Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 11-C1.1 Open reduction; plate fixation

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Glossary

1 Principles top

Proper reduction of the major proximal humerus fragments is essential. enlarge

Proper reduction

Proper reduction of the major proximal humerus fragments is essential. In particular, the valgus impacted humeral head must be elevated sufficiently, so that the tuberosities can be placed underneath it.


Sutures in the rotator cuff tendon insertions aid manipulation, reduction, and temporary fixation of a proximal humerus fracture enlarge

Suture reduction and fixation of the tuberosities

Sutures in the rotator cuff tendon insertions aid manipulation, reduction, and temporary fixation of a proximal humerus fracture.
Traction on the sutures helps achieve reduction. When tied, they bring the fragments together and stabilize them.


Sutures placed through the insertions of each rotator cuff tendon increase stability 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.


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 Reduction and preliminary fixation top

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 …


Expose the proper location for a suture in the infraspinatus tendon insertion 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.


Correct the valgus impaction by elevating the lateral aspect of the humeral head enlarge

Reduce the humeral head

Correct the valgus impaction by elevating the lateral aspect of the humeral head. The required force may vary according to the degree of impaction.

Various techniques can be used to lift the humeral head such as:
A) Digital pressure
B) Use of a blunt periosteal elevator (as illustrated)


 A varus force can be applied to the humeral shaft. This can be achieved by using a fulcrum in the axilla. enlarge

C) Leverage. A varus force can be applied to the humeral shaft. This can be achieved by using a fulcrum (eg, the surgeons fist, as shown, or a roll of towels) in the axilla.


Combination of direct manipulation and leverage for the reduction of proxial humerus fractures enlarge

D) Combination of direct manipulation and leverage.


Disimpaction of jammed bone fragments with bone punch enlarge

E) If the fragments are jammed together, disimpaction with a bone punch may be required.


Incising the periosteum enlarge

Pearl: incising the periosteum
Exposure and reduction of the humeral head may be aided by dividing any soft-tissue connections between the tuberosities and extending this incision proximally between the fibers of the supraspinatus tendon.


If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). enlarge

Note: If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). This is because the typical “intertuberosity” fracture line of a four-part fracture is actually lateral to the bicipital groove, and thus through the greater tuberosity.


It might still be advantageous to secure the humeral head using 2 or 3 K-wires enlarge

Fix the humeral head temporarily

Quite often, the initial humeral head reduction is sufficiently stable that preliminary fixation is not required. Nevertheless, it might still be advantageous to secure the humeral head using 2 or 3 K-wires. Make sure that they are anterior enough to avoid interfering with the plate application.
Note: In the following illustrated procedure, K-wires are used.

If the greater tuberosity is comminuted, additional smaller K-wires may be needed to fix separated fragments.


Pull the sutures between the subscapularis and the infraspinatus tendons horizontally ... enlarge

Reduce the tuberosities

If the humeral head is properly reduced and the correct inclination of the humeral head is achieved, the tuberosities can now easily be positioned underneath the humeral head. Pull the sutures between the subscapularis and the infraspinatus tendons horizontally …


... and tie them together. enlarge

… and tie them together.


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

Confirm reduction

After preliminary fixation check the reduction visually and by image intensification.

Visual control
There should be no gap or step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly against the shaft fragment.


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°.
Valgus displacement of the humeral head must be corrected so there is enough room laterally for the tuberosities to be reduced.


This intraoperative x-ray shows an unacceptable step-off. enlarge

This intraoperative x-ray shows an unacceptable step-off.


Check that there is no anteversion or excessive retroversion of the humeral head. enlarge

Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive retroversion of the humeral head. This view might also reveal malpositioned tuberosities.


In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and ... enlarge

In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and not the patient’s arm when obtaining the axial/lateral.


Tighten the horizontal sutures between the subscapularis and infraspinatus tendons. enlarge

Pearl: reduction of tuberosities under humeral head
Anatomical reduction requires proper approximation of the tuberosities underneath the humeral head. Secure this by tightening the horizontal sutures between the subscapularis and infraspinatus tendons (lesser and greater tuberosities).


A common mistake in reduction of the humeral head, is its insufficient elevation in relation to the humeral shaft. enlarge

Pitfall: insufficient reduction of humeral head
A common mistake in reduction of the humeral head is insufficient elevation of the humeral head laterally, in relation to the humeral shaft. This keeps the tuberosities from fitting properly under the humeral head. As shown, the humeral head may remain below the top of the tuberosities.

Proper reduction may be aided by incising the periosteum and supraspinatus tendon.


In osteoporotic bone, stability may be increased by leaving medial impaction of the humeral head. enlarge

Pearl: osteoporotic bone
In osteoporotic bone, stability may be increased by accepting some
medial impaction of the humeral head.

3 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.


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

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.


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.

4 Supplementary rotator cuff tendon sutures 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.

5 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.

6 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.

7 Case example top

This clinical photograph of a right shoulder shows sutures placed in the rotator cuff before reduction of the humeral head. enlarge

This clinical photograph of a right shoulder shows sutures placed in the rotator cuff before reduction of the humeral head.
Note: the periosteum over the fracture site has already been incised.


This intraoperative x-ray (AP of the proximal humerus) shows the humeral head reduced with a periosteal elevator. enlarge

This intraoperative x-ray (AP of the proximal humerus) shows the humeral head reduced with a periosteal elevator.


The plate is first positioned on the lateral aspect of the humerus after reduction and suture fixation of the tuberosities. enlarge

The plate is first positioned on the lateral aspect of the humerus after reduction and suture fixation of the tuberosities. The insertion guide is somewhat prominent and may catch on the overlying deltoid. Attaching the plate with a single screw ensures that it is properly positioned, after which the insertion guide can be attached.


This illustration shows the properly positioned plate with the insertion guide attached. enlarge

This illustration shows the properly positioned plate with the insertion guide attached.


Guided drilling, through drill sleeve, using the “woodpecker” technique (with alternating advancing and withdrawing the drill). enlarge

Guided drilling, through drill sleeve, using the “woodpecker” technique (with alternating advancing and withdrawing the drill).


Measurement of hole length with a depth gauge. The subchondral bone should be palpable with the gauge. enlarge

Measurement of hole length with a depth gauge. The subchondral bone should be palpable with the gauge.


If in doubt, check the depth gauge placement with the image intensifier. enlarge

If in doubt, check the depth gauge placement with the image intensifier.


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

Insert a locking-head screw through the screw sleeve.


This shows five locking-head screws placed into the humeral head, and supplementary tension band sutures of the rotator cuff. enlarge

This shows five locking-head screws placed into the humeral head, and supplementary tension band sutures of the rotator cuff with associated fragments.


Final check intraoperative x-rays show the completed osteosynthesis. enlarge

Final check intraoperative x-rays show ...


enlarge

... the completed osteosynthesis.


X-rays of the completed osteosynthesis. enlarge

X-rays of the completed osteosynthesis.

v2.0 2011-05-02