Humeral Tip-apex-distance as a Prognostic Marker for Proximal Humeral Fractures in 203 Patients

Dominik Saul1, *, #, Tobias Himmelmann2, #, Klaus Dresing1
1 Department of Trauma, Orthopaedics and Reconstructive Surgery, Georg-August-University of Goettingen, Goettingen, Germany
2 MVZ Prof. Uhlenbrock u. Partner, Dortmund, Germany

Article Metrics

CrossRef Citations:
Total Statistics:

Full-Text HTML Views: 1271
Abstract HTML Views: 454
PDF Downloads: 265
ePub Downloads: 227
Total Views/Downloads: 2217
Unique Statistics:

Full-Text HTML Views: 738
Abstract HTML Views: 318
PDF Downloads: 189
ePub Downloads: 173
Total Views/Downloads: 1418

Creative Commons License
© 2017 Saul et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Trauma, Orthopaedics and Reconstructive Surgery, Georg-August-University of Goettingen, Goettingen, Partner, Dortmund, Germany, Fax: 0551 39-8787, Tel: 0551 39-6050; Email:

These authors contributed equally to this work



Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare.


Determination of predictive factors for the failure of osteosynthesis with the loss of fixation or migration of screws in humeral head fractures.


From 1995 to 2011, 408 patients with proximal humeral fractures [mean age 66.6 years, 50.9-82.3 years] and osteosynthesis were analyzed. Two hundred and three received open reduction internal fixation (ORIF) with the PHILOS® plate. The non-locking plate was used in 80, the locking plate in 16 and humeral head prosthesis in 26 patients, in addition to 23 patients undergoing other procedures. Intraoperative reduction that achieved an anatomical alignment of the medial aspect of the humerus (humeral calcar) was assessed in 94 patients by postoperative X-ray analysis. The loss of fixation was evaluated by a follow-up of three to five X-rays and measurement of the humeral tip-apex-distance (HTAD).


For stable fixed fractures with an intact calcar, percentual HTAD was significantly higher than for unstable fixed fractures (p=0.04). Morbidity, such as hypertension, orthopedic operations or diabetes, strongly influenced the HTAD, while postoperative passive motion treatment modestly affected the HTAD over time.


The anatomic reconstruction of the calcar, leading to stable fixation of humeral head fractures, can significantly prevent an overproportioned decrease in the HTAD in postoperative X-rays and seems to be vital in multimorbid patients. Measurement of the HTAD over time delivers a tool for early detection of secondary loss of fixation.

Keywords: Humeral head fracture, Humeral tip-apex-distance, HTAD, Philos® plate, Calcar, Loss of fixation, Postoperative treatment.