
Evidence Summary
Percutaneous plating through two minimal incisions (a lateral deltoid split plus a distal shaft incision) has been reported without axillary nerve injury or loss of reduction. However, a randomized trial of two- and three-part fractures found better function with the deltopectoral approach and more complications with the deltoid split.
Locking plates gave better short-term outcomes than locked intramedullary nails. Long-term outcomes were equal, and nailing had fewer complications.
In elderly patients with three- or four-part fractures, locked plating has not been shown to be better than nonoperative treatment.
Surgical Technique — Deltopectoral Approach (Technique 62.5)
Positioning and Imaging
Place the patient on a radiolucent table, with a bump raising the shoulder and thorax 30–40° off the table.
Position the C-arm on the side opposite the surgeon. Rolling it back gives a Grashey (true AP) view; rolling it forward gives a lateral view of the shoulder and humerus.
Check fluoroscopy after positioning, to make sure adequate intraoperative images can be obtained.
Approach
Expose the proximal humerus through a deltopectoral approach.
Release the anterior part of the deltoid as needed to expose the fracture.
Reduction
If needed, place a threaded pin in the posterior humeral head as a joystick to derotate the head into position.
Sutures through the rotator cuff tendons help mobilize the fragments and can later be passed through the plate to augment fixation.
Restore the correct orientation of the articular head relative to the shaft. In valgus-impacted patterns, this can be done through the displaced tuberosity fracture lines with a tamp or Cobb elevator.
Three- and four-part fractures: Place sutures in the cuff tendons attached to the displaced tuberosities. Reduce the tuberosities to each other and to the articular segment with sutures or K-wires. Additional cuff sutures can be used to tie the tuberosities to the plate.
Simpler patterns: Reduce the fracture, hold it with K-wires, and confirm on fluoroscopy.
Plate Placement
Place the plate on the proximal humerus posterior to the biceps tendon and hold it with K-wires. Confirm its position on fluoroscopy.
Too proximal: Impingement.
Too close to the biceps tendon: Risk of injury to the anterior humeral circumflex artery.
Ideal: The inferior screws lie close to the medial calcar. Screws into the inferomedial head add stability when there is medial comminution.
Fixation
Insert locking screws into the head and one cortical screw into the shaft, and confirm that alignment is maintained.
If necessary, the plate can be positioned to give the head more valgus, and locked off the bone in the shaft.
Once accurate reduction is confirmed, insert the remaining screws under fluoroscopic guidance.
Check every screw with an "approach-withdrawal" technique on AP and lateral views to confirm a subchondral position with no joint penetration.
Campbell's Concepts: Technical Tips
Keep the long head of the biceps until fixation is complete. It is a useful guide to the correct rotation of the head and tuberosities relative to the shaft. If tenodesis is done before reduction, this landmark is lost and rotation becomes hard to judge.
Set plate height with calcar K-wires: Temporarily fixing the plate with K-wires through the calcar screw holes is an efficient way to set the correct height before inserting other screws.
Alternative — Anterolateral Acromial Approach (eTechnique 62.1; Gardner et al., Mackenzie)
Position the patient beach-chair or supine semilateral.
Starting at the palpable anterolateral corner of the acromion, make a 10 cm incision running distally along the deltoid fibers.
Identify the anterior deltoid raphe between the anterior and middle heads and split it for several centimeters.
For maximal exposure, split up to the acromial margin, but not more than 5 cm distal to the origin, to protect the axillary nerve.
Place a stay suture at the inferior end of the split to prevent distal propagation.
Reduce the fragments indirectly, working within the tuberosity fracture lines. Cuff sutures help with mobilization and reduction.
With the axillary nerve protected, slide the plate from proximal to distal beneath the axillary nerve, until the nerve lies over the junction of the head and shaft parts of the plate.
Keep the plate on the "bare spot" of the lateral cortex posterior to the bicipital groove, to avoid the vessels that penetrate the humeral head.
Fix the plate to the shaft through the lower soft-tissue window, distal to the axillary nerve.
Irrigate, then close the raphe and deltoid fascia with absorbable sutures.
Postoperative Care
Start early rehabilitation with active-assisted range-of-motion exercises. The same protocol applies after the anterolateral approach.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.5 and eTechnique 62.1.