1 Principles top
Shoulder pain and impingement are common with significant prominence of the greater tuberosity. Displacement of greater than 5 mm is currently recommended as the main indication for reduction and fixation.
2 Reduction of the glenohumeral joint top
Reduction of the glenohumeral joint should be performed as an emergency procedure.
There are various techniques to reduce the glenohumeral joint.
- Combined traction technique
- Modified Stimson technique
Unless reduction is carried out very soon after dislocation, analgesia or anesthesia are typically necessary. An initial attempt with conscious sedation may succeed. If not, general anesthesia with complete muscle relaxation may be required. If closed reduction is unsuccessful, open reduction may be necessary.
Combined traction technique
The patient is placed supine on a table. The injured arm is pulled longitudinally and, with the help of a second person, laterally as well.
A sheet around the chest may be used for counter-traction.
Modified Stimson technique
In the modified Stimson technique the patient is placed prone with the shoulder beyond the lateral edge of the table. A weight is attached to the wrist. Over time the musculature becomes fatigue and/or relaxed so that the humeral head reduces spontaneously, or with gentle manipulation.
Confirmation of reduction
The reduction is confirmed by x-ray. One should pay special attention to obtain a true AP view in order to confirm the glenohumeral reduction. Look carefully at the greater tuberosity, and determine its degree of displacement accurately.
3 Reduction and preliminary fixation of the greater tuberosity topenlarge
Insert stay sutures through the supraspinatus, and if necessary, the infraspinatus tendon.
Cleaning the fracture bed
Clean the fracture bed and remove any hematoma. Prepare the margin of the fracture by removing or reflecting the periosteum, 2 or 3 mm back from the fracture line.
Reduce the greater tuberosity properly by pulling on the stay suture(s). Be careful not to fragment the tuberosity with bone holding clamps.
Once the fragment is at the correct level, rotate the arm so that the fragment can fit anatomically into the bony defect.
Temporarily secure the reduction with 1 or 2 K-wires.
4 Fixation topenlarge
There are several techniques to fix the greater tuberosity. The choice depends on
- Size of the fragment
- Bone quality (osteoporosis)
- Degree of fragmentation
A) Screw fixation (cannulated or standard screws; with or without washers)
This is mainly indicated for single large fragment with good bone quality.
B) Tension band sutures
Tension band sutures are more secure for patients with osteoporosis or comminution because they can be placed through tendon insertion sites, which may be stronger than the bone itself. The sutures can be placed in patterns that are optimal for stabilizing comminuted fractures.
Distal anchorage of tension band sutures can be through an anterior to posterior drill hole in the humerus (B1), to screws (B2), through suture anchors, or through the lateral cortex of the humerus just distal to the fracture site. Combinations of these techniques are possible.
Insert a 3.5 mm lag screw. The lag screw should engage the medial cortex, distal to the articular surface. Cannulated screws may also be used.
Note: washers may make the screw heads more prominent and may result in shoulder impingement. Washers may be less problematic with more distally placed screws.
Check the fixation under image intensifier control.
If possible, insert a second lag screw in order to achieve rotational stability.
Note: make sure to avoid the axillary nerve by placing the second screw rather proximal.
Once the lag screw(s) are inserted, the K-wire(s) used for temporary fixation, and any stay sutures, should be removed.
Tension band suture
The most secure anchorage for a tension band suture is in the rotator cuff tendon, just before it inserts into the bone. Pass the needle parallel to the bone, picking up a good bite of tendon. In osteoporotic patients, these sutures are stronger than when placed through the bone.
Distal anchorage – drill hole
Distal anchorage can be done through a drill hole, typically horizontal.
Use a 2.0 mm drill bit to prepare the drill hole and a suture passer as needed.
The suture is passed, shown here in a figure-of-eight fashion through the bore hole and tied securely. The suture should be passed to stabilized comminution as needed.
Distal anchorage - screw
Pass the suture through a washer and the washer over a cortex screw. The screw is then placed into the neck region.
Note: be aware of the axillary nerve when inserting the screw.
The suture is then tightened and tied.
Using a screw rather than a drill hole for anchoring has the advantage of less space and a smaller approach required.
Alternative: intraosseous sutures
Sutures can be placed through the rotator cuff tendon, and around a small tuberosity fragment, so the suture lies deep to the fragment and over it. Distal suture anchorage is here shown with monocortical drill holes, through the humeral cortex distal to the tuberosity fragment. Several such sutures should be placed to increase stability.
Once the sutures are placed, the tuberosity fragment is reduced and stabilized with K-wires.
Then, the sutures are tied individually to secure the fragment.
Option: the sutures could be placed as mattress sutures through the tendon proximal to the tuberosity fragment.
Note the monocortical drill holes through which the sutures are anchored distally.
Tension band suture with proximal suture anchors
Especially in osteoporotic bone and/or multifragmentary tuberosities, additional suture anchors are helpful. If suture anchors are used, they have to be inserted prior to reduction
The suture anchor is placed directly into the margin of the fracture as close as possible to the articular cartilage.
The sutures are then passed through the supraspinatus tendon, close to the medial insertion line of the supraspinatus.
Reduce the greater tuberosity anatomically and secure it temporarily with one or two K-wires. Tighten and tie the sutures of the suture anchors.
Distal fixation is illustrated here to a screw below the tuberosity fragment as shown previously.
Pass the sutures through the washer of a screw inserted in the metaphyseal region distal to the fragment greater tuberosity to anchor the tension ban. Tighten the suture to hold the tuberosity and fragment in place and to counteract the pull of the rotator cuff. Remove the inserted K-wires.
Combination of lag screw fixation and tension band suturing
The beneficial effect of tension band suturing can be combined with screw osteosynthesis.
Repair of rotator cuff interval
Place several additional sutures or a running suture to close the lateral portion of the rotator cuff interval between the supraspinatus and subscapularis tendons. Any rotator cuff tear identified should also be repaired.
5 Final check of osteosynthesis topenlarge
Using image intensification, carefully check for correct reduction and fixation (including proper implant position and length) at various arm positions. Ensure that screw tips are not intraarticular.
Also obtain an axial view.
In the beach chair position, the C-arm must be directed appropriately for orthogonal views. Position arm as necessary to confirm that reduction is satisfactory, fixation is stable, and no screw is in the joint.