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Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus 11-C1.3 Open reduction; screw fixation

back to skeleton

Glossary

1 Principles top

Proper reduction

Proper reduction of the humeral head fragment is key. This may require an glenohumeral arthrotomy, via either an osteotomy of the lesser tuberosity or tenotomy of the subscapularis tendon, to improve visualization and manipulation.

2 Reduction and preliminary fixation top

Reduction of the humeral head may be possible with digital pressure without open exposure. enlarge

Reduction of the humeral head

Reduction of the humeral head may be possible with digital pressure without open exposure. If this is unsuccessful, one could use a periosteal elevator or a bone hook inserted into the glenohumeral joint through a small incision of the rotator cuff.

Prolonged attempts at closed reduction are not encouraged. Proceed with open reduction through an anterior shoulder arthrotomy. Click here for a description.

One or two threaded pins in the humeral head may be used as “joy-sticks”, to aid the reduction.


Secure the reduced humeral head temporarily using 2 or 3 K-wires. As shown, they are placed from distal to proximal. enlarge

Fix the humeral head temporarily

Secure the reduced humeral head temporarily using 2 or 3 K-wires. As shown, they are placed from distal to proximal.

Make sure that they are anterior enough to avoid interfering with the screw application.


Be sure 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.

Remember that the C-arm should be placed so that AP and axial views can both be obtained by C-arm repositioning without motion of the patient’s arm.

3 Fixation top

At least two screws should be inserted to fix the fracture. Therefore, insert guide wires at the foreseen cannulated screw ... enlarge

Cannulated or non-cannulated screws can be used according to the surgeon’s preference. We illustrate the use of 3.5 mm cannulated screws. A larger diameter screw may be preferred for larger bone fragments, particularly in the surgical neck region.

Since interfragmentary compression is desired, use a lag screw technique, with partially threaded screws, or lateral overdrilling, to compress the fracture.

Guide wire insertion
At least three screws should be inserted to fix the fracture. Therefore, insert guide wires at the foreseen cannulated screw positions. Check the position of the guide wires by image intensification.

Note: beware the axillary nerve and the bicipital tendon.


Insert 3.5 mm cannulated screws of correct length over the guide wires. enlarge

Cannulated screw insertion

Insert 3.5 mm cannulated screws of correct length over the guide wires. The screw must not perforate the articular cartilage. Use washers only in osteoporotic bone.

4 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.

v2.0 2011-05-02