Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 3-part, surgical neck and tuberosity, no impaction

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1 Introduction top

Not indicated for B2.3 fractures enlarge

The displaced greater tuberosity must be reduced and fixed stably. The metaphyseal fracture must be reduced and fixed stably. Be certain that screws will provide adequate stability.

Closed reduction with screw fixation is not recommended for lesser tuberosity fractures.

Fractures with metaphyseal comminution should not be treated with screw fixation because this does not provide sufficient stability

2 Principles top

In some cases it is beneficial to perform a closed reduction and closed osteosynthesis. This induces no further damage to the soft-tissue and does not disturb the fracture zone including the fracture hematoma. It also does not disturb the subacromial space and allows prolonged immobilization postoperatively in a shoulder immobilizer.

The overall stability of cannulated screws alone is limited and 2-3 weeks postoperative immobilization in a shoulder immobilizer is recommended.

Danger zone around the axillary nerve enlarge

Risk of axillary nerve injury

The main structure at risk is the axillary nerve. The axillary nerve should be protected by limiting the incision to less than 5 cm distal to the acromial edge, by palpating the nerve, and by avoiding maneuvers that stretch the nerve during reduction and fixation. Remember the course of the nerve when placing K-wires.

3 Reduction and preliminary fixation top

Reduction enlarge

Reduction/Fixation of the tuberosities

Sequence of repair:

  1. Reduction/fixation of the tuberosity (thereby converting the 3-part fracture into a 2-part situation)
  2. Reduction/fixation of the proximal humeral fragment to the shaft

For improved stability an additional (cannulated) lag screw can be placed in the lesser tuberosity.

Rotator cuff sutures: Subscapularis and supraspinatus tendon 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.

Infraspinatus tendon 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, with properly placed retractors, and/or repositioning the arm.

Stay sutures enlarge

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

Preliminary traction suture enlarge

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

Pull 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.

Direct reduction of the greater tuberosity enlarge

Reduction of the greater tuberosity

Direct reduction of the greater tuberosity fragment is performed by pulling the sutures or, …

Instrumentation enlarge

… with instruments (eg, elevator) applied either through the incision (as illustrated) or through a separate stab incision.

Preliminary fix the tuberosity enlarge

Preliminary fix the greater tuberosity

Tighten and tie the transverse sutures in order to preliminarily fix the greater tuberosity fragment. Thereby, the 3-part fracture is converted into a 2-part situation.

Reduction of the head fragment enlarge

Reduction of the head fragment

Distal traction, perhaps augmented with increased angulation, will help to reduce the fracture.

Using an elevator enlarge

Use of an elevator
Sometimes, the incision allows insertion of an elevator to disimpact the humeral head, or to help to correct inclination/torsion and to restore a normal relationship of the medial fracture surface. The proximal fragment should be reduced anatomically to the shaft.
The actual process of reduction is done with image intensifier control.

Preliminary fixation enlarge

Preliminary fixation

Quite often, the humeral head is not stable enough and requires additional preliminary fixation using 2 or 3 K-wires.

Confirmation of reduction
The correct reduction must be confirmed in both AP and lateral views using image intensifier control.

4 Definitive fixation top

Percutaneously inserted screws to fix the head fragment enlarge

Fixation of the head fragment

Two or more percutaneously inserted screws linking the shaft fragment to the head fragment are inserted first.
Cannulated 3.5 mm lag screws (as illustrated), or non-cannulated small fragment lag screws are used according to the surgeon’s preference.
This illustration shows two screws inserted over guide wires.
Note: Washers may be advisable in poor bone stock. Generally, they are not preferable as they make the screw heads more prominent and may result in shoulder impingement.

Screw insertion into humeral head enlarge

Fixation of the greater tuberosity

Remove K-wires and guides wires from the shaft.
Fixation of the head fragment is followed by insertion of a screw into the greater tuberosity.
Again, in this case, the screw is inserted over a guide wire.

Completed osteosynthesis enlarge

Completed osteosynthesis

The illustration shows the completed osteosynthesis.

5 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