Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 11-A3 Open reduction; plate fixation

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Glossary

1 A3.1: Principles top

Reduction technique
For A3 fractures generally, the most appropriate reduction technique will depend upon the fracture morphology.
A3.1 (medial hinge intact):

  • Fix plate to the humeral head and use it as reduction aid
  • Reduce and fix the shaft to the plate

Proper reduction
After reduction, both, the sagittal and the coronal plane should be correct. Particular attention should be paid to the correct rotation.
 
Correct plate position
A correct plate position must be ensured in order to avoid loss of reduction and impingement.


Standard plates provide an alternative option, for example the modified cloverleaf plate (B). enlarge

Angular stable versus standard plates

This procedure describes proximal humeral fracture fixation with an angular stable plate (A). Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf plate (B). Presently, the specific indications, advantages, and disadvantages of angular stable and standard plates are being clarified. There is some evidence that angular stable plate provide better outcomes. In addition to type and technique of fixation, the quality of reduction, the soft-tissue handling, and the characteristics of the injury and patient significantly influence the results. There is no evidence that the use of angular stable plates will overcome these other factors.

2 A3.1: Insert sutures top

Insert holding sutures through the insertions of the subscapularis, supraspinatus, and infraspinatus tendon. enlarge

Insert holding sutures through the insertions of the subscapularis, supraspinatus, and infraspinatus tendon.

3 A3.1: Plate position top

Correct plate position enlarge

Correct plate position

The correct plate position is:

  1. about 5-8 mm distal to the top of the greater tuberosity
  2. aligned properly along the axis of the humeral shaft 
  3. slightly posterior to the bicipital grove (2-4 mm)

To confirm a correct axial plate position insert a K-wire through the proximal hole of the insertion guide. enlarge

Confirmation of correct plate position
The correct plate position can be checked by palpation of its relationship to the bony structures and also confirmed by image intensification.

To confirm a correct axial plate position insert a K-wire through the proximal hole of the insertion guide. The K-wire should rest on the top of the humeral head.


Pitfall: plate too close to the bicipital groove enlarge

Pitfall 1: plate too close to the bicipital groove
The bicipital tendon and the ascending branch of the anterior humeral circumflex artery are at risk if the plate is positioned too close to the bicipital groove. (The illustration shows the plate in correct position, posterior to the bicipital groove).


Pitfall: plate too proximal enlarge

Pitfall 2: plate too proximal
A plate positioned too proximal carries two risks: 

  1. The plate can impinge the acromion
  2. The most proximal screws might penetrate or fail to securely engage the humeral head

4 A3.1: Attaching the plate to the humeral head top

Use an appropriate sleeve to drill holes for the humeral head screws. enlarge

The plate is fixed on the lateral side of the humeral head with locking-head screws.

Drill holes
Use an appropriate sleeve to drill holes for the humeral head screws. Do not drill through the subchondral bone and into the shoulder joint.


If the plate is properly positioned, the screws will be placed correctly in the humeral head. enlarge

If the plate is properly positioned, the screws will be placed correctly in the humeral head. If there is any question about plate positioning (eg, very short proximal segment) confirm proper placement with two K-wires inserted through wire guides before inserting screws.


“Woodpecker”-drilling technique enlarge

Avoiding intraarticular screw placement
Screws that penetrate the humeral head may significantly damage the glenoid cartilage. Primary penetration occurs when the screws are initially placed. Secondary penetration is the result of subsequent fracture collapse. Drilling into the joint increases the risk of screws becoming intraarticular.

Two drilling techniques help to avoid drilling into the joint.

Pearl 1: “Woodpecker”-drilling technique (as illustrated)
In the woodpecker-drilling technique, advance the drill bit only for a short distance, then pull the drill back before advancing again. Keep repeating this procedure until subchondral bone contact can be felt. Take great care to avoid penetration of the humeral head.

Pearl 2: Drilling near cortex only
Particular in osteoporotic bone, one can drill only through the near cortex. Push the depth gauge through the remaining bone until subchondral resistance is felt.


Determine screw length enlarge

Determine screw length
The intact subchondral bone should be felt with a depth gauge or blunt pin to ensure that the screw stays within the humeral head. The integrity of the subchondral bone can be confirmed by palpation or the sound of the instrument tapping against it. Typically, choose a screw slightly shorter than the measured length.



Insert a locking-head screw through the screw sleeve into the humeral head. enlarge

Insert screw
Insert a locking-head screw through the screw sleeve into the humeral head. The sleeve aims the screw correctly. Particularly in osteoporotic bone, a screw may not follow the hole that has been drilled.


Place a sufficient number of screws into the humeral head. enlarge

Number of screws and location
Place a sufficient number of screws into the humeral head. At this stage, only four screws are sufficient to fix the plate and allow for reduction using the plate. After reduction has been achieved, further screws might be inserted into the humeral head. Bone quality and fracture morphology should be considered. In osteoporotic bone a higher number of screws may be required.

5 A3.1: Reduction and fixation of the plate to the humeral shaft top

The plate is used as a handle to reduce the humeral head towards the shaft. enlarge

Use the plate as reduction aid
The plate is used as a handle to reduce the humeral head towards the shaft. It must be attached correctly to the humeral head before this is done. Provisional K-wire fixation using K-wire guides can help with this as demonstrated above.


Once preliminary reduction is achieved a bicortical non-locking screw inserted through the elongated hole. enlarge

Once preliminary reduction is achieved a bicortical non-locking screw is inserted through the elongated hole. Make sure to insert the screw perpendicular to the humeral shaft.

By tightening this screw in the humeral shaft, the malpositioned humeral head will be aligned to the humeral shaft, thus achieving a correct reduction.


Option: preliminary fracture fixation with K-wires enlarge

Option: preliminary fracture fixation with K-wires
As an alternative to reducing the fracture with a plate, an open reduction can be performed manually and temporarily secured using 2 K-wires. Make sure to place them from anterior in order to avoid interference with the foreseen plate position.


Confirm proper rotational alignment enlarge

Confirm proper rotational alignment
Correct rotational alignment must be confirmed. This can be done by matching the fracture configurations on both sides of the fracture. This would be useful in the more transverse fracture configuration as shown in the illustration.

Pearl: check retroversion
The bicipital groove might be a good indicator for correct rotation. In case of correct rotation, no gap/angulation is visible at the level of the fracture.

Remember that the humeral head is normally retroverted, facing approximately 25° posteriorly (mean range: 18°-30°) relative to the distal humeral epicondylar axis. This axis is perpendicular to the forearm with the elbow flexed to 90°.

Confirmation of overall reduction
The correct reduction must be confirmed by image intensification in both AP and lateral views.


Insert one or two additional bicortical screws into the humeral shaft. enlarge

Insert additional screws

Insert one or two additional bicortical screws into the humeral shaft. Additional screws might also be inserted into the humeral head.


Secure the tendons of the rotator cuff with additional tension band sutures through the small holes in the plate. enlarge

Supplementary rotator cuff tendon sutures

Secure the tendons of the rotator cuff (subscapularis, supraspinatus, infraspinatus) with additional tension band sutures through the small holes in the plate.


A common mistake seen is inadequate reduction. enlarge

Pitfall: inadequate reduction
A common mistake is inadequate reduction. Residual varus malalignment often results in further (secondary) displacement with varus malunion or fixation failure and possible nonunion.


Using image intensification, carefully check for correct reduction and fixation at various arm positions. enlarge

Final check of osteosynthesis

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. enlarge

Also obtain an axial view.


In the beach chair position, the C-arm must be directed appropriately for orthogonal views. enlarge

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.

6 A3.2/.3: Principles top

Reduction technique
For A3 fractures generally, the most appropriate reduction technique will depend upon the fracture morphology.

A3.2 and A3.3 (medial hinge disrupted/medial comminution)
Reduce a medially displaced fracture by pulling the humeral shaft to the plate by tightening an initial bicortical non-locking screw in the humeral shaft.

Proper reduction
Achieving proper reduction may be very demanding due to the characteristic metaphyseal instability of A3.2 and A3.3 fractures. Comminuted (A3.3 fractures) may be reduced appropriately by using the laterally applied plate as a model for an appropriate reduction. The plate is first attached distally and then brought into contact with the comminuted zone and proximal segment, to which it is affixed. Once initially stabilized, confirm satisfactory reduction before insertion of all the planned screws.
After reduction, both, the sagittal and the coronal plane should be correct. Particular attention should be paid to the correct rotation.
 
Correct plate position
A correct plate position must be ensured in order to avoid loss of reduction and impingement.


Standard plates provide an alternative option, for example the modified cloverleaf plate (B). enlarge

Angular stable versus standard plates
This procedure describes proximal humeral fracture fixation with an angular stable plate (A). Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf plate (B). Presently, the specific indications, advantages, and disadvantages of angular stable and standard plates are being clarified. There is some evidence that angular stable plate provide better outcomes. In addition to type and technique of fixation, the quality of reduction, the soft-tissue handling, and the characteristics of the injury and patient significantly influence the results. There is no evidence that the use of angular stable plates will overcome these other factors.

7 A3.2/.3: Insert sutures top

Insert holding sutures through the insertions of the subscapularis, supraspinatus, and infraspinatus tendon. enlarge

Insert holding sutures through the insertions of the subscapularis, supraspinatus, and infraspinatus tendon.

8 A3.2/.3: Reduction and preliminary fixation top

Attempt to reduce A3.2/.3 fractures with distal traction on the arm. enlarge

Reduction

Attempt to reduce A3.2 and A3.3 fractures with distal traction on the arm. In transverse A3.2 fractures, proper placement of the shaft against the proximal fragment may be stable. An oblique or comminuted fracture (A3.3) is usually unstable.
If there is medial comminution, special attention must be paid to prevent varus malalignment.


In A3.2 and A3.3 fractures, the fracture is preferably reduced with the help of the plate. enlarge

Use the plate as reduction aid
In A3.2 and A3.3 fractures, the fracture is preferably reduced with the help of the plate. This is most effective when the shaft is medially displaced or the fracture is in valgus malalignment. As illustrated, the plate is positioned on the lateral side of the humeral shaft. A single non-locking screw is placed perpendicularly into the shaft.

By tightening this screw, the humeral shaft will be pulled toward the plate. This maneuver “fine-tunes” the reduction.


Confirm proper rotational alignment. enlarge

Confirm proper rotational alignment
Correct rotational alignment must be confirmed. This can be done by matching the fracture configurations on both sides of the fracture. This would be useful in the more transverse fracture configuration as shown in the illustration.

Pearl: check retroversion
The bicipital groove might be a good indicator for correct rotation. In case of correct rotation, no gap/angulation is visible at the level of the fracture.

Remember that the humeral head is normally retroverted, facing approximately 25° posteriorly (mean range: 18°-30°) relative to the distal humeral epicondylar axis. This axis is perpendicular to the forearm with the elbow flexed to 90°.

Confirmation of overall reduction
The correct reduction must be confirmed by image intensification in both AP and lateral views.

9 A3.2/.3: Plate position top

Correct plate position enlarge

Correct plate position

The correct plate position is:

  1. about 5-8 mm distal to the top of the greater tuberosity
  2. aligned properly along the axis of the humeral shaft 
  3. slightly posterior to the bicipital grove (2-4 mm)

Confirmation of correct plate position enlarge

Confirmation of correct plate position
The correct plate position can be checked by palpation of its relationship to the bony structures and also confirmed by image intensification.

To confirm a correct axial plate position insert a K-wire through the proximal hole of the insertion guide. The K-wire should rest on the top of the humeral head.


Pitfall: plate too close to the bicipital groove enlarge

Pitfall 1: plate too close to the bicipital groove
The bicipital tendon and the ascending branch of the anterior humeral circumflex artery are at risk if the plate is positioned too close to the bicipital groove. (The illustration shows the plate in correct position, posterior to the bicipital groove).


Pitfall: plate too proximal enlarge

Pitfall 2: plate too proximal
A plate positioned too proximal carries two risks: 

  1. The plate can impinge the acromion
  2. The most proximal screws might penetrate or fail to securely engage the humeral head

10 A3.2/.3: Plate fixation top

Use an appropriate sleeve to drill holes for the humeral head screws. enlarge

Fix plate to the humeral head

Drill holes
Use an appropriate sleeve to drill holes for the humeral head screws. Do not drill through the subchondral bone and into the shoulder joint.


“Woodpecker”-drilling technique enlarge

Avoiding intraarticular screw placement
Screws that penetrate the humeral head may significantly damage the glenoid cartilage. Primary penetration occurs when the screws are initially placed. Secondary penetration is the result of subsequent fracture collapse. Drilling into the joint increases the risk of screws becoming intraarticular.

Two drilling techniques help to avoid drilling into the joint.

Pearl 1: “Woodpecker”-drilling technique (as illustrated)
In the woodpecker-drilling technique, advance the drill bit only for a short distance, then pull the drill back before advancing again. Keep repeating this procedure until subchondral bone contact can be felt. Take great care to avoid penetration of the humeral head.

Pearl 2: Drilling near cortex only
Particular in osteoporotic bone, one can drill only through the near cortex. Push the depth gauge through the remaining bone until subchondral resistance is felt.


Determine screw length enlarge

Determine screw length
The intact subchondral bone should be felt with a depth gauge or blunt pin to ensure that the screw stays within the humeral head. The integrity of the subchondral bone can be confirmed by palpation or the sound of the instrument tapping against it. Typically, choose a screw slightly shorter than the measured length.


Insert a locking-head screw through the screw sleeve into the humeral head. enlarge

Insert screw
Insert a locking-head screw through the screw sleeve into the humeral head. The sleeve aims the screw correctly. Particularly in osteoporotic bone, a screw may not follow the hole that has been drilled.


Place a sufficient number of screws (often 5) into the humeral head. enlarge

Number of screws and location
Place a sufficient number of screws (often 5) into the humeral head. The optimal number and location of screws has not been determined. Bone quality and fracture morphology should be considered. In osteoporotic bone a higher number of screws may be required.


It is strongly recommended to use “calcar screws” in all varus displaced fractures, especially, if there is medial comminution. enlarge

Calcar screws
It is strongly recommended to use “calcar screws” in all varus displaced fractures, especially, if there is medial comminution (A3.3). Their purchase in the inferomedial humeral head adds mechanical stability.


Insert one or two additional bicortical screws into the humeral shaft. enlarge

Insert additional screws into the humeral shaft

Insert one or two additional bicortical screws into the humeral shaft.


Secure the tendons of the rotator cuff with additional tension band sutures through the small holes in the plate. enlarge

Supplementary rotator cuff tendon sutures

Secure the tendons of the rotator cuff (subscapularis, supraspinatus, infraspinatus) with additional tension band sutures through the small holes in the plate.


A common mistake seen is inadequate reduction. enlarge

Pitfall: inadequate reduction
A common mistake is inadequate reduction. Residual varus malalignment often results in further (secondary) displacement with varus malunion or fixation failure and possible nonunion. 


This illustration shows the completed osteosynthesis for a A3.3 fracture using calcar screws. enlarge

Completed osteosynthesis

This illustration shows the completed osteosynthesis for a A3.3 fracture using calcar screws.


Using image intensification, carefully check for correct reduction and fixation at various arm positions. enlarge

Final check of osteosynthesis

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. enlarge

Also obtain an axial view.


In the beach chair position, the C-arm must be directed appropriately for orthogonal views. enlarge

In the beach chair position, the C-arm must be directed appropriately for orthogonal views.

11 Use of standard plates top

If no angular stable plate is available, a standard plate provides an alternative. The described procedure (reduction, ... enlarge

If no angular stable plate is available, a standard plate provides an alternative. The described procedure (reduction, preliminary fixation, and rotator cuff sutures) is essentially the same for standard plates, except for the screws. A good choice from the standard plates is the small fragment cloverleaf plate, with its tip cut off, and contoured as necessary. This plate allows multiple small fragment screws for the humeral head.

Be aware that angular stable implants provide better fixation, especially in osteoporotic bone. On the other hand, even angular stable plates are not a substitute for good surgical technique and judgment. Advances in fracture classification, understanding of the blood supply, use of rotator cuff tendon sutures, anatomical fracture reduction, and provisional fixation, represent improvements in care. When combined with optimal implants, these contributions offer the best chance of a good outcome.

v2.0 2011-05-02