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Review Article
- Minimally invasive plate osteosynthesis of the clavicle and humerus: indications, surgical techniques, and clinical outcomes
- Hoon-Sang Sohn1, Yunjong Choi2, Sang-Jin Shin2
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DOI: https://doi.org/10.12671/jmt.2026.00220
Published online: August 21, 2026
1Department of Orthopedic Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
2Department of Orthopedic Surgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
- Correspondence to: Sang-Jin Shin Department of Orthopedic Surgery, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, 260 Gonghang-daero, Gangseo-gu, Seoul 07804, Korea Tel: +82-2-6959-1656 Email: sjshin622@ewha.ac.kr
• Received: May 24, 2026 • Revised: June 23, 2026 • Accepted: June 29, 2026
© 2026 The Korean Orthopaedic Trauma Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
- Minimally invasive plate osteosynthesis (MIPO) is an established strategy for lower-extremity fractures because it preserves periosteal vascularity, maintains fracture hematoma, and promotes secondary bone healing through relative stability. Its use has expanded to fractures around the shoulder girdle, including fractures of the clavicle, proximal humerus, humeral shaft, and distal humerus. However, adoption in the upper extremity has been more cautious because of complex regional anatomy, narrow soft-tissue corridors, and the proximity of major neurovascular structures. This review summarizes current evidence on the indications, surgical techniques, clinical outcomes, and complications of MIPO for clavicle and humerus fractures. For clavicle fractures, MIPO is most commonly indicated for displaced multifragmentary midshaft fractures and provides union rates and functional outcomes comparable to those of conventional open reduction and internal fixation, with potential advantages in soft-tissue preservation and cosmesis. In proximal humerus fractures, MIPO performed through a deltoid-splitting approach has yielded favorable outcomes in selected two- and three-part fractures, whereas four-part fractures have less predictable outcomes and higher complication rates. In humeral shaft fractures, anterior MIPO provides stable fixation without routine radial nerve exploration and has shown reliable union with fewer complications in selected fracture patterns. For extra-articular distal humerus fractures, minimally invasive anterior and posterior plating techniques, including the use of an inverted proximal humeral internal locking system plate, have shown favorable clinical and radiographic outcomes despite technical challenges related to limited distal fixation. Overall, MIPO can achieve high union rates and satisfactory functional outcomes in clavicular and humeral fractures when indications are appropriate, safe anatomical corridors are respected, and surgical technique is meticulous.
Introduction
Open reduction and internal fixation (ORIF) remains one of the most commonly utilized surgical strategies for fracture management. Despite its widespread use, this technique is associated with several well-recognized complications, including deep infection, nonunion, implant failure, and refracture following implant removal [1-3]. These adverse outcomes are thought to be partly attributable to extensive periosteal stripping and soft-tissue disruption at the fracture site, which may compromise the biological environment necessary for fracture healing [4]. Minimally invasive plate osteosynthesis (MIPO) has emerged as an alternative fixation strategy founded on the principles of indirect reduction and bridge plating without direct exposure of the fracture site. By preserving periosteal blood supply and maintaining fracture hematoma, MIPO supports a biologically favorable environment that facilitates secondary bone healing through relative stability [5]. However, MIPO also presents several technical limitations. Because the fracture site is not directly visualized, the accuracy of reduction depends substantially on surgical experience and fluoroscopic interpretation. Furthermore, the technique carries an inherent risk of neurovascular injury and typically requires increased intraoperative fluoroscopic guidance [6].
MIPO has become well established in the management of lower-extremity fractures, with numerous studies demonstrating favorable clinical and radiographic outcomes [7-9]. These advantages have largely been attributed to preservation of periosteal blood supply, maintenance of fracture hematoma, and promotion of secondary bone healing through relative stability. More recently, the application of MIPO has expanded to fractures around the shoulder girdle, including the clavicle, proximal humerus, humeral shaft, and distal humerus, with an increasing number of studies reporting satisfactory union rates and functional outcomes when appropriate indications and meticulous surgical techniques are employed [6,10,11]. However, adoption of MIPO in the upper extremity has progressed more cautiously than in the lower extremity. This is primarily related to the complex regional anatomy, the close proximity of critical neurovascular structures such as the axillary and radial nerves, and the limited safe corridors available for implant insertion. In addition, indirect reduction techniques in the upper extremity are often technically demanding because restoration of alignment, length, and rotational profile must be achieved without direct visualization of the fracture site. These technical challenges are further compounded by region-specific biomechanical considerations, including cantilever forces in the clavicle, varus collapse in the proximal humerus, torsional stress in the humeral shaft, and limited distal fixation in distal humerus, which necessitate distinct fixation strategies.
Given these anatomical, biomechanical, and technical considerations, the indications, surgical strategies, and potential complications associated with MIPO vary substantially according to the involved anatomical region. Accordingly, comprehensive understanding of both the shared biological principles and the region-specific technical challenges of MIPO around the shoulder is essential for optimizing clinical outcomes. Although several previous reviews have addressed MIPO techniques for specific fracture locations, a comprehensive review integrating region-specific indications, anatomical considerations, surgical techniques, and clinical outcomes across the clavicle and humerus remains limited. Therefore, this review aims not only to summarize the current evidence regarding MIPO for clavicle and humerus fractures, but also to provide a practical framework for orthopedic trauma surgeons by emphasizing region-specific indications, surgical strategies, clinical outcomes, potential complications, and safe anatomical corridors associated with each anatomical region. A summary of the key indications, surgical approaches, neurovascular structures at risk, fixation strategies, and major complications for each anatomical region is provided in Table 1. This narrative review was based on a literature search of PubMed and Google Scholar databases. Studies addressing the indications, surgical techniques, clinical outcomes, and complications of MIPO for clavicle and humeral fractures were reviewed, with emphasis on clinically relevant studies, comparative investigations, and representative technical reports published in English.
Written informed consent was obtained from the patients for publication of their images in this review.
Clavicle fracture
MIPO for clavicle fractures is primarily indicated for displaced multifragmentary midshaft fractures in which anatomical reduction of each intermediate fragment is not essential for restoration of satisfactory functional alignment. In these fracture patterns, the principles of bridge plating and biologic fixation permit maintenance of fracture fragment vascularity while preserving overall clavicular length and alignment. Selected simple midshaft fractures may also be considered for MIPO, particularly in the presence of substantial soft-tissue compromise or when extensive surgical exposure is undesirable. However, in simple fracture configurations with minimal soft-tissue injury, where direct anatomical reduction can be reliably achieved, conventional ORIF generally remains the preferred treatment strategy. Accordingly, the advantages of MIPO are considered most pronounced in multifragmentary midshaft clavicle fractures rather than in simple fracture patterns [12].
To achieve adequate construct stability, fixation should include at least three screws within both the medial and lateral main fragments. By utilizing two limited incisions and indirect reduction techniques, MIPO preserves periosteal blood supply and surrounding soft-tissue attachments while minimizing surgical dissection. Biomechanical studies have generally demonstrated greater construct stiffness and higher bending load to failure with superior plating compared with anteroinferior plating configurations [13,14]. Nevertheless, clinical studies have reported comparable union rates and functional outcomes between the two fixation strategies [15-17]. Anteroinferior plating may provide advantages related to reduced implant prominence and decreased soft-tissue irritation, whereas superior plating offers greater mechanical rigidity [15]. In multifragmentary clavicular fractures associated with segmental bone defects, anteroinferior plating may be preferable because the cantilever effect generated by superior plating constructs can increase bending stress concentration at the fracture site [18]. A randomized clinical trial involving 37 patients with clavicle fractures compared superior and anteroinferior plating techniques and demonstrated no significant differences in clinical or radiographic outcomes between the two plate positions. Both techniques achieved satisfactory fracture union and functional recovery without major complications [19]. In summary, superior plating generally provides greater biomechanical stiffness and resistance to bending forces, whereas anteroinferior plating may reduce implant prominence and soft-tissue irritation. Therefore, plate position should be selected according to fracture morphology, soft-tissue condition, and surgeon preference, as both techniques have demonstrated comparable clinical outcomes.
The patient is positioned in the beach-chair position, and fluoroscopy is arranged to obtain anteroposterior and oblique cephalic and caudal tilt views. A lateral incision approximately 3 cm in length is created along the anterior border of the clavicle, and the deltoid-trapezius interval is carefully developed to expose the lateral clavicular segment. A submuscular tunnel is subsequently created toward the medial side using a periosteal elevator while carefully protecting the underlying neurovascular structures. The plate is inserted through the lateral window in a reversed orientation to allow passage across the fracture site and is then rotated into its anatomical position. A second medial incision is created over the medial portion of the plate, and blunt dissection is performed beneath the platysma and pectoralis major to facilitate definitive plate positioning (Fig. 1). Indirect fracture reduction is achieved using percutaneous joystick techniques with threaded Kirschner wires to correct vertical displacement and restore alignment. Temporary fixation is established using 2.8-mm drill bits placed at both ends of the plate, followed by insertion of cortical screws to restore anterior-posterior alignment. After satisfactory reduction and implant positioning are confirmed fluoroscopically, definitive fixation is completed using locking screws [11,20]. Following definitive fixation, meticulous soft-tissue repair is performed to restore muscular continuity and ensure adequate implant coverage.
Sohn et al. [20] reported a clinical series of 19 patients with displaced midshaft clavicle fractures treated using the anteroinferior MIPO technique (Fig. 2). Radiographic union was achieved in all patients at a mean of approximately 15 weeks postoperatively. Clavicular length was successfully restored without clinically significant shortening, and shoulder range of motion was nearly symmetric to that of the contralateral extremity at final follow-up. No major complications were observed; however, one patient developed localized hypoesthesia, and another sustained a refracture adjacent to the plate following subsequent trauma [20]. A recent large-scale meta-analysis evaluating MIPO for clavicle midshaft fractures demonstrated outcomes comparable to those of ORIF with respect to time to union, functional outcomes, and complication rates; [21]. However, MIPO demonstrated several additional advantages, including shorter operative time, lower rates of neurological impairment, and superior cosmetic outcomes [22,23].
Proximal humerus fracture
MIPO for proximal humerus fractures is most commonly performed through a deltoid-splitting approach using indirect fracture reduction and locking plate fixation [24,25]. Favorable clinical and radiographic outcomes have been reported particularly in displaced two-part fractures and selected three-part fractures, whereas four-part fractures are associated with significantly inferior outcomes and substantially higher complication rates [26,27]. Consequently, the application of MIPO in complex fracture configurations, particularly four-part fractures, remains controversial because accurate reduction and stable fixation may be difficult to achieve using minimally invasive techniques alone. In such circumstances, conversion to an open approach should be considered when satisfactory reduction cannot be reliably obtained [26]. Fractures associated with substantial medial cortical or calcar comminution, as well as poor bone quality, also warrant careful consideration because inadequate medial column support is strongly associated with postoperative loss of reduction and screw cutout following locking plate fixation [26,28]. Therefore, careful patient selection and thorough assessment of fracture morphology, reducibility, bone quality, and medial column integrity are essential when considering MIPO for proximal humerus fractures [6,27]. In practical terms, ideal candidates for MIPO include displaced two-part fractures and selected three-part fractures in which satisfactory indirect reduction and stable fixation can be achieved. Conversely, four-part fractures, fractures with severe medial calcar comminution, poor bone quality, or irreducible fracture patterns should be approached with caution because these factors are associated with increased risks of loss of reduction and fixation failure. When adequate reduction cannot be reliably obtained through minimally invasive techniques, conversion to an open approach should be considered.
The patient is positioned supine with the affected arm draped free to allow intraoperative manipulation and fluoroscopic assessment. Compared with the beach-chair position, the supine position facilitates reduction by preventing posterior sagging of the arm. Closed reduction is initially attempted under fluoroscopic guidance using longitudinal traction combined with varus or valgus-directed correction, although varus correction is required in most cases. Restoration of the medial calcar and correction of varus deformity are essential before definitive fixation.
A proximal incision approximately 4–5 cm in length is created beginning distal to the anterolateral corner of the acromion. The deltoid muscle is split longitudinally along its anterior raphe without detachment. Because the axillary nerve typically crosses beneath the deltoid approximately 5–7 cm distal to the acromion, careful protection of the nerve is mandatory throughout the procedure. During preparation of the submuscular tunnel, the axillary nerve is palpated digitally while the index finger is maintained beneath the deltoid to guide safe passage of the plate and minimize the risk of iatrogenic injury (Fig. 3A).
When greater tuberosity fragmentation is present, nonabsorbable sutures placed at the rotator cuff-bone junction and temporary Kirschner wires may be used to facilitate reduction and provisional fixation (Fig. 3B). After creation of a subdeltoid extraperiosteal tunnel, the plate is inserted distally through the proximal window. Plate height should be maintained approximately 5 mm inferior to the greater tuberosity to avoid subacromial impingement.
A distal incision is then created through the deltoid-biceps interval, preserving the cephalic vein whenever possible. The brachialis muscle is split longitudinally to expose the anterior humeral shaft. Reduction is achieved indirectly using a positional cortical screw inserted through the elongated combi-hole, which draws the shaft toward the plate and restores the neck-shaft angle and coronal alignment (Fig. 3C). Rotational alignment and plate position are subsequently confirmed fluoroscopically, including axillary views obtained with gentle shoulder abduction and external rotation.
Once satisfactory reduction has been achieved, proximal locking screws are inserted in a divergent configuration, followed by additional distal fixation. In fractures with medial metaphyseal comminution or poor bone quality, inferomedial calcar screws or fibular strut graft augmentation may be added to improve medial column support and reduce the risk of secondary varus collapse. Shoulder abduction to approximately 90° facilitates insertion of inferomedial screws while reducing tension on the axillary nerve.
Final fluoroscopic assessment should confirm restoration of overall alignment, appropriate plate position, and satisfactory screw length in multiple planes. Early passive and active range-of-motion exercises are initiated postoperatively as tolerated.
Sohn and Shin [26] evaluated 62 patients with proximal humerus fractures treated using the MIPO technique, including 27 two-part, 24 three-part, and 11 four-part fractures (Fig. 4). Patients with four-part fractures demonstrated significantly lower Constant scores and significantly decreased neck-shaft angles at final follow-up compared with patients with two- and three-part fractures. Furthermore, the overall complication rate was significantly higher in the four-part fracture group and included postoperative shoulder stiffness as well as radiographic complications such as plate impingement, screw penetration, varus collapse, and malreduction. In another clinical study involving 34 patients with proximal humerus fractures treated using MIPO, radiographic union was achieved in all patients, with satisfactory functional outcomes and no major complications [29]. A meta-analysis including 11 studies comparing ORIF and MIPO for proximal humerus fractures demonstrated no significant differences between the two techniques with respect to Constant scores, radiographic outcomes, and complication rates; however, operative time was significantly shorter in the MIPO group [30]. Collectively, these findings suggest that satisfactory radiographic and functional outcomes, including reliable fracture union and restoration of proximal humeral alignment, can be achieved using MIPO in appropriately selected displaced proximal humerus fractures. However, outcomes in four-part fractures remain comparatively less favorable than those observed in two- and three-part fractures. Careful reduction of comminuted proximal humerus fractures is particularly important for restoration and maintenance of the neck-shaft angle. When adequate reduction cannot be reliably achieved using a minimally invasive approach, timely conversion to an open technique should be considered. In a prospective randomized clinical trial comparing MIPO with conventional open plating, the authors similarly reported no significant differences in functional outcomes or radiographic parameters between the two groups, although operative time was significantly shorter in the MIPO group [27]. Kim et al. [31] compared inferomedial screw augmentation with fibular strut allograft augmentation in proximal humerus fractures with medial comminution treated using MIPO. They reported superior radiographic stability and lower rates of surgical failure in the fibular allograft group, particularly in four-part fractures.
Humeral shaft fracture
MIPO for humeral shaft fractures is particularly advantageous for fracture patterns that are amenable to healing under conditions of relative stability, including long oblique, spiral, comminuted, and segmental fracture configurations. Because the technique relies on bridge plating and indirect reduction without interfragmentary compression, it is generally less suitable for simple transverse fractures, which typically require absolute stability to facilitate primary bone healing [32,33]. Preservation of fracture hematoma and periosteal blood supply under these low-strain conditions promotes secondary callus formation, which constitutes the biological foundation of minimally invasive fixation techniques. The applicability of MIPO in the humeral shaft is further supported by the unique anatomical and biomechanical characteristics of this region. The radial nerve courses obliquely along the spiral groove and transitions from posterior to anterior within the distal third of the humerus, rendering extensive exposure during conventional open plating potentially hazardous. In this context, anterior MIPO permits fracture stabilization while minimizing direct manipulation within this zone of neurovascular vulnerability [3]. Indirect reduction methods include manual traction, external fixator-assisted reduction, joystick techniques using Kirschner wires or Schanz pins, and reduction utilizing the plate itself in combination with screws or a collinear clamp [27]. Biomechanically, the humeral shaft is subjected predominantly to torsional and bending stresses rather than axial loading forces. Consequently, bridge plating under conditions of relative stability is particularly well suited to comminuted and segmental fracture patterns, in which preservation of fracture biology may enhance secondary callus formation and fracture healing [34]. Furthermore, compared with intramedullary nailing, anterior plate fixation avoids violation of the rotator cuff tendon while still permitting reliable restoration of humeral length, coronal alignment, and rotational profile [35,36]. When meticulously performed, MIPO enables indirect fracture reduction using the plate as a reduction aid, thereby minimizing soft-tissue disruption while maintaining sufficient biomechanical stability to facilitate fracture healing [27].
For MIPO of humeral shaft fractures, the patient is positioned supine on a radiolucent table with the affected arm freely draped to allow unrestricted manipulation during reduction. The elbow is maintained in flexion with the forearm supinated to move the radial nerve away from the anterior surface of the humerus. Fluoroscopy is positioned perpendicular to the operating table to obtain true anteroposterior and lateral images throughout the procedure.
A limited proximal incision is created through the deltopectoral interval, whereas the distal window is made over the anterior aspect of the distal humerus several centimeters proximal to the elbow crease. Unlike the conventional anterolateral approach used in open plating, this direct anterior approach minimizes the risk of radial nerve injury. The biceps muscle is retracted medially, and the brachialis is split longitudinally to expose the anterior cortex. During distal exposure, particular attention should be paid to the musculocutaneous nerve along the medial border of the brachialis muscle. Because the radial nerve remains protected posteriorly by the lateral portion of the brachialis muscle, routine exploration of the nerve is generally unnecessary.
An extraperiosteal tunnel is developed along the anterior humeral surface using blunt dissection, connecting the proximal and distal windows. The plate is typically advanced from distal to proximal along the anterior cortex. Indirect reduction is facilitated by first securing the proximal fragment to the plate. After confirming proper alignment between the plate and proximal shaft under fluoroscopy, provisional fixation is achieved using a drill bit or temporary fixation device inserted through the proximal plate hole. A cortical screw is then inserted to bring the humeral shaft toward the plate and establish reduction. Because the plate functions as an extension of the proximal fragment, accurate proximal alignment is essential for restoration of length, coronal alignment, and rotation.
Following manual or indirect reduction of the distal fragment, temporary distal fixation is obtained in a similar manner. Additional cortical screws may be used to fine-tune reduction before insertion of definitive locking screws proximally and distally. Final fluoroscopic assessment should confirm restoration of alignment and rotational profile. Comparison with the contralateral extremity is helpful to minimize rotational malalignment.
Particular caution is required during distal screw insertion because the radial nerve crosses the posterior aspect of the humerus approximately 12–16 cm proximal to the lateral epicondyle. This region corresponds to the transition zone of the radial nerve from the posterior to the anterior compartment and therefore represents the area of greatest vulnerability during bicortical drilling and distal screw insertion. In this region, careful drilling and consideration of unicortical fixation may reduce the risk of iatrogenic nerve injury. The overall objective of fixation is stable bridge plating while preserving fracture biology and minimizing soft-tissue disruption.
Sohn et al. [27] reported the clinical outcomes of MIPO in 21 patients with humerus midshaft fractures. Radiographic union was achieved in 20 patients at a mean of 17.5 weeks postoperatively (Fig. 5). In two patients, intraoperative conversion to open reduction was required because of technical failure of the minimally invasive technique. One patient developed nonunion, and one patient experienced malunion. According to the University of California Los Angeles (UCLA) Shoulder Rating Scale, 18 patients achieved excellent results and three achieved good outcomes. No neurological complications were observed in this series. Randell et al. [3] compared outcomes between 28 patients treated using MIPO and 28 patients treated using ORIF for humeral shaft fractures and reported no significant differences in radiographic alignment or Disabilities of the Arm, Shoulder and Hand (DASH) scores between the two groups; however the overall complication rate was significantly lower in the MIPO group. External fixator-assisted reduction has been described as a useful adjunctive technique during MIPO for humeral shaft fractures. By inserting Schanz pins into the proximal and distal fragments and connecting them with a unilateral external fixator, restoration and maintenance of length, alignment, and rotational control can be achieved during plate insertion [37]. In a comparative study by Kulkarni et al. [38] evaluating humeral diaphyseal fractures, 44 patients treated with intramedullary nailing, 34 treated with ORIF, and 34 treated with MIPO were analyzed. The mean time to union was significantly shorter in the intramedullary nailing group (12.7 weeks) than in the MIPO group (14.5 weeks) and the ORIF group (13.6 weeks). However, nonunion did not occur in any patient treated with MIPO, compared with five patients in the ORIF group and ten patients in the intramedullary nailing group, representing a statistically significant difference. The UCLA Shoulder Rating Scale was significantly higher in the MIPO group, whereas the Mayo Elbow Performance Score (MEPS) demonstrated no significant differences among the three treatment groups. Overall, when considering nonunion rates, functional outcomes, and complication profiles collectively, MIPO demonstrated superior clinical outcomes compared with the alternative treatment modalities.
Although MIPO for humeral shaft fractures is technically demanding, available evidence suggests that it can provide satisfactory union rates and favorable restoration of shoulder and elbow function. Nevertheless, meticulous attention to fracture reduction techniques and fixation strategy remains essential to minimize postoperative complications such as malreduction and nonunion.
Distal humeral shaft (extra-articular) fracture
Extra-articular distal humerus fractures present substantial challenges for internal fixation because the distal fragment is frequently short, osteoporotic, and subjected to complex bending and rotational stresses, thereby increasing the risk of fixation failure with conventional plating techniques. To address these challenges, both anterior and posterior plating strategies have been described for MIPO [39]. Anterior plating avoids routine radial nerve dissection and has been associated with shorter operative time and a lower risk of iatrogenic radial nerve injury. In addition, the anterior approach facilitates insertion of a greater number of distal screws and is associated with fewer implant-related symptoms. However, when the fracture extends distally toward the olecranon fossa, the anterior approach may be limited because the distal fragment may not provide sufficient space to accommodate the number of screws required for stable fixation. In contrast, posterior plating offers several mechanical advantages, including plate placement along a relatively flat posterior surface, fixation along the tension side of the humerus, direct visualization of the radial nerve, and improved lateral column fixation of the distal fragment [40]. However, posterior plating requires radial nerve dissection and is associated with a higher incidence of implant-related symptoms secondary to plate prominence beneath the relatively thin posterior soft-tissue envelope. Consequently, meticulous preoperative planning of plate position and distal screw configuration is essential to achieve stable fixation within this anatomically constrained region [41]. In summary, anterior plating offers the advantages of avoiding routine radial nerve dissection, reduced implant prominence, and the ability to accommodate a greater number of distal screws, although fixation may be limited in very distal fracture patterns. Posterior plating provides excellent visualization of the radial nerve and favorable distal fixation along the tension side of the humerus but requires nerve dissection and is associated with a higher incidence of implant-related symptoms. Inverted proximal humeral internal locking system (PHILOS) plating represents a useful modification of anterior plating that may improve distal fixation through multiple divergent locking screws while preserving the biological advantages of a minimally invasive approach. The use of an inverted PHILOS plate, originally designed for proximal humerus fractures, has been proposed as an alternative fixation option for extra-articular distal humerus fractures [42]. Owing to its precontoured geometry and divergent locking screw configuration, the inverted PHILOS plate may permit secure fixation of the distal fragment while preserving the advantages of a minimally invasive approach.
The patient is positioned supine on a radiolucent operating table with the affected arm left free to allow intraoperative manipulation and fluoroscopic assessment. A longitudinal distal incision approximately 5 cm in length is created over the anterior aspect of the distal humerus. The interval is developed by retracting the biceps muscle medially and splitting the brachialis muscle longitudinally to expose the anterior humeral cortex. Because the radial nerve remains protected posteriorly by the lateral portion of the brachialis muscle, routine radial nerve exploration is generally unnecessary unless preoperative nerve palsy is present.
After exposure of the distal humerus, a submuscular extraperiosteal tunnel is created proximally along the anterior surface of the humeral shaft using blunt dissection with a periosteal elevator. In cases with residual coronal deformity, indirect reduction may be achieved using a temporary Schanz pin inserted into the lateral condyle as a joystick to correct varus or valgus malalignment (Fig. 6A).
An inverted PHILOS plate is then passed along the anterior humeral surface through the prepared tunnel. Under fluoroscopic guidance, the distal portion of the plate is positioned over the distal fragment and provisionally stabilized using a locking drill bit. A cortical screw inserted through the combi-hole is subsequently used to draw the distal fragment toward the plate, thereby restoring sagittal alignment and bone-plate contact.
Attention is then directed to the proximal fragment. Rotational alignment is corrected using a temporary Kirschner wire while the rotational profile of the proximal humerus is assessed fluoroscopically. Coronal alignment between the plate and humeral shaft is confirmed on the anteroposterior view in a manner similar to standard MIPO techniques for humeral shaft fractures. Additional cortical screws are inserted sequentially to reduce the proximal humeral fragment (Fig. 6B, C).
Final fixation is achieved using three or four bicortical screws in the proximal fragment according to bridge plating principles and appropriate plate-screw density, while the distal fragment is secured with multiple locking screws whenever feasible. Careful drilling and accurate screw-length measurement are particularly important because the proximal locking holes of the inverted PHILOS plate have divergent trajectories.
Postoperatively, the arm is supported in a sling for approximately 4 weeks. Passive and active range-of-motion exercises of the shoulder and elbow are initiated early as tolerated.
Sohn and Shin [42] evaluated 23 patients with extra-articular distal humeral fractures treated using a modified application of an inverted PHILOS plate, including both open and minimally invasive techniques (Fig. 7). Radiographic union was achieved in all patients at a mean of 20.8 weeks, with excellent functional outcomes reflected by a mean MEPS of 97.6 and without major complications requiring reoperation. However, these outcomes represent a mixed cohort treated with both open and minimally invasive techniques and therefore cannot be attributed exclusively to MIPO. Notably, application of the inverted PHILOS plate permitted insertion of a greater number of locking screws into the distal fragment (mean, 5.6), thereby increasing plate-screw density and improving distal fixation stability [42].
In a subsequent comparative study, anterior plating using the modified PHILOS technique was compared with posterior plating using an extra-articular distal humerus plate. Both techniques demonstrated satisfactory clinical and radiographic outcomes, with no significant differences in union rate, elbow range of motion, or functional scores. However, anterior plating was associated with significantly shorter operative time, greater distal screw density, and a markedly lower incidence of implant-related symptoms. In contrast, posterior plating was frequently associated with implant prominence and postoperative discomfort, resulting in a higher rate of secondary implant removal [39]. Similarly, Jitprapaikulsarn et al. [43] reported favorable outcomes following anterior MIPO using an inverted PHILOS plate in 12 patients. All fractures achieved radiographic union without loss of reduction, implant failure, infection, or iatrogenic nerve injury. Functional outcomes were excellent, and no secondary procedures were required during follow-up. These findings further support the reproducibility and safety of anterior MIPO using an inverted PHILOS plate in centers other than the original developer institution. Collectively, these findings suggest that anterior MIPO using an inverted PHILOS plate can provide reliable fracture union and favorable functional outcomes while offering distinct advantages with respect to distal fixation stability and implant-related morbidity.
Conclusion
Clinical evidence has demonstrated that when appropriate indications are selected and anatomical safe zones are meticulously respected, MIPO can provide the biological advantages of limited soft-tissue disruption, preservation of periosteal vascularity, and high rates of fracture union while maintaining satisfactory functional recovery. However, surgeons should recognize the inherent limitations of indirect reduction techniques and maintain a low threshold for conversion to open procedures when adequate reduction or stable fixation cannot be reliably achieved.
Ultimately, MIPO around the shoulder girdle should be regarded as a technically demanding yet highly valuable surgical strategy, with successful clinical outcomes largely dependent on precise indication selection, meticulous surgical planning, appropriate window placement, accurate plate insertion sequence, and comprehensive understanding of regional neurovascular anatomy. From a practical perspective, MIPO is generally favored for multifragmentary, long oblique, spiral, comminuted, and segmental fracture patterns in which indirect reduction and biologic fixation can be effectively utilized. In contrast, conventional open plating may be more appropriate for simple fracture configurations requiring anatomical reduction and absolute stability, irreducible fractures, or situations in which safe implant placement cannot be reliably achieved through limited surgical exposure. Ultimately, the choice between MIPO and open plating should be individualized according to fracture morphology, bone quality, soft-tissue condition, and surgeon experience.
Nevertheless, the current body of evidence remains limited, as most available studies are retrospective, single-center investigations with relatively small sample sizes. Although several comparative studies and a limited number of randomized trials have reported encouraging outcomes, higher-level evidence remains insufficient to establish definitive superiority of MIPO over conventional fixation techniques across all fracture patterns. Furthermore, the learning curve associated with indirect reduction techniques and the increased reliance on intraoperative fluoroscopy should be recognized when adopting these procedures. Future prospective multicenter studies and well-designed comparative trials are warranted to further define optimal indications, evaluate long-term outcomes, and clarify the relative benefits of MIPO in different fracture configurations.
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Author contributions
Conceptualization: HSS, SJS. Data curation: HSS, YC. Methodology: SJS. Resources: HSS. Supervision: SJS. Validation: HSS. Writing-original draft: HSS, YC. Writing-review & editing: HSS, SJS. All authors read and approved the final manuscript.
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Conflicts of interest
No potential conflict of interest relevant to this article was reported.
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Funding
None.
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Data availability
Not applicable.
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Acknowledgments
None.
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Supplementary materials
None.
Article Information
Fig. 1.
(A) Lateral approach demonstrating development of the deltoid-trapezius interval and creation of a submuscular tunnel. (B) The plate is inserted through the lateral window in an inverted orientation and advanced across the fracture site. (C) The plate is rotated into its anatomical position, and a second medial incision is created to facilitate definitive plate positioning through blunt dissection beneath the platysma and pectoralis major muscles.
Fig. 2.
A 43-year-old male patient with a fragmentary wedge-type (AO/OTA 15.2B3) midshaft clavicle fracture. (A) Preoperative radiograph showing a displaced fragmentary wedge fracture of the clavicle. (B) Immediate postoperative radiograph after minimally invasive plate osteosynthesis. (C) Radiograph obtained 13 months postoperatively showing solid bony union with maintained alignment and stable fixation without implant-related complications.
Fig. 3.
(A) Digital palpation of the axillary nerve during preparation of the submuscular tunnel to prevent iatrogenic nerve injury. (B) Temporary fixation of the reduced greater tuberosity using Kirschner wires positioned to avoid interference with subsequent plate placement. (C) Indirect restoration of the neck-shaft angle and correction of varus-valgus alignment using a positional cortical screw inserted through the elongated combi-hole to draw the humeral shaft toward the plate.
Fig. 4.
Representative radiographs of a proximal humerus fracture treated with minimally invasive plate osteosynthesis through a deltoid-splitting approach. (A) Preoperative anteroposterior and axial radiographs showing a displaced proximal humerus fracture. (B) Immediate postoperative radiographs showing restoration of alignment and fixation with a locking plate inserted using a minimally invasive technique. (C) Final follow-up radiographs showing successful fracture union with maintained reduction and stable implant position, without evidence of fixation failure.
Fig. 5.
A 34-year-old male patient with an AO/OTA 12B2 humeral shaft fracture. (A) Preoperative radiographs showing a displaced wedge-type fracture. (B) Immediate postoperative radiographs after minimally invasive plate osteosynthesis with bridge plating fixation. (C) Radiographs obtained 12 months postoperatively showing solid radiographic union with satisfactory alignment. (D) Clinical photograph showing the limited surgical windows used for minimally invasive plate osteosynthesis.
Fig. 6.
Representative fluoroscopic images showing key reduction maneuvers during minimally invasive plate osteosynthesis for an extra-articular distal-third humeral shaft fracture. (A) Correction of varus-valgus malalignment using a temporary Schanz pin inserted into the lateral condyle as a joystick. (B, C) Sequential reduction of the proximal fragment using temporary Kirschner-wire fixation and cortical screw insertion to restore rotational and coronal alignment before definitive fixation.
Fig. 7.
(A) Preoperative radiographs of a 55-year-old female patient with an extra-articular distal-third humeral shaft fracture. (B) Immediate postoperative radiographs showing fixation with an inverted proximal humeral internal locking system plate applied using a minimally invasive technique. (C) Radiographs obtained 13 months postoperatively showing solid bony union without loss of alignment or implant-related complications.
Table 1.
Key considerations for MIPO according to anatomical region
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Fig. 1. (A) Lateral approach demonstrating development of the deltoid-trapezius interval and creation of a submuscular tunnel. (B) The plate is inserted through the lateral window in an inverted orientation and advanced across the fracture site. (C) The plate is rotated into its anatomical position, and a second medial incision is created to facilitate definitive plate positioning through blunt dissection beneath the platysma and pectoralis major muscles.
Fig. 2. A 43-year-old male patient with a fragmentary wedge-type (AO/OTA 15.2B3) midshaft clavicle fracture. (A) Preoperative radiograph showing a displaced fragmentary wedge fracture of the clavicle. (B) Immediate postoperative radiograph after minimally invasive plate osteosynthesis. (C) Radiograph obtained 13 months postoperatively showing solid bony union with maintained alignment and stable fixation without implant-related complications.
Fig. 3. (A) Digital palpation of the axillary nerve during preparation of the submuscular tunnel to prevent iatrogenic nerve injury. (B) Temporary fixation of the reduced greater tuberosity using Kirschner wires positioned to avoid interference with subsequent plate placement. (C) Indirect restoration of the neck-shaft angle and correction of varus-valgus alignment using a positional cortical screw inserted through the elongated combi-hole to draw the humeral shaft toward the plate.
Fig. 4. Representative radiographs of a proximal humerus fracture treated with minimally invasive plate osteosynthesis through a deltoid-splitting approach. (A) Preoperative anteroposterior and axial radiographs showing a displaced proximal humerus fracture. (B) Immediate postoperative radiographs showing restoration of alignment and fixation with a locking plate inserted using a minimally invasive technique. (C) Final follow-up radiographs showing successful fracture union with maintained reduction and stable implant position, without evidence of fixation failure.
Fig. 5. A 34-year-old male patient with an AO/OTA 12B2 humeral shaft fracture. (A) Preoperative radiographs showing a displaced wedge-type fracture. (B) Immediate postoperative radiographs after minimally invasive plate osteosynthesis with bridge plating fixation. (C) Radiographs obtained 12 months postoperatively showing solid radiographic union with satisfactory alignment. (D) Clinical photograph showing the limited surgical windows used for minimally invasive plate osteosynthesis.
Fig. 6. Representative fluoroscopic images showing key reduction maneuvers during minimally invasive plate osteosynthesis for an extra-articular distal-third humeral shaft fracture. (A) Correction of varus-valgus malalignment using a temporary Schanz pin inserted into the lateral condyle as a joystick. (B, C) Sequential reduction of the proximal fragment using temporary Kirschner-wire fixation and cortical screw insertion to restore rotational and coronal alignment before definitive fixation.
Fig. 7. (A) Preoperative radiographs of a 55-year-old female patient with an extra-articular distal-third humeral shaft fracture. (B) Immediate postoperative radiographs showing fixation with an inverted proximal humeral internal locking system plate applied using a minimally invasive technique. (C) Radiographs obtained 13 months postoperatively showing solid bony union without loss of alignment or implant-related complications.
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Minimally invasive plate osteosynthesis of the clavicle and humerus: indications, surgical techniques, and clinical outcomes
| Region | Main indication | Surgical approach | Neurovascular structure at risk | Fixation strategy | Major complications |
|---|---|---|---|---|---|
| Clavicle | Multifragmentary midshaft fracture | Anteroinferior or superior MIPO | Subclavian vessels, brachial plexus | Bridge plating | Hypoesthesia, implant irritation, refracture |
| Proximal humerus | Displaced 2-part and selected 3-part fractures | Deltoid-splitting approach | Axillary nerve | Locking plate fixation | Varus collapse, screw penetration, shoulder stiffness |
| Humeral shaft | Long oblique, spiral, comminuted, segmental fractures | Anterior MIPO | Radial nerve, musculocutaneous nerve | Bridge plating | Malreduction, nonunion |
| Extra-articular distal humerus | Distal-third diaphyseal fractures | Anterior MIPO, posterior MIPO, inverted PHILOS | Radial nerve | Distal fixation with locking screws | Implant irritation, fixation failure, nerve injury |
Table 1. Key considerations for MIPO according to anatomical region
MIPO, minimally invasive plate osteosynthesis; PHILOS, proximal humeral internal locking system.
