الفهرس 
Anatomy of proximal humerusOnly 14 pages are availabe for public view
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Abstract
Fractures of the proximal humerus are relatively common injuries in
adults, representing 4% - 5% of all fractures presenting to the accident and
emergency department and approximately 5% of fractures of the
appendicular skeleton. The estimated incidence of proximal humerus
fractures is 70/100.000 per year worldwide.
Proximal humerus fractures are the seventh most frequent fracture in
adults, and the third in patients over 65 following wrist and femoral neck
fractures. This is mainly an osteoporotic fracture and its prevalence increases
as one moves north in Europe.
Despite the fact that the majority of proximal humerus fractures can
be successfully treated conservatively with a good clinical outcome, the
percentage of fractures treated with internal fixation continues to rise.
The surgical modalities used are trans osseous suture fixation, closed
reduction and percutaneous fixation, open reduction and internal fixation
with conventional plates, locking plate fixation and hemiarthroplasty which
have shown to have mixed results.
Open reduction and internal fixation using proximal humerus internal
locking system (PHILOS) plate has the advantages of anatomical reduction,
stable rigid fixation, provides angular and axial stability, and minimizes the
risks of screw toggle and pull out as well as reduction loss, divergent or
convergent locked screws improve the pullout resistance of the whole
construct, but PHILOS plates carries the risk of joint stiffness, implant
failure and avascular necrosis of the humeral head.
Closed reduction and percutaneous fixation with straight wires has the
advantage of a less invasive technique but it carries the risk of insecure
fixation, loss of reduction and wire migration.
Kapandji described his palm tree technique of percutaneous pinning
for the treatment of displaced surgical neck fractures with divergent K-wires
introduced at the V deltoid level. In his technique Kapandji inserts three
curved wires through one hole at the V-shaped insertion of the deltoid
muscle. The wires are made divergent and then driven into the subchondral
bone of the proximal fragment to maximize the stability. It is a good
technique but it has some problems. To reach the V-shaped insertion of the
deltoid muscle a formal skin incision must be done (4 cm according to
Kapandji). Insertion of the wires at the level of the deltoid tuberosity carries
the risk of radial nerve injury especially if the drill bit slipped posteriorly.
Few authors are experienced in this technique and have reported the results,
including simple and complex fractures.
El-Alfy BS introduced some modifications for the technique to avoid
these problems. The modifications involve insertion of each wire through a
separate hole in the distal fragment, the entry points for the wires are shifted
proximal to the deltoid tuberosity to be safer and a small bend is made at the
tips of the wires to facilitate their insertion and this modification called the
modified palm tree technique.
The aim of this work was to compare the outcome of surgical
treatment of proximal humerus fractures using PHILOS plate versus using
modified palm tree technique.
This prospective randomized study was carried out on 28 patients with
proximal humerus fractures at El-Menoufia University Hospital and ElMogamaa Al-Teby Medical Insurance Hospital in Tanta. They were
subdividedrandomly into two groups: group A: 14 patients surgically
treated by PHILOS plate. group B: 14 patients surgically treated by
modified palm tree technique.