1 Principles top
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 topenlarge
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. For a description of the anterior shoulder arthrotomy see the deltopectoral approach.
One or two threaded pins in the humeral head may be used as “joy-sticks”, to aid the reduction.
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.
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 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. 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.
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.