Extend the exposure
In order to retrieve the humeral head it is necessary to achieve a proper exposure. To do this, divide the soft tissues over the fracture, and extend this incision along supraspinatus muscle fibers as shown.
Note: If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). This is because the typical “intertuberosity” fracture line of a four-part fracture is actually lateral to the bicipital groove, and thus through the greater tuberosity.
Retrieve the humeral head
Any remaining medial capsular attachment to the head should be carefully released with special attention not to damage the axillary nerve medial to the proximal humerus.
Be sure that all loose small fragments are removed.
Keep the humeral head for later measurements and bone grafting.
Osteotomy of lesser tuberosity
In 3-part fractures with the lesser tuberosity attached to the humeral head, the lesser tuberosity has to be osteotomized in order to retrieve the humeral head.
Illustration shows the correct location of the osteotomy.
Inspect the glenoid fossa
Resect the tendon of long head of the biceps at its labral origin and retrieve the intermediate tendon.
Inspect the glenoid fossa in order to rule out any injury.
If there is a glenoid fracture, osteosynthesis should be performed now.
Remove any bony fragments.