There is continued concern over complication rates (20–30% of cases) in locked proximal humeral plating. The most common sequelae of this is screw penetration of the humeral head. This is associated with natural settling of the fracture, malreducition in varus, insufficent medial support of the fracture. The proximity of the screws to the articular surface can also be influential on outcome if collapse occurs. Our operative technique is to establish the rotation of the humeral head where the drill appears closest to the articular margin (by sequential xray screening) and subtract from this to avoid intra-articular penetration of the humeral head. 55 Consecutive patients of average age 56.4 years (14.7–86.1), 17 male and 38 females, who underwent PHILOS plating were identified using Bluespier database. Xrays were analysed for fracture pattern, restoration of neck-shaft angle, plate positioning, number and configuration of screws and presence of screw penetration both intra-operatively and at postoperative follow-up. There were 6.07 screws used per head (total 330). There was one intraoperative screw penetration and 3 patients had evidence of screw penetration at follow-up, which required implant removal (total screw penetration rate of 7%). There was one case of AVN. The mean neck shaft angle was 137 degrees (anatomical 135 degrees). Accurate reduction of fractures and placement of screws in the humeral head using image intensifier can act to minimise risk of screw penetration and make some of the complications of locked proximal humeral plating avoidable

Objectives. Our objective was to perform a systematic review of the literature and conduct a meta- analysis to investigate the effect of initial varus or valgus displacement of proximal humerus on the outcomes of patients with proximal humerus fractures treated with open reduction and internal fixation. Methods. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing postoperative outcomes associated with initial varus versus initial valgus displacement of proximal humerus fracture. The Newcastle–Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results. We identified two retrospective cohort studies and one retrospective analysis of a prospective database, enrolling a total of 243 patients with proximal humerus fractures. Our analysis showed that initial varus displacement was associated with a higher risk of overall complication (RR 2.28, 95% CI 1.12–4.64, P = 0.02), screw penetration (RR 2.30, 95% CI 1.06–5.02, P = 0.04), varus displacement (RR 4.38, 95% CI 2.22–8.65, P < 0.0001), and reoperation (RR 3.01, 95% CI 1.80–5.03, P < 0.0001) compared to valgus displacement. There was no significant difference in avascular necrosis (RR 1.43, 95% CI 0.62–3.27, P = 0.40), infection (RR 1.49, 95% CI 0.46–4.84, P = 0.51), and non-union or malunion (RR 1.37, 95% CI 0.37–5.04, P = 0.64). Conclusions. The best available evidence demonstrates that initial varus displacement of proximal humerus fractures is associated with higher risk of overall complication, screw penetration, varus displacement, and reoperation compared to initial valgus displacement. The best available evidence is not adequately robust to make definitive conclusions. Further high quality studies, that are adequately powered, are required to investigate the outcomes of initial varus and valgus displacement in specific fracture types

Background. Distal radius fractures are common injuries but no clear consensus regarding optimal management of unstable fractures exists. Open reduction and internal fixation with volar plates is an increasingly popular but the associated complication rate can be 10%. Intramedullary nails are an alternative offering the potential advantages of reduced risk of tendon injury and intra-articular screw penetration. This article systematically reviews the published literature evaluating the biomechanics, outcomes and complications of intramedullary nails in the management of distal radius fractures. Methods. A systematic review of Medline and EMBASE databases was performed for studies reporting the biomechanics, functional outcome or complications following intramedullary nailing of distal radius fractures. Critical appraisal was performed with respect to validated quality assessment scales. Results. 16 studies were included for review. The biomechanical studies concluded that intramedullary nails had at least comparable strength to locking plates. The clinical studies reported that IM nailing was associated with comparable ROM, functional outcome and grip strength to alternative fixation techniques. However, the mean complication rate was 17.6% (range 0 to 50%) with the most common complication being neurapraxia of the superficial radial nerve in 9.5%. Conclusion. This systematic review of pooled data from published series has shown that IM nailing can give comparable clinical results to current treatment modalities in extra-articular and simple intra-articular distal radius fractures. However the evidence is insufficient to determine whether IM nailing has any clinically important advantage over well-established alternatives. The complication rate reported is higher than that in contemporary studies for volar plating and this raises concerns about the role of this technique particularly when comparative studies have failed to show any major advantage to its use. Further adequately powered RCTs comparing the technique to both volar plates and percutaneous wire fixation are required. Level of evidence. IIa – systematic review of cohort studies. Conflict of Interests. The authors confirm that they have no relevant financial disclosures or conflicts of interest. Ethical approval was not sought as this was a systematic review