In old age patients, the 3^rd most frequent fracture is proximal humerus fracture. Of all the fracture of the body bone, the proximal humerus fracture accounts for up to 4 to 5% [1,2] Of all the type of humerus fracture the proximal fracture rates the most fracture of the humerus that accounts for 45%. In the old age population, there is a high risk of osteoporosis occurrence. The fixation of proximal humerus fracture in old patients is tricky and of high difficult levels [3,4].

The disintegration of the stretch hand is the most frequent mechanism of injury in elder women suffering from osteoporosis. In young patients, elevated energy trauma is the most common [5]. The maximal amount of the proximal humerus fracture are the displaced fracture that can be fixed with a non-operative method. This method provides diminished movements and little resistance to the movements of the humerus [6-8].

There are different techniques for the fixation of the humerus fracture: Open reduction, intermedialliary nailing, internal fixation with the proximal humeral plates, arthroplasty, and minimally invasive methods with pins or screws. The with the use of proximal humerus internal locking system there is the stability of the angulations and it also reduces the elevated impediment rates with fractures related to osteoporosis [9-11].

There are non-locking plates like cloverleaf plates and T plates. However, there use in the osteopenic bones they have elevated failure rates. Studies have also shown that there are high impediment rates up to 40% of subacromial impingement along with avascular necrosis and screw loosening. In the previous study done the authors have reported that when tension bend wiring is done in the management of proximal humerus fracture it does not provide any advantage [12,13].

With the use of intramedullary nails, there is a reduced lever but they are associated with high complication rates (31%). With the use of proximal screws, the chief difficulty seen is the loosening of the screws. As compared to the conventional plates the newly blades plates are inflexible, but there is a high failure rate due to inadequate hold and superior profile in the osteoporotic bones [14,15].

Owing to the anatomy of the proximal humerus the locking plates were designed accordingly.

Once the fracture is reduced, the proximal plate was applied on the lateral aspect of the proximal humerus and the first in the head portion the locking screws were inserted. While placing the locking plate the care was taken so that it is placed 5-6 mm distal to the upper end of tuberosity and the lateral to the tendon of bicep muscles.

To counteract the pull of the pectoralis major muscle in case of the medially displaced shaft, the first cortical screw of length 3.5 mm was inserted in the shaft portion. Following that, locking screws in the head was inserted. Postoperative x-ray was acquired in all patients.

During the study portion, a total of 20 patients diagnosed with proximal humerus fractures were included in the study. Out of a total of 20 patients, there were 16 men and 4 women. The mean age of the patients was found to be 42.5 years.

Postoperative protocol

The first dose of intravenous antibiotics was given preoperatively and the next four doses were given post-operatively, so a total of five days antibiotics were administered. Depending upon the pain and active ROM the pendulum exercise was started and the shoulder immobilizer was used. After the two weeks of periods, the suture removal was done.

Clinical and radiographic evaluation

With the help of Constant Murley's shoulder score, the functional evaluation was done. At the end of 2^nd, 4^th, 8^th, and 12^th week the follow-up was done and also at the end of 1 month.

With the collection of points at the end of the follow-up period, they were graded as poor with score 0-55 points, when the score was between 56-70 points it was graded as moderate and the score of 71-85 score is graded as a good score and it was graded as excellent for the score 86-100 points.

To assess the union of the fracture, the radiographs were taken at every follow-up period. Also, the radiographs were taken to assess the loss of reduction, any displacement of the fracture and varus-valgus angulations was also distinguished with the help of radiographs.

Callus formation, presence of bridging osseous trabeculae, and cortical continuity were measured as confirmation of radiological union. A humeral head-shaft angle is an angle amid the humeral shaft axis and head.

Fig-2: Patient 1 Pre-Operative X-Ray, Patient 1 Post-operative 6 months X-Ray.

In the osteoporotic bones and metaphyseal bones, the benefit of the locking plate is the protected fixation with the angularly stable plates. The benefit of the locking plates is the multi-directional screws to endure the more angular and physiological load. There is numerous clinical study, that specifies the proximal humerus locking plates having a good effect in proximal humerus fracture.

In the present study, 45% (n =9) of the patients had an exceptional result. On the whole mean Constant–Murley score was 75.04. Aggarwal et al [17]. in their study establish moderate to excellent outcome in 90% of patients. The mean age of the patients in this series was 58.51 years (range 23-81 years) and fracture types were Neer’s 2-part, 3-part, and 4-part fractures and fracture-dislocations.

The mean Constant score for 4-part fractures was 66 ± 12.61 and was significantly lesser to other types. In the present research, the assessments of subcomponents of Constant score demonstrate a significant difference between a 4-part fracture and the other two fracture types.

Parmaksizoglu et al [18] in their study demonstrated 68.7% excellent to good results. The mean age was 63 years (range 29-82 years) and fractures were Neer’s 3-part, and 4-part 31.8% (n=10). Patients have not accomplished the finest results.

The mean Constant score for 4-part fractures was 70.09 which were significantly lowered compared to 2-part and 3-part fractures. This finding is similar to the above-mentioned studies. Screw perforation happened in the present study in 1 case. Comparable incidence of screw perforation has been accounted for in various studies. No osteonecrosis happened in our series.

This could be due to the lesser number of patients in the 4-part fracture group. Also, a larger part of fractures in the 4-part group was in the surgical neck region and therefore had a low risk of osteonecrosis.

In the present study, various mal reduction of >20 degrees happened in 5%of cases (n = 1). All the patients with various mal reductions had a steady score of <70. 5% of cases(n=1) had external infection. The drawback of this research is not having a control group. A randomized study comparing the outcome of other treatment modalities will almost certainly provide an improved guideline for the management of these fractures.