1 Closed versus open reduction top
Anatomical reduction of the humeral head fragment is essential for this procedure. If closed reduction is unsatisfactory, proceed to an open procedure with a glenohumeral arthrotomy. First divide the subscapularis tendon or reflect it along with the lesser tuberosity. For a description of the anterior shoulder arthrotomy see the deltopectoral approach.
2 Reduction and preliminary fixation topenlarge
Reduction of the humeral head
In cases of slightly displaced humeral head fragments one can abstain from a reduction and just fix the humeral head percutaneously with screws.
In cases of displaced humeral head fragments reduction can be achieved by moderate digital pressure or manipulation onto the humeral head.
If this is unsuccessful, one could try to achieve a better reduction with the help of periosteal elevator or a bone hook inserted into the glenohumeral joint through a small incision of the rotator cuff.
Temporary fixation of the humeral head
The reduction of the humeral head is temporarily secured using 2 or 3 K-wires (as illustrated), or cannulated screw guide wires.
3 Fixation topenlarge
Cannulated or non-cannulated screws can be used according to the surgeon’s preference. We illustrate the use of 3.5 mm cannulated screws. Since interfragmentary compression is desired, use proper lag screw technique. Screw threads should not block fracture compression.
Guide wire insertion
At least two 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.
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.
The illustration shows the completed osteosynthesis.
4 Final check of osteosynthesis topenlarge
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.
Test the stability of the glenohumeral joint after the bony fixation.