Abstract:
A proximal humerus fracture plate for promoting healing of a fracture of a human humerus, comprising: an upper section having at least one screw hole for receiving an upper screw, the trajectory of the screw hole is a lateral to medial orientation; a transitional section having at least one screw hole for receiving a middle screw, the transitional section integral with the upper section and curved sufficiently to avoid a deltoid tuberosity, the middle screw fixing the transitional section along a lateral cortex of the humerus; and, a lower section having at least one screw hole for receiving a lower screw, the trajectory of the screw hole is an anterior to posterior orientation, the lower section integral with the transitional section.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    None. 
       STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH 
       [0002]    Not Applicable. 
       BACKGROUND OF THE INVENTION 
       [0003]    Proximal humeral fractures represent about 4-5% of all fractures and represent the third most common fracture among older patients. In many patients, the proximal humeral fracture most typically results from a fall. The damage to the humerus can be compounded by osteoporosis or an otherwise weakened bone that is found more frequently in older female patients. In younger patients, proximal humeral fractures are more likely to be a result of high-energy trauma; such as an automobile accident or a sporting injury. 
         [0004]    The majority of proximal humeral fractures are minimally or non-displaced and are generally treated non-operatively. 
         [0005]    However, operative fixation is indicated in displaced, angulated and rotated fracture patterns. Among the operative solutions commonly used for fixation are: (1) osteosuture and tension band technologies; (2) percutaneous fixation using pins and wires; (3) rigid intramedullary nailing (e.g., using a large rod inside the bone); (4) plate osteosynthesis (e.g., using open reduction internal fixation using plate(s) and screws); (5) arthroplasty (e.g. using a prosthesis to replace a broken portion of a humerus); and, other indication-specific techniques. 
         [0006]    There are two primary categories for surgical fixation: (1) a device that is within the skin (internal fixation); and (2) a device that extends out of the skin (external fixation). There are two common types of internal fixation approaches for long bone surgery: (a) a plate that is screwed to the outside of the bone; or (b) a rod that goes down the center of the bone. 
         [0007]    Current plate technology uses straight, also refered to as linear, plates, as illustrated in FIG. IB. For example, U.S. Pat. No. 6,096,040, issued to Esser, on Aug. 1, 2000, claims a linear bone plate. Additional examples of current proximal humeral plates are the Stryker A×SOS Locking Plating System, produced by Stryker Trauma AG at least as early as 2011. The Zimmer Periarticular Locking Plate, produced by Zimmer at least as early as 2006 are both examples of currently available linear plating systems. These straight plates limit the trajectory of the screws within the humeral head, which has been found to be problematic. 
         [0008]    As illustrated in  FIG. 1A , a humerus H is part of a human skeleton S.  FIG. 1B  illustrates a current linear bone plate.  FIG. 2  illustrates the humerus H separated from skeleton S. The shaft of a long bone, such as the humerus H, is typically classified as the diaphysis. The end of such a bone is typically classified as the epiphysis. Bone that is transitional between the midshaft and the end is typically classified as the metaphysis. 
         [0009]    Metaphysis and epiphysis bone are softer and more porous. The bone of the metaphysics and epiphysis is less dense than the diaphysial bone of the shaft. Since metaphysical and epiphyseal bone are cancellous bone, they are more affected by osteoporosis. Repair of metaphysis and epiphysis fractures are often complicated by their proximity to a joint. Due to the bone quality and anatomic shapes of the metaphyseal and epiphyseal bone, fixation of plates and screws in these areas is typically more difficult than fixation of plates and screws in diaphysis shaft. This may be especially true if the patient is elderly and suffers from osteoporosis. Thus, proper placement of screws in epiphysis and metaphysis bone is desirable to obtain appropriate fixation of a plate. Phrased differently, a current linear plate may obtain good fixation to the diaphysis, but fail to obtain appropriate fixation to the epiphysis and metaphysis. 
         [0010]    While not every proximal humeral fracture is the same, the Neer system of proximal humeral fractures is based on four parts of the humerus. The four parts are as follows:
   (I) fracture of the greater tuberosity:   (II) fracture of the lesser tuberosity;   (III) fracture of the humeral head; and.   (IV) fracture of the neck.   
 
         [0015]    According to Neer, a fracture is displaced when there is more than 1 cm (one centimeter) of displacement and/or 45° of angulation of any one fragment with respect to the others. 
         [0016]    Two-part fractures involve any of the 4 parts and include 1 fragment that is displaced. Three-part fractures include a displaced fracture of the surgical neck in addition to either a displaced greater tuberosity or lesser tuberosity fracture. Four-part fractures include displaced fractures of the surgical neck and both tuberosities. 
         [0017]      FIG. 3  is a chart of the Neer system of classifying displaced proximal humeral fractures. Fractures of the proximal humerus typically follow these fracture lines. With this said, humerus H can fracture in patterns not illustrated in  FIG. 3  and the Neer system is merely a way of classifying fractures. For example, humerus H may suffer complex fractures that extend into the shaft, both above and below the deltoid insertion. The Neer system may be thought of as helping surgeons to identify patients that likely would benefit from surgery. It does not determine the type of surgical intervention that might be medically beneficial. 
         [0018]    Currently, surgeons find it problematic to use existing linear proximal plates to resolve these issues. If a surgeon has identifies a fracture that meets the indications for surgery then one of the options noted above could be used. If a surgeon selects Open-Reduction Internal Fixation (ORIF), a surgical plate could be medically beneficial. 
         [0019]      FIG. 4  illustrates X-rays of a current linear plate fixed to a patient&#39;s humerus.  FIG. 4  further illustrates the linearality of the current plates. Use of the current linear plate will produce sub-optimal screw trajectory within the humeral head. If the surgeon attempts to position the distal section of the current linear plate sufficiently anterior to avoid the deltoid tuberosity, the proximal head of the plate will be correspondingly moved anterior. This de-optimizes screw trajectory within the humeral head. Obviously, poor screw placement, likely results in sub-optimal fixation of the current linear plate to the humerus H, and particularly to the head of humerus H, Phrased differently, and as illustrated in  FIG. 4 , the screws fixing current linear plates to the humeral bead obtain less purchase than is optimal. Screw trajectories that pass through more bone are generally thought to obtain better purchase, also referred to as fixation, to the bone, including bone of the humeral head. Generally speaking because of the shape of the humeral head, screw trajectories through the humeral head are preferred to be in the lateral to medial orientation to optimize fixation of the plate and screws. With current plates, to avoid disruption of the deltoid insertion and the deltoid tuberosity, the plate is placed more anterior than is optimal. As the plate is placed more anteriorly, the screws are more in the posterior surface of the humerus. This results in the screws in the humeral head being oblique, and results in screws that don&#39;t obtain appropriate fixation in the anterior portion of the humeral head. 
         [0020]    Current linear plates have various issues. First, installation of the current linear plates can require significant removal of the deltoid tuberosity and detachment of the deltoid. Second, not ail fractures will heal. If the fracture is treated with open reduction internal fixation with a plate, and the bone fails to heal appropriately, then a reverse total shoulder arthroplasty may be the appropriate treatment. A reverse total shoulder arthroplasty employs the intact function of the deltoid. Detachment of the deltoid can preclude use of a reverse total shoulder arthroplasty, in the event of the failure of surgery using the current plate to appropriately resolve the fracture of the humerus because of the fracture failing to heal. Third, and as discussed above, if the surgeon attempts to position the distal section of the current linear plate sufficiently anterior to avoid the deltoid tuberosity, the proximal head of the plate will be correspondingly moved anteriorly. This de-optimizes screw trajectory within the humeral head. Poor screw placement likely results in sab-optimal fixation of the current, linear plate to the humerus, and particularly to the head of humerus. Fourth, current plates typically have screw trajectories that run obliquely thought the humeral head from anterolateral to postromedial, rather than the more optimal true lateral to medial within the head. Current plates have all of the screw trajectories in essentially a single plane. Screw trajectories in more than one plane will provide greater strength and improved plate fixation. 
         [0021]    Current plates are linear, and only provide fixation in essentially a single plane. When current plates are placed anterior to the deltoid insertion, the screws have a poor trajectory within the humeral head. With anterior plate positioning, the screw trajectory limits screw fixation in the anterior portion of the humeral head, which is sub-optimal. When the current plates are placed laterally, the plates damage the deltoid insertion, where the deltoid muscle attaches to the humerus. 
         [0022]    The plate that is the subject of this patent application curves around the humerus where the proximal portion of the plate is on the lateral surface of the humeral head and the distal portion of the plate is on the anterior surface of the humeral shaft. The screws through the proximal portion have a true lateral to medial direction within the humeral head. This lateral to medial screw trajectory in the humeral head gives more optimal fixation by allowing screws be placed throughout the humeral head. The plate that is the subject of this patent application also has screws through the distal portion that have a trajectory in an anterior to posterior direction in the humeral shaft. The plate that is the subject of this patent application allows for the screws to obtain fixation in multiple planes. The curve of the plate allows the plate to avoid the deltoid tuberosity avoiding damage to the deltoid tendon and the deltoid insertion of the deltoid tuberosity. The curved portion also allows for oblique screws within the humeral metaphysis. The oblique metaphysis screws compliment the lateral to medial screws within the humeral head. The lateral to medial screw trajectory optimizes screw fixation within humeral head, while preserving the attachment of the deltoid muscle. In addition, the configuration allow the plate to extend down the entire length of the humerus allowing the plate to treat more complex fractures that extend into the humeral shaft without compromising the deltoid and avoiding potential damage to nerves, such as the radial nerve. 
       SUMMARY OF THE INVENTION 
       [0023]    A proximal humerus fracture plate for promoting healing of a fracture of a human humerus, comprising: an upper section having at least one screw hole for receiving an upper screw, the trajectory of the screw hole is a lateral to medial orientation; a transitional section having at least one screw hole for receiving a middle screw, the transitional section integral with the upper section and curved sufficiently to avoid a deltoid tuberosity, the middle screw to fix the transitional section along a lateral cortex of the humerus; and, a lower section having at least one screw hole for receiving a lower screw, the trajectory of the screw hole is an anterior to posterior orientation, the lower section integral with the transitional section. 
         [0024]    These and other embodiments will be more fully appreciated from the description below. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0025]      FIG. 1A  is a front view of a human skeleton. 
           [0026]      FIG. 1B  is a front view of a prior art current linear bone plate. 
           [0027]      FIG. 2  is a perspective view of a human humerus. 
           [0028]      FIG. 3  is a chart of the Neer system of classifying displaced proximal humeral fractures, 
           [0029]      FIG. 4  are X-rays of a current linear plate installed in a patient 
           [0030]      FIG. 5A  is a lateral view of a proximal humeral fracture plate for repairing a fracture of a patient&#39;s left humerus. 
           [0031]      FIG. 5B  is a lateral view of a proximal humeral fracture plate for repairing a fracture of the patient&#39;s right shoulder. 
           [0032]      FIG. 5C  is an anterior view of the proximal humeral fracture plate of  FIG. 5A . 
           [0033]      FIG. 5D  is an anterior view of the proximal humeral fracture plate of  FIG. 5B . 
           [0034]      FIG. 5E  is an anterior view of the proximal humeral fracture plate of  FIGS. 5A and 5C  fixed to the patient&#39;s left humerus. 
           [0035]      FIG. 5F  is a detailed view of a transitional section of the proximal humeral fracture plate shown in  FIGS. 5A and 5C . 
           [0036]      FIG. 5G  is a detailed view of the upper section of the proximal humeral fracture plate shown in  FIG. 5E . 
           [0037]      FIG. 5H  is a detailed view of the transitional section of the proximal humeral fracture plate shown in  FIG. 5F . 
           [0038]      FIG. 6A  is a lateral view of an alternative embodiment of the upper section of the proximal humeral fracture plate shown in  FIGS. 5A, 5B, 5C, 5D, 5E, 5F, 5G and 5H . 
           [0039]      FIG. 6B  is a side view of the alternative embodiment of the upper section of proximal humeral fracture plate shown in  FIG. 6A . 
           [0040]      FIG. 6C  is a side view of the alternative embodiment of the upper section of proximal humeral fracture plate shown in  FIG. 6A . 
           [0041]      FIG. 6D  is a detailed side view of the loop shown in  FIG. 6A . 
           [0042]      FIG. 7A  is a superior view of the proximal humeral fracture plate for repairing a fracture of a patient&#39;s left humerus. 
           [0043]      FIG. 7B  is a perspective view of the proximal humeral fracture plate shown in  FIG. 7A , An upper section of the proximal humeral fracture plate shown in  FIG. 7A  is illustrated in dashed lines. 
           [0044]      FIG. 7C  is a, perspective view of the proximal humeral fracture plate shown in  FIGS. 7A and 7B . 
           [0045]      FIG. 7D  is a perspective view of the proximal humeral fracture plate shown in  FIGS. 7A, 7B and 7C . 
           [0046]      FIG. 7D  is a perspective view of the proximal humeral fracture plate shown in  FIGS. 7A, 7B, and 7C . 
           [0047]      FIG. 7E  is a perspective view of the proximal humeral fracture plate shown in  FIGS. 7A, 7B, 7C and 7D . 
           [0048]      FIG. 7F  is a superior view of the proximal humeral fracture plate shown in  FIGS. 7A, 7B, 7C, 7D and 7E . 
           [0049]      FIG. 8  is a perspective view of an external targeting arm used to facilitate fixation of the proximal humeral plate to the patient&#39;s shoulder. 
       
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       [0050]    Corresponding reference numbers indicate corresponding parts throughout the several views of the drawings and specification. Corresponding reference numbers indicate corresponding parts throughout the several views of the drawings and specification. 
         [0051]      FIGS. 5A  illustrates a proximal humeral plate  10  for use on a patient&#39;s left shoulder. An upper section  20  has a screw hole  24  for receiving a screw to fix the proximal humerus plate to a head of the left humerus H. The trajectory of the screw hole  24  is a lateral to medial orientation. A transitional section  30  has holes  34  for receiving a screw  36  (not shown) to fix the transitional section along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid a deltoid tuberosity T (seen in  FIG. 2 ). A lower section  40  has screw holes  44  for receiving a screw  46  (not shown), the trajectory of screw hole  44  is an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . Preferably, plate  10  should be fixed to the shaft of humerus H distally using a non-locking screw through hole  56 . Preferably, hole  56  should be oblong to permit plate  10  to slide proximally or distally along humerus H before a screw  58  (not shown) is fully tightened to hold plate  10  in position. In other words, the non-locking screw  58  would compress plate  10  to humerus H to provide provisional fixation of plate  10 . It is preferable to compress plate  10  to humerus H such that there is no gap between humerus H and plate  10  and non-locking screws are preferred to compress plate  10  to humerus H. It has been found that surgeons may inadvertently fix plate  10  to humerus H with a gap between plate  10  and humerus H. This is undesirable and should be avoided. It has also been found that Kirschner wires [not shown] can be used to provisionally position plate  10 . Preferably, after plate  10  has been provisionally fixed to humerus H, locking screws will be used to fix plate  10  to humerus H. 
         [0052]      FIGS. 5B  illustrates a proximal humeral plate  10 ′ for use on a patient&#39;s right shoulder. Unlike linear plates, which are used for both the left and right humerus, plate  10 ′ is specific for use to the right shoulder and is, preferably, a mirror image of plate  10 . An upper section  20 ′ has screw hole  24 ′ for receiving a screw  26 ′ (not shown) to fix the proximal humerus plate to a head of the right humerus H. As with plate  10 , the trajectory of screw hole  24 ′ for plate  10 ′ is a lateral to medial orientation. A transitional section  30 ′ has screw holes  34 ′ for receiving a screw  36 ′ to fix transitional section  30 ′ along a lateral cortex of the right humerus H. Transitional section  30 ′ is integral with the upper section  20 ′ and curves sufficiently to avoid a deltoid tuberosity T. A lower section  40 ′ has screw holes  44 ′ for receiving a screw  46 ′. As with plate  10 , the trajectory of screw hole  44 ′ for plate  10 ′ is an anterior to posterior orientation. Lower section  40 ′ is integral with the transitional section  30 ′. Preferably, plate  10 ′ should be fixed to the shaft of humerus H distally using a non-locking screw  58 ′ (not shown) through hole  56 ′. Preferably, hole  56 ′ should be oblong to permit plate  10 ′ to slide proximally or distally along humerus H before screw  58 ′ is fully tightened to hold plate  10 ′ in position. In other words, the non-locking surgical screw  58 ′ would provisionally fix plate  10 ′ to right humerus H to provide provisional fixation of plate  10 ′ to humerus H and thereby hold plate  10 ′ against humerus H. It is preferable to compress plate  10 ′ to humerus H such that there is no gap between humerus H and plate  10 ′ and non-locking screw  58 ′ are preferred to compress plate  10 ′ to humerus H. It has been found that surgeons may inadvertently fix plate  10 ′ to humerus H with a gap between plate  10 ′ and humerus H. As discussed above, this is undesirable and should be avoided. As also discussed above, preferably, after plate  10 ′ has been provisionally fixed to humerus H, locking screws will be used to fix plate  10  to′ humerus H. 
         [0053]    Preferably, non-locking screws should be used in oval screw holes and locking screws should be used with circular screw holes. 
         [0054]      FIG. 5C  illustrates plate  10  with screws  26  and  36  inserted into holes  24  and  34 , respectively. As discussed above, the trajectory of the screws  26  for holes  24  is a generally lateral to medial orientation. Phrased differently, screws  26  transit the head of humerus H in a generally lateral to medial orientation. As also discussed above, the trajectory of screws  36  fixes the transitional section  30  of plate  10  along a lateral cortex of the humerus H. Screws  46  are inserted into holes  44  and have a generally anterior to posterior trajectory. 
         [0055]      FIG. 5D  illustrates plate  10 ′ with surgical screws  26 ′ and  36 ′ inserted into holes  24 ′ and  34 ′, respectively. As discussed above, the trajectory of the screws for holes  24 ′ is a generally lateral to medial orientation. As also discussed above, the trajectory of screws  36 ′ fixes the transitional section  30 ′ of plate  10 ′ along a lateral cortex of the humerus H. Screws  46 ′ are inserted into holes  44 ′ and have a generally anterior to posterior trajectory. 
         [0056]      FIG. 5E  illustrates plate  10  fixed to left humerus H. For purposes of the present application, both the left humerus and the right humerus are referred to as humerus H. Screws  26  and  36  (shown in dashed lines) are inserted into holes  24  and  34  to fix plate  10  to humerus H.  FIG. 5E  also illustrates that upper section  10  is fixedly attached to the head of humerus H. Optimally, upper section  20  would start just distal to the tip of the greater tuberosity (seen in  FIG. 2 ) and would run along the lateral cortex of humerus H to allow for lateral to medial screw placement in the head of humerus H. Plate  10  would then curve anteriorly such that transitional section  30  would avoid deltoid tuberosity T. Transitional section  30  is fixed to the distal portion of humerus H. As illustrated in  FIG. 5D , transitional section  30  would curve plate  10  anteriorly to avoid damage to the deltoid tuberosity T. Alternatively, the deltoid tuberosity T may also be referred to as the deltoid insertion. Irrespective of which word is used to describe this boney structure, the tuberosity T is where the deltoid muscle attaches to the humerus H.  FIG. 5E  also illustrates that upper section  20  is fixed to the head of humerus H and that the trajectory of screws  26  passing through upper section  20  are in a lateral to medial orientation.  FIG. 5E  also illustrates transitional section  30 . Transitional section  30  has screw holes  34  for receiving screws  36  to fix the transitional section along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid a deltoid tuberosity T. Lower section  40  has screw holes  44  for receiving screws  46  (not shown), the trajectory of the screws are in an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . 
         [0057]      FIG. 5F  illustrates a detailed view of transitional section  30  curving anteriorly to avoid damage to the deltoid insertion. A portion of lower section  40  is illustrated and screw  46  and screw hole  44  can be seen in  FIG. 5F .  FIG. 5F  also illustrates screw holes  34  therethrough transitional section  30 . Screws  36  fix transitional section  30  along the lateral cortex of the humerus H and support bone repair and healing. 
         [0058]      FIG. 5G  also illustrates an imaginary dashed line reflecting that plate  10  is preferably positioned such that the top of upper section  20  is flush with the top of humerus H and does not project above the top of humerus H. If this mis-placement occurs, plate  10  may impinge on the patient&#39;s acromion. This is undesirable because it may prevent appropriate rotation of the patient&#39;s arm or damage the patient&#39;s acromion or other tissue. It can result in patient pain or discomfort and also limit the range of motion of the patient&#39;s shoulder. These are undesirable outcomes. 
         [0059]      FIG. 5H  illustrates that hole  56  of plate  10  can be used to adjust the position of plate  10  upwardly or downwardly before fixation of plate  10  to humerus B, For example, when initially placed, plate  10  might be located such that the top of upper section  20  projects above the top of humerus H. As discussed above, this is undesirable. Screw  58  is shown in dashed lines to reflect the relative positions of plate  10  and screw  58  in this undesirable plate placement. If this situation occurs, the surgeon would likely elect to slide plate  10  downwardly until the top of upper section  20  is flush with the top of humerus H, as seen in  FIG. 5G , and does not project above the top of humerus H. For example, after plate  10  is slide downwardly, screw  58 , now shown in solid, would be in a different relative position within hole  56 . After plate  10  is appropriately positioned, screw  58  could be tightened to fix plate  10  to humerus H. 
         [0060]      FIGS. 6A, 6B and 6C  illustrate the alternative embodiment of plate  10  further comprising loops  62 . Loops  62  allow suture fixation of the rotator cuff to plate  10 .  FIG. 6A  illustrates that a suture S can readily pass through loops  62 .  FIGS. 6B and 6C  illustrate that, optimally, upper section  20  will be sufficiently concave to generally conform to the convex outer shape of a head of humerus H and also appropriate positions for loops  62 . Loops  62  could be used in conjunction with one plate, for example plate  10  or  10 ′, or both plates could have loops  62 .  FIG. 6B  also illustrates that screws  26  can be locking screws. As seen by the left most screw  26 , which for purposes of illustration, is slightly withdrawn from screw hole  24  to illustrate that screws  26  can be locking screws or non-locking screws. 
         [0061]      FIG. 6D  illustrates loop  62  and further emphasizes that suture can readily pass through loop  62  and that top of the arch of loop  62  is positioned above upper plate  20 . Of course, loop  62  does not have to be arched and this is merely an illustrative example. Irrespective of the shape of loop  62 , suture should be able to readily pass therethrough. 
         [0062]      FIG. 7A  illustrates a top view of plate  10  fixed to humerus H. Upper section  20  has screw holes  24  for receiving a screw  26  to fix the proximal humerus plate to a head of the left humerus H. As discussed above, the trajectory of the screws  26  are a lateral to medial orientation. While not visible in  FIG. 7A , transitional section  30  has holes  34  for receiving screws  36  to fix the transitional section along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid a deltoid tuberosity T. A lower section  40 , which is also not visible in  FIG. 7A , has screw holes  44  for receiving screws  46 , the trajectory of screws  46  is an anterior to posterior orientation. 
         [0063]      FIG. 7B  illustrates a medial view of plate  10  fixed to humerus H. In  FIG. 7B , upper section  20  is positioned laterally on humerus H and is not visible because, from this viewing position, it is on the opposite side of humerus H. While upper section  20  is not visible (and therefore shown in dashed), the trajectories of screws  26  are generally in a lateral to medial orientation. Screw holes  34  receive screws  36  to fix the transitional section along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid a deltoid tuberosity T. Lower section  40  has screw holes  44  for receiving screws  46 , the trajectory of screws  46  is an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . 
         [0064]      FIG. 7C  illustrates an anterior view of plate  10  fixed to humerus H. As discussed above, plate  10  has upper section  20 , transitional section  30  and lower section  40 . As also discussed above upper section  20  has holes  24  that receive screws  26  the trajectories of screws  26  are in a lateral to medial orientation. Screw holes  34  receive screws  36  to fix the transitional section  30  along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid deltoid tuberosity T. Lower section  40  has screw holes  44  for receiving screws  46 , the trajectory of screws  46  is an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . It is particularly apparent from  FIG. 7C  that screws  26 ,  36  and  46  do not have the same trajectories. 
         [0065]      FIG. 7D  illustrates a lateral view of plate  10  fixed to humerus H. As discussed above, plate  10  has upper section  20 , transitional section  30  and lower section  40 . As also discussed above upper section  20  has holes  24  that receive screws  26  the trajectories of screws  26  are in a lateral to medial orientation. Screw holes  34  receive screws  36  to fix the transitional section  30  along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid deltoid tuberosity T. Lower section  40  has screw holes  44  for receiving screws  46 . The trajectory of the screws  26  are in an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . It is particularly apparent from  FIG. 7D  that screws  26 ,  36  and  46  do not have the same trajectories. 
         [0066]      FIG. 7E  illustrates a posterior view of plate  10  fixed to humerus H. As discussed above, plate  10  has upper section  20 , transitional section  30  and lower section  40 . As also discussed above, upper section  20  has holes  24  that receive screws  26 . The trajectories of screws  26  are in a lateral to medial orientation. Screw holes  34  receive screws  36  to fix the transitional section  30  along a lateral cortex of the humerus H. Transitional section  30  is integral with the upper section  20  and is curved sufficiently to avoid deltoid tuberosity T. Lower section  40  has screw holes  44  for receiving screws  46 , the trajectory of screws  46  are in an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . It is particularly apparent from  FIG. 7E  that screws  26 ,  36  and  46  do not have the same trajectories. 
         [0067]      FIG. 7F  illustrates a superior view of plate  10  fixed to humerus H. As discussed above, plate  10  has upper section  20 , transitional section  30  (not shown in  FIG. 7F ) and lower section  40 . As also discussed above, upper section  20  has holes  24  (not shown in  FIG. 7F ) that receive screws  26 , the trajectories of screws  26  are in a lateral to medial orientation. Lower section  40  has screw holes  44  (not shown in  FIG. 7F ] for receiving screws  46 . The trajectory of screw holes  24  and screws  26  are in an anterior to posterior orientation. Lower section  40  is integral with the transitional section  30 . It is particularly apparent from  FIG. 7F  that screws  26  and  46  do not have the same trajectories and are preferably perpendicular to each other. Screws  36  are not shown in  FIG. 7F . 
         [0068]      FIG. 8  illustrates an external targeting arm  90  is used to facilitate fixation of the proximal humeral plate  10  to the patient&#39;s shoulder. External targeting arm  90  has locking guide  92  and driver  94 . In order to place screw  26  through screw holes  24 , the surgeon makes a small incision through the deltoid to access plate  10 . Locking guide  92  is passed therethrough the deltoid and mates with screw hole  24  to form a pathway to guide screw  26  such that screw  26  cars be used to fix plate  1 . 0  to the patient&#39;s humerus. This process can be repeated to allow the surgeon to place sufficient screws  26 ,  36  and  46  to appropriately fix plate  10  to humerus H. Typically, the surgeon&#39;s screw placement can be guided fluroscopically or any other alternative means. This is preferred because the deltoid is not required to be detached for this process. In addition, the patient&#39;s arm is not, generally speaking, moved or rotated to place screws  26 ,  36 ,  46 . As discussed above, movement of the patient&#39;s arm can negatively affect the surgery because it can result in loss of reduction. 
         [0069]    When referring to the trajectory or orientation of screws or screw holes, it should be understood that trajectory or orientation is not exact and that screws or screw holes that are generally in a particular trajectory or orientation are within this description. For example, in  FIG. 7F , screws  26  are generally in a lateral to medial orientation or trajectory. Because screws  26  are generally in a lateral to medial orientation, they are considered to have a lateral to medial orientation. The same holds true for other screws and screw holes of this application. As discussed above, upper section  20  has holes  24  that receive screws  26 . The trajectories of screws  26  are in a lateral to medial orientation. However, screws  26  may be angled slightly such that they are not exactly co-linear with the lateral to medial orientation of screw hole  24 . Screw holes  34  receive screws  36  to fix the transitional section  30  along a lateral cortex of the humerus H. As with screws  26 , screws  36  may be slightly angled. Lower section  40  has screw holes  44  for receiving screws  46 , the trajectory of screws  46  are in an anterior to posterior orientation. As with screws  26  and  36 , screws  46  may be slightly angled. Lower section  40  is integral with the transitional section  30 . While the orientation of the trajectory of screw holes  24 ,  34  and  33  have been described, screw holes  24 ,  34  and  44  are sized such that screws  26 ,  36  and  46  can be angled to have a path that is five, ten or even fifteen degrees or more from the orientation of the trajectory of the respective screw hole that the screw passes therethrough. Phrased differently, as seen in  FIG. 7B , screws  46  are not parallel because each screw  46  has been angled slightly differently through its respective screw hole  44 . 
         [0070]    While the invention has been illustrated and described in detail in the drawings and description, the same is to be considered as an illustration and is not limited to the exact embodiments shown and described. All equivalents, changes and modifications that come within the spirit of the invention are also protected by the claims that are set forth below.