Original Article| Volume 28, ISSUE 2, P432-437, March 2023

The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach

Published:December 02, 2021DOI:



      The purpose of this study was to evaluate the incidence and risk factors for axillary nerve injury after plate fixation of humeral fractures using minimal invasive deltoid-splitting approach. We hypothesized that the use of medial support screw (MSS) would be associated with the outcome of axillary nerve injury.


      This study retrospectively evaluated consecutive 32 patients who underwent surgical treatments for proximal or midshaft humeral fractures. Of them, we included 26 patients who were examined by electromyography/nerve conduction (EMG/NCV) study at 3–4 weeks postoperatively. We excluded 6 patients because two of them were not compliant to EMG/NCV and the remaining two died due to unrelated medical illness. Outcome assessments included pain, functional scores, range of motion, and radiographic results.


      There were 8 male and 18 female patients with mean age of 67 ± 15 years. Mean duration of follow-up period was 31 ± 11 months. The mean time to EMG/NCS after surgery was 3.5 ± 0.6 weeks. EMG/NCS examinations revealed incomplete axillary nerve injury in 8 patients (31%) without complete nerve injury. Active forward elevation at 3 months postoperatively was significantly lower in patients with axillary nerve injury than in those without it (99° ± 12 and 123° ± 37, respectively, p = 0.047), although final clinical outcomes were not different. At surgery, MSS was used in 17 patients (65%), and 8 of them were associated with nerve injury. The use of MSS was only correlated with the outcome of axillary nerve injury, because the axillary nerve injury developed only in MSS group (p = 0.047). The MMT grade 4 in abduction strength was more common in patients with axillary nerve injury than in those without (p = 0.037).


      Axillary nerve injury was a concern after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach. The use of medial support screw to improve the stability could increase a risk of axillary nerve injury when used with this approach.
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        • Sohn H.S.
        • Jeon Y.S.
        • Lee J.
        • Shin S.J.
        Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: a prospective randomized controlled trial.
        Injury. 2017 Jun; 48: 1175-1182
        • Laflamme G.Y.
        • Rouleau D.M.
        • Berry G.K.
        • Beaumont P.H.
        • Reindl R.
        • Harvey E.J.
        Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial.
        J Orthop Trauma. 2008 Mar; 22: 153-158
        • Acklin Y.P.
        • Stoffel K.
        • Sommer C.
        A prospective analysis of the functional and radiological outcomes of minimally invasive plating in proximal humerus fractures.
        Injury. 2013 Apr; 44: 456-460
        • Rancan M.
        • Dietrich M.
        • Lamdark T.
        • Can U.
        • Platz A.
        Minimal invasive long PHILOS(R)-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus.
        Injury. 2010 Dec; 41: 1277-1283
        • Brunner A.
        • Thormann S.
        • Babst R.
        Minimally invasive percutaneous plating of proximal humeral shaft fractures with the proximal humerus internal locking system (PHILOS).
        J Shoulder Elbow Surg. 2012 Aug; 21: 1056-1063
        • Kamineni S.
        • Ankem H.
        • Sanghavi S.
        Anatomical considerations for percutaneous proximal humeral fracture fixation.
        Injury. 2004 Nov; 35: 1133-1136
        • Spiegelberg B.G.
        • Riley N.D.
        • Taylor G.J.
        Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation - an anatomical study.
        Injury. 2014 Aug; 45: 1185-1189
        • Stecco C.
        • Gagliano G.
        • Lancerotto L.
        • Tiengo C.
        • Macchi V.
        • Porzionato A.
        • De Caro R.
        • Aldegheri R.
        Surgical anatomy of the axillary nerve and its implication in the transdeltoid approaches to the shoulder.
        J Shoulder Elbow Surg. 2010 Dec; 19: 1166-1174
        • Smith J.
        • Berry G.
        • Laflamme Y.
        • Blain-Pare E.
        • Reindl R.
        • Harvey E.
        Percutaneous insertion of a proximal humeral locking plate: an anatomic study.
        Injury. 2007 Feb; 38: 206-211
        • Saran N.
        • Bergeron S.G.
        • Benoit B.
        • Reindl R.
        • Harvey E.J.
        • Berry G.K.
        Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide.
        Injury. 2010 Oct; 41: 1037-1040
        • Dang K.H.
        • Ornell S.S.
        • Reyes G.
        • Hussey M.
        • Dutta A.K.
        A new risk to the axillary nerve during percutaneous proximal humeral plate fixation using the synthes PHILOS aiming system.
        J Shoulder Elbow Surg. 2019 Sep; 28: 1795-1800
        • Daube J.R.
        AAEM minimonograph #11: needle examination in clinical electromyography.
        Muscle Nerve. 1991 Aug; 14: 685-700
        • Wilbourn A.J.
        Electrodiagnosis of plexopathies.
        Neurol Clin. 1985 Aug; 3: 511-529
        • Gardner M.J.
        • Weil Y.
        • Barker J.U.
        • Kelly B.T.
        • Helfet D.L.
        • Lorich D.G.
        The importance of medial support in locked plating of proximal humerus fractures.
        J Orthop Trauma. 2007 Mar; 21: 185-191
        • Bai L.
        • Fu Z.
        • An S.
        • Zhang P.
        • Zhang D.
        • Jiang B.
        Effect of calcar screw use in surgical neck fractures of the proximal humerus with unstable medial support: a biomechanical study.
        J Orthop Trauma. 2014 Aug; 28: 452-457
        • Ponce B.A.
        • Thompson K.J.
        • Raghava P.
        • Eberhardt A.W.
        • Tate J.P.
        • Volgas D.A.
        • Stannard J.P.
        The role of medial comminution and calcar restoration in varus collapse of proximal humeral fractures treated with locking plates.
        J Bone Joint Surg Am. 2013 Aug 21; 95 (e113(1-7))
        • Zhang L.
        • Zheng J.
        • Wang W.
        • Lin G.
        • Huang Y.
        • Zheng J.
        • Edem Prince G.A.
        • Yang G.
        The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study.
        Int Orthop. 2011 Nov; 35: 1655-1661
        • Traver J.L.
        • Guzman M.A.
        • Cannada L.K.
        • Kaar S.G.
        Is the axillary nerve at risk during a deltoid-splitting approach for proximal humerus fractures?.
        J Orthop Trauma. 2016 May; 30: 240-244
        • Wu C.H.
        • Ma C.H.
        • Yeh J.J.
        • Yen C.Y.
        • Yu S.W.
        • Tu Y.K.
        Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches.
        J Trauma. 2011 Nov; 71: 1364-1370
        • Westphal T.
        • Woischnik S.
        • Adolf D.
        • Feistner H.
        • Piatek S.
        Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings.
        J Shoulder Elbow Surg. 2017 Mar; 26: 464-471
        • Roderer G.
        • Sperfeld A.D.
        • Hansen P.
        • Krischak G.
        • Gebhard F.
        • Kassubek J.
        Electrophysiological assessment of the deltoid muscle after minimally invasive treatment of proximal humerus fractures - a clinical observation.
        Open Orthop J. 2011; 5: 223-228
        • Khan L.A.
        • Robinson C.M.
        • Will E.
        • Whittaker R.
        Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach.
        Injury. 2009 Feb; 40: 181-185
        • Fischer C.
        • Frank M.
        • Kunz P.
        • Tanner M.
        • Weber M.A.
        • Moghaddam A.
        • Schmidmaier G.
        • Hug A.
        Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures.
        Injury. 2016 Aug; 47: 1725-1731
        • Visser C.P.
        • Coene L.N.
        • Brand R.
        • Tavy D.L.
        Nerve lesions in proximal humeral fractures.
        J Shoulder Elbow Surg. 2001 Sep-Oct; 10: 421-427