Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Isolated anatomical neck, slight displacement

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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 top

Manual reduction of humeral head enlarge

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.

Fixing the humeral head temporarily using K-wires enlarge

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 top

Inserted guide wires 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. 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.

Insertion of cannulated screws 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.

Completed osteosynthesis enlarge

Completed osteosynthesis

The illustration shows the completed osteosynthesis.

4 Final check of osteosynthesis top

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.

Test the stability of the glenohumeral joint after the bony fixation.

v2.0 2011-05-02