Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates
© The Author(s) 2014
Received: 3 September 2013
Accepted: 5 March 2014
Published: 1 April 2014
The aim of this retrospective study was to compare outcomes and complications of displaced fractures of the shaft of the humerus treated with limited-contact dynamic compression plates (LCDCPs) and locking compression plates (LCPs).
Materials and methods
Two hundred and twelve patients with displaced fractures of the shaft of the humerus, treated with plate osteosynthesis from January 2005 to December 2009 were reviewed. One hundred and two patients (group A) were treated with LCDCP osteosynthesis and 110 patients (group B) were treated with LCP osteosynthesis. Clinical and radiological assessments were made at monthly intervals for the first 6 months and then at 2-month intervals for the next 6 months. Primary outcome measures like operative time, duration of hospital stay, time to fracture union, union rate and secondary outcome measures (functional outcome and complications such as infection, malunion, delayed union, nonunion, implant failure and iatrogenic radial nerve palsy) were compared between both groups. The ULCA scoring system and Mayo elbow performance index (MEPI) were used to assess shoulder and elbow functions, respectively. Rodriguez-Merchan criteria were used to assess the functional outcomes of the fracture fixation.
There was no significant difference found between the two groups in terms of primary outcome measures. According to Rodriguez-Merchan criteria, comparison of functional outcomes of both groups showed insignificant difference (p = 0.48). There was no significant difference found between the two groups regarding mean ULCA score (p = 0.34) and mean MEPI sore (p = 0.54). In terms of complications, no significant difference was found between the two groups.
This study concludes that the principle of fracture fixation was more important than plate selection in fractures of the shaft of the humerus.
Level of evidence
Fractures of the humeral shaft are relatively common, representing between 3 and 5 % of all fractures [1, 2]. Open reduction and internal fixation (ORIF) with plating is generally accepted as the best method of treatment for displaced diaphyseal fractures of the humerus in the adult, with advantages of stable fixation, direct visualization, protection of the radial nerve, and sparing of the adjacent shoulder and elbow joint from injury. Fixation techniques based on compression principles have a lower incidence of nonunion and are found to hasten rehabilitation, with less joint stiffness . Limited-contact dynamic compression plates (LCDCPs), based on principles of dynamic compression and reduced bone-plate contact are used commonly nowadays for operative fixation of fractures of the humeral shaft. Another implant, the locked compression plate (LCP), which has features of compression and point bone-plate contact (minimum contact) is also used for fixation of humeral shaft fractures. Many authors have proved the superiority of locking plates over dynamic compression plates in various cadaveric long-bone models [4–6]. Some biomechanical studies have suggested that locking-plate constructs are stiff and suppress interfragmentary motion to a level that may be insufficient to reliably promote secondary fracture-healing [7–9].
There are very few clinical studies in the literature comparing locked plate and limited-contact dynamic compression plate fixation of humerus shaft fractures. The aim of this study is to investigate whether a difference in plate design improves the outcome in managing a particular chosen group of humeral shaft fractures. We hereby present a retrospective study of humerus shaft fractures treated with ORIF with LCDCP or LCP.
Materials and methods
During the period of 5 years from January 2005 to December 2009, 280 patients with displaced fractures of the shaft of the humerus were admitted to our hospital for internal fixation. Medical records and X-ray films were retrieved for all of the patients (212 patients) who had undergone open reduction and plate osteosynthesis of the fractured humerus shaft.
Age >16 and <65 years
Closed diaphyseal fracture of humerus treated with ORIF with either LCDCP or LCP. (Indications for plate osteosynthesis were closed diaphyseal fracture of the humerus with shortening >3 cm, rotation >30°, angulation >20° and conservative treatment failure with loss of reduction).
Medical records for a follow-up period of at least 1 year should be available for each case included in this study.
Demographic profile of study
Age in years, Mean (range)
36.8 ± 8.9 years (18–65 years)
37.6 ± 10.8 years (22–64 years)
73 : 29
75 : 35
70 : 32
65 : 45
Preoperative radial nerve injury
Mechanism of injury
Road traffic accident
Fracture type(AO classification)
Type 12 A
Type 12 B
Type 12 C
Patients were immobilized using a sling, while active and active-assisted range of motion began as soon as could be tolerated by the patient after surgery, generally on the 3rd day. All patients were followed up at 1 month intervals for the first 6 months after the surgery, and then at 2-month intervals for the next 6 months after surgery. Anteroposterior (AP) and lateral radiographs were taken at each follow-up visit. Shoulder and elbow range of motion was assessed at each follow-up visit.
Fracture union time, complications and functional outcomes were also recorded. The UCLA scoring system was used to assess shoulder function  and the Mayo elbow performance index (MEPI)  was used to assess elbow function. All patients were also evaluated on the basis of the outcome criteria of Rodriguez-Merchan  which consists of scores of shoulder and elbow movements along with pain and disability in the postoperative period, and has four categories of excellent, good, fair and poor outcomes.
The complications were evaluated in terms of infections (superficial or deep or chronic osteomyelitis), delayed union, nonunion, implant failure, secondary loss of reduction, implant breakage and refracture after plate removal. Malunion was defined as healing occurring at more than 15° of angulation. A delayed union was diagnosed when no satisfactory signs of healing were present at the 16-week follow-up visit. A nonunion was diagnosed when healing had not occurred after 6 months. Fractures which healed in <6 months were classified as unions.
Student’s t-test was used to analyze the difference of means for different parameters. The test was referenced for a two-tailed p value and a 95 % confidence interval was constructed around sensitivity proportion using normal approximation method. Statistical analyses were performed using SPSS software. A value of <0.05 was considered statistically significant.
The mean duration of injury for group A was 6.8 ± 2.8 days (range 2–10 days), while for group B it was 7.2 ± 3.2 days (range 1–14 days). There was no statistical significance between the two groups (p = 0.62). The mean operation time was 90.4 ± 40.6 min (range 70–140 min) in group A and 105.8 ± 30.1 min (range 68–150 min) in group B (p = 0.18). The incidence of iatrogenic radial nerve palsy in group B, 3.63 %, was insignificantly higher than in group A, 2.94 % (p = 0.52). The mean time to fracture union was 17.2 ± 6.8 weeks (range 10–48 weeks) in group A and 15.8 ± 5.1 weeks (range 12–42 weeks) in group B and there was no statistically significant difference found between the two groups (p = 0.28).
Comparison of functional outcomes of both groups
LCDCP (group A)
73 (71.56 %)
19 (18.62 %)
8 (7.84 %)
2 (1.96 %)
LCP (group B)
83 (75.45 %)
17 (15.45 %)
7 (6.36 %)
3 (2.72 %)
Comparison of complications of both groups
8 (7.84 %)
7 (6.36 %)
Iatrogenic radial nerve palsy
3 (2.94 %)
4 (3.63 %)
6 (5.88 %)
9 (8.18 %)
2 (1.96 %)
3 (2.72 %)
2 (1.96 %)
Refracture after implant removal
The internal fixation methods for humerus shaft fractures can be broadly grouped into plating or intramedullary techniques. Plate osteosynthesis remains the gold standard of fixation of humeral shaft fractures compared to other methods . The reliability of union, together with early mobilization and return of the arm to normal function, favors the use of primary plate fixation in treatment of humeral diaphyseal fractures.
Shen et al.  retrospectively analyzed data from 43 patients with fractured humerus shafts treated with DCP and LCP using minimally invasive plate osteosynthesis (MIPO) techniques, and showed that there was no significant difference when outcomes and complications of the two types of implants were compared. Hur et al.  retrospectively analyzed data from 19 elderly patients with fractured humerus shafts treated with LCDCP and LCP. In their study, loosening of the plate occurred in one case each from the LCP group and the LCDCP group. The rest of the patients achieved union uneventfully without any complications. Union rate and clinical scores were not significantly different between the two groups. They advised that the principle of fracture fixation was more important than plate selection in humeral shaft fractures of elderly patients. Results of the present study are comparable with the reported literature [14, 15]. In their prospective study, Sommer et al.  published the results of use of various LCPs in treatment of 144 patients with 169 fractures, and concluded that the LCP was a technically mature option in complex fracture situations and in revision operations after the failure of other implants. Ring et al.  treated 24 patients with osteoporotic delayed union (9 patients) and nonunion (15 patients) of the humeral diaphysis with LCP. All the fractures eventually healed and, using a modification of the Constant and Murley shoulder score, the results were good or excellent in 22 patients and fair in 2 patients.
Gardener et al.  compared the mechanical behavior under cyclic loading of LCP constructs and LCDCP constructs. Traditional compression plating failed significantly earlier in torsion. In AP bending, traditional constructs demonstrated significantly greater energy absorption, suggesting greater deformation. Fracture motion and stiffness measurements were discordant in the LCDCP specimens in torsion. In contrast, the LCP specimen had no discordance in stiffness and fracture motion. On the other hand, many of the other parameters compared between the two plates showed no difference, and the overall clinical advantage of locked plates is subtle. Xiong et al.  also showed in their cadaveric study that the LCP has a lower interface contact area and lower average force than that of the LCDCP and that the LCP is a good alternative for treating forearm and humerus diaphyseal fractures. In their study, Hoerdemann et al.  compared the in vitro biomechanical characteristics of LCDCP and LCP constructs in an osteotomy gap model of femoral fracture in neonatal calves and showed that insertion torque sufficient to provide adequate stability in femurs of newborn calves could not be achieved reliably with 4.5-mm cortical screws, and that LCP constructs were significantly more resistant to compression than LCDCP constructs. Leung and Chow  compared LCDCP with PC-Fix and LCP in treatment of closed forearm fractures in their randomized control trial and said that the LCP is effective for use as a bridging device in treating comminuted fractures; its usage in simple fractures and its superiority over conventional plating systems is yet to be proved.
The limitation of our study was small sample size in both groups and absence of long-term follow-up. A randomized control trial, preferably triple blinded or at least double blinded in nature, involving a large number of patients with long-term follow-up is needed to evaluate significant differences between LCDCP and LCP fixation in fractures of the shaft of the humerus.
Our study concludes that the final outcome is determined by using proper principles of plating and it is the proper application of the principles of plating and not the type of plate which decides outcomes and complications.
Conflict of interest
The authors declare that they have no conflict of interest.
The protocol of this study was approved by the institutional review board. This study was authorized by the local ethical committee and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki as revised in 2000. The need for informed consent was waived by the ethical committee since the rights and interests of the patients would not be violated and their privacy and anonymity was assured by the study design.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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