Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 11-B2 Open reduction; plate fixation

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Glossary

1 Principles top

The greater tuberosity is typically displaced posterosuperiorly due to the pull of the rotator cuff. enlarge

Proper reduction

The greater tuberosity is typically displaced posterosuperiorly due to the pull of the rotator cuff. The humeral head is typically rotated posteriorly due to the pull of the subscapularis tendon on the intact lesser tuberosity. Both aspects of deformity have to be corrected precisely. If there is a valgus/varus malposition of the humeral head this has to be corrected to allow a proper reduction of the greater tuberosity.


Placing and tensioning horizontal sutures helps reduce and stabilize the free tuberosity fragment. enlarge

Suture fixation of the separated tuberosity

Placing and tensioning horizontal sutures helps reduce and stabilize the free tuberosity fragment.


Sutures placed through the insertions of each rotator cuff tendon increase stability, and should also be used. enlarge

Tension band sutures in addition to plate and screws

Sutures placed through the insertions of each rotator cuff tendon increase stability, and should be used as well as the plate and screws, particularly for more comminuted and/or osteoporotic fractures. With osteoporotic bone, the tendon insertion is often stronger than the bone itself, so that sutures placed through the insertional fibers of the tendon may hold better than screws or sutures placed through bone.
These additional sutures are typically the last step of fixation.


In B2.3 fractures, it is necessary to restore the medial column as well as possible. enlarge

Medial calcar comminution

In B2.3 fractures (with medial metaphyseal comminution), it is necessary to restore the medial column as accurately as possible. Restoring a medial bony buttress helps avoid varus collapse.

It is also crucial to reduce the humeral head adequately since the combination of remaining varus displacement and medial comminution predisposes to secondary varus collapse and/or implant failure.


Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf. 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 Reduction and preliminary fixation top

Goals of reduction

The goal of reduction is to restore the normal location of all fracture components. For B2.1 and B2.2 fractures, the humeral head and separated tuberosity must be reduced properly.

The optimal reduction and fixation procedure for the B2 fracture subtypes depends on the involved tuberosity, and whether or not the calcar region is comminuted.

Proximal humeral reconstruction

  1. Reduce and fix the lesser/greater tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
  2. Reduce the metaphyseal fracture component to the shaft and fix it

In the following procedure, involvement of the greater tuberosity is assumed. For details for proper reduction in cases of lesser tuberosity involvement, please click here.

Metaphyseal comminution
In B2.3 fractures (with medial metaphyseal comminution), it is necessary to realign the medial column fragments as accurately as possible while preserving their soft-tissue attachments and vascularity. Once healed, the restored medial bony buttress helps prevent varus collapse. With medial comminution, initial fixation must be secure enough to resist varus collapse.
It is also crucial to reduce the humeral head adequately since the combination of remaining varus displacement and medial comminution predisposes to secondary varus collapse and/or implant failure.


Begin by inserting sutures into the insertion fibers of subscapularis tendon (1) and the supraspinatus tendon (2). enlarge

Place rotator cuff sutures

Subscapularis and supraspinatus tendon
Begin by inserting sutures into the subscapularis tendon (1) and the supraspinatus tendon (2). Place these sutures just superficial to the tendon’s bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities.


Next, place a suture into the infraspinatus tendon insertion (3). enlarge

Infraspinatus tendon
Next, place a suture into the infraspinatus tendon insertion (3). This can be demanding, and may be easier with traction on the previously placed sutures, or with properly placed retractors.


It is easier the further lateral of an approach is used. A) shows an deltopectoral approach and B) an anterolateral approach. enlarge

Variations depending on the approach chosen
Inserting sutures into the infraspinatus tendon is easier with a lateral approach. A) shows a deltopectoral approach and B) an anterolateral (transdeltoid) approach.


Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon. enlarge

Use of stay sutures
Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.


Insert a preliminary traction suture into the visible part of the posterior rotator cuff ... enlarge

Insert a preliminary traction suture into the visible part of the posterior rotator cuff ...


... and pull it anteriorly. enlarge

... and pull it anteriorly. This will expose the proper location for a suture in the infraspinatus tendon insertion. Then the initial traction suture is removed.

Pearl: larger needles
A stout sharp needle facilitates placing a suture through the tendon insertion.


Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head. enlarge

Pearl: use of retractors
Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.


Similarly, a so-called delta retractor may improve deltoid retraction. enlarge

Similarly, a so-called delta retractor may improve deltoid retraction.


Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone. enlarge

Pitfall: use of forceps or clamps in osteoporotic bone
Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone. This should be avoided by using sutures as “handles” for manipulation and reduction.


Reduce the involved tuberosity by pulling the sutures. enlarge

Reduce the involved tuberosity

Reduce the involved tuberosity by pulling the sutures.


Tie a knot to stabilize the tuberosity to the head fragment. Thereby, the 3-part fracture is converted into a 2-part situation. enlarge

Tie a knot to stabilize the tuberosity to the head fragment. Thereby, the 3-part fracture is converted into a 2-part situation.


Reduce the metaphyseal fracture component enlarge

B2.1 and B2.2

Reduce the metaphyseal fracture component
The reduction of the metaphyseal fracture component in B2.1 and B2.2 fractures depends on the intrinsic stability and displacement of the humeral head. Longitudinal traction on the arm may be necessary.
One can use sutures through the rotator cuff, or a joy stick (eg, threaded pin) to help reduce the humeral head onto the humeral shaft.


Alternatively, one can fix a plate laterally to the humeral head, reduce the humeral head with the help of a plate. enlarge

Alternative: use plate as reduction aid
Alternatively, one can fix a plate laterally to the humeral head, reduce the humeral head with the help of a plate (as a handle). The plate is then fixed to the shaft with a bicortical screw. Interfragmentary compression of the metaphyseal fracture (LCP technique or other maneuver) should be considered.


enlarge

Depending on fracture morphology, one might also be able to reduce the metaphyseal fracture component by pulling the humeral shaft towards a plate that has not yet been attached to the humeral head.


The fracture reduction is temporarily secured using 2 or 3 K-wires. enlarge

Preliminary fixation with K-wires
The fracture reduction is temporarily secured using 2 or 3 K-wires. Make sure to place them from anterior in order to avoid interference with the foreseen plate position.

If necessary, an additional K-wire may be used to preliminary stabilize the greater tuberosity.


In B2.3 fractures, it is necessary to restore the medial column as well as possible. enlarge

B2.3: Additional medial calcar comminution

In B2.3 fractures, it is necessary to restore the medial column as well as possible, especially if combined with a varus displacement of the humeral head. In this case, it is also crucial to reduce the humeral head adequately since the combination of varus deformity and medial comminution predisposes to secondary varus collapse and/or implant failure.
The severity of the medial calcar comminution varies. With a single large fragment, a lag screw may be considered. It could be placed before (as illustrated) or after the plate is applied.


Multifragmentary comminution of the medial cortex might be stabilized with a small plate. enlarge

Multifragmentary comminution of the medial cortex might be stabilized with a small plate.

3 Confirmation of reduction top

There should be no gap and no step-off between the tuberosities. enlarge

After preliminary fixation of the reduction confirm the result visually and by image intensification.

Visual control
There should be no gap and no step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly into the fracture gap.
Moreover, one should pay attention to the correct rotational alignment. This can be assessed by the course of the bicipital groove.


Confirm the inclination of the humeral head. enlarge

Radiographic confirmation
The AP x-ray should show the correct relationship between the humeral head and the tuberosities.
Superolaterally, the humeral head and the greater tuberosity should be flush without a step-off or gap. In particular, make sure that the greater tuberosity is not above the humeral head.
Confirm the inclination of the humeral head. The centrum collum diaphyseal angle (CCD) is illustrated. It is the angle between the axis of the humeral diaphysis, and the axis of the humeral neck, best identified as a perpendicular to the base of the humeral head. The CCD should be approximately 135°.
Varus malalignment of the humeral head should be corrected so that the CCD angle is close to 135°. A CCD angle of 120° or less is a predictor of secondary varus collapse, especially when medial support is missing.

4 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

5 Plate fixation top

Attach the plate to the humeral shaft with a bicortical small fragment 3.5 mm screw inserted through the elongated hole. enlarge

Attach plate to humeral shaft

Attach the plate to the humeral shaft with a bicortical small fragment 3.5 mm screw inserted through the elongated hole.

Pearl 1: fine tuning of plate position
If the first screw is inserted only loosely in the center of the elongated hole, fine-tuning of the plate position is still possible. With the plate in proper position, tighten this screw securely.


Pearl: preliminary plate fixation with K-wires enlarge

Pearl 2: preliminary plate fixation with K-wires
For x-ray confirmation of plate position, one can fix the plate preliminarily to the bone with several 1.4 mm K-wires inserted through the small plate holes, before placing any screws.


Alternative provisional plate fixation: K-wires inserted through their appropriate K-wire sleeves. enlarge

Pearl 3: insert K-wires through appropriate guiding sleeves.


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. enlarge

Calcar screws
It is strongly recommended to use “calcar screws” in all varus displaced fractures, especially, if there is medial comminution as in B2.3 fractures. Their purchase in the inferomedial humeral head adds mechanical stability.


Lesser tuberosity fixation enlarge

Lesser tuberosity fixation
If the lesser tuberosity is involved, lag screw fixation might be considered. This technique may be superfluous when appropriate tension band sutures are placed through the rotator cuff insertions. Another option is one or more absorbable polymer pins.
If in doubt, once the sutures are secure, check the stability of the lesser tuberosity clinically by rotating the arm. If there is any micro movement visible or palpable consider additional fixation, which is typically placed after the rest of the fixation.


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.

Any K-wires placed during the procedure may now be removed.

6 Circumferential tension band suturing top

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

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

7 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.

8 Final check of osteosynthesis top

Carefully check for correct reduction and fixation (including proper implant position and length) at various arm positions. enlarge

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.

v2.0 2011-05-02