الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Proximal humeral fractures contribute to 4 – 5 % of all fractures and accounts for 45 % of all humeral fractures. This type of fracture is considered the third most common fracture associated with osteoporosis after intertrochanteric fractures and distal radius fractures.
Proximal humeral fractures may be stable or unstable fracture. Unstable fracture is identified by angulations of more than 45 degrees or displacement of more than 1 cm. Also unstable fracture is identified by Neer as displacement or angulations of two-part, three-part and four-part fractures.
Now, many surgeons prefer to use humeral head preserving technique by using locked compressive low contact PHILOS plate. The anatomical design of this plate provides angular stability as it has many holes and surgeons are able to lock the screw in various directions in the head of the humerus. So this plate is better in providing more stability especially in osteoporotic bone, ensure less bone de-vascularization and less soft tissue damage. Many patients experience less pain and more shoulder range of motion.
Some use standard open delto-pectoral approach technique, others prefer minimally invasive techniques. Standard delto-pectoral approach is known to have better look on fracture morphology by naked eye, fracture is easily reduced with manual manipulation especially comminuted fractures and if there is intra-articular extension of fracture or acceptable reduction can’t be achieved, it is easily to covert decision to joint replacement either by hemi-arthroplasty or total shoulder arthroplasty. Minimally invasive deltoid splitting approach is known to have good access to postero-lateral surface so there is no extensive soft tissue dissection to visualize postero-lateral fragment in proximal humeral fractures. Also this approach may have less operative time, less blood loss, early discharge from hospital, early better patient satisfaction and less complication.
In delto-pectoral approach, there is extensive soft tissue dissection, more blood loss and operative time, increased risk of avascular necrosis in humeral head due to more damage to blood supply and there is difficulty to access postero-lateral fragment of proximal humeral fractures. While in Minimally invasive approach reduction is more difficult as reduction is usually indirect, so accepted fracture alignment is needed before doing approach by doing longitudinal traction of fracture and then correct varus\valgus angulation at surgical neck. Also, in minimally invasive delto-pectoral approach there is high risk of axillary nerve injury.
Aim of our study is to compare between minimally invasive approaches versus standard open deltopectoral approach in management of proximal humeral fractures regarding operative outcomes, functional outcomes, time to healing and complications rate.
There are 11 articles included in our study, 2 articles are in randomized controlled trial design and 9 articles are in comparative prospective or retrospective studies. The 11 articles include 855 patients, 407 patients undergo minimally invasive techniques and 448 undergo open reduction technique
Results of meta-anlysis of our study states that MIPO is better than ORIF regarding operative time, length of hospital stay, functional outcome measured by Constant Murley shoulder score, pain measured by constant score, activity of daily living, range of motion. But there is no statistically significant difference regarding operative blood loss, post-operative pain measured by VAS score, muscle power, time to healing and complication rates
It is generally recommended to use MIPO in fixation of proximal humeral fractures but if the fracture is highly comminuted four-part fracture that closed acceptable reduction can’t be done, ORIF through deltopectoral approach is recommended.