Surgical Discussion

Patient positioning:  The patient was positioned supine in a semi-beach-chair position,

Anatomical surgical approach:  A deltopectoral approach was utilized

Upon exploration, extensive scarring consistent with the sub acute time scale and callus formation around the deltoid muscle were noted, complicating exposure. Additionally, the long head of biceps tendon was found torn with its distal portion unidentifiable. The fracture site exhibited significant callus formation obscuring anatomical landmarks; meticulous debridement was performed to mobilize fragments for reduction. Anatomical reduction was achieved under direct vision and provisionally held with Kirschner wires. Challenges encountered included managing soft tissue adhesions without compromising vascular supply or further damaging muscle integrity. A PHILOS plate was positioned optimally as confirmed by multiplanar fluoroscopy before final screw fixation ensuring angular stability.

Postoperative protocol:   Immediate postoperative protocol encouraged full range of motion exercises within pain tolerance limits. Non-weight bearing instructions were given for 6 weeks post-operatively followed by weight-bearing as tolerated, gradually increasing activity levels based on clinical assessment and radiographic evidence of union.

Orthopaedic implants used:   PHILOS (Proximal Humerus Internal LOcking System) Plate - Kirschner wires for provisional fixation