1 Principles top
Optimal stability for fixation of the anatomic neck in these fracture dislocations is probably provided by angular stable plates which should be considered for patients with better bone quality and limited comminution.
A deltopectoral approach is almost always required for glenohumeral reduction.
In these fractures there is a glenohumeral dislocation and a displaced anatomical neck fracture. In some cases, neurovascular compromise results from fracture fragment displacement. If this is the case, emergency treatment is necessary. Definitive reduction and fixation should not be long delayed, particularly if one wishes to salvage the humeral head. Hemiarthroplasty should be considered alternatively for elderly, infirm, and/or severely osteoporotic patients.
Closed reduction of the glenohumeral dislocation might be attempted. It is preferable to do this in the OR to permit conversion to an open reduction, if possible. This may avoid need for an additional anesthetic.
2 Glenohumeral reduction topenlarge
First of all, a reduction of the glenohumeral dislocation should be performed. In cases of undisrupted periosteal sleeves, this might be done in a closed manner (as illustrated). If the periosteal sleeve is disrupted, an open reduction of the glenohumeral dislocation becomes more likely. In these cases, it might become necessary to perform an arthrotomy to the glenohumeral joint via either an osteotomy of the lesser tuberosity or tenotomy of the subscapularis tendon.
Use a deltopectoral approach.
With longitudinal traction applied to the arm, the dislocated humeral head may be reduced using direct digital pressure pushing it back into position.
Option: bone hook
A bone hook can be placed carefully around the calcar avoiding damage to the articular cartilage. The head can then be pulled laterally and guided into position. Note: avoid neurovascular injury.
3 Fracture fixation following glenohumeral reduction top
Once the dislocation is reduced the fracture pattern may be reassessed and one can continue with open plating, or open screw fixation, or exceptionally, with hemiarthroplasty, if satisfactory fixation cannot be achieved.