Sequence of reduction
Reduce and fix the tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation).
Reduce the proximal humeral segment to the shaft with the nail and fix it.
Suture reduction and fixation of the greater tuberosity
Sutures in the rotator cuff tendon insertions aid manipulation, reduction, and temporary fixation of a proximal humerus fracture.
Traction on the sutures helps achieve reduction. When tied, they bring the fragments together and stabilize them.
Reduction of the metaphyseal fracture component
If the entry point has been chosen correctly, insertion of the nail will help reduce the fracture.
Correct nail entrance point
A proper and precise entrance point of the humeral nail is crucial. An incorrect entry site results in malreduction of the metaphyseal fracture.
Preliminary reduction of the fracture helps with identification of the correct nail entry site. K-wire “joy-sticks” (as illustrated) or sutures through the rotator cuff insertions aid with reduction.
Risk of axillary nerve injury
The main structure at risk is the axillary nerve. The axillary nerve should be protected by limiting the incision to less than 5 cm distal to the acromial edge, by palpating the nerve, and by avoiding maneuvers that stretch the nerve during reduction and fixation.
Remember the course of the nerve when placing the distal screws.
Tension band sutures in addition to nail
Sutures placed through the insertions of each rotator cuff tendon increase stability, and should be used as well as the nail and screws, particularly for more comminuted and/or osteoporotic fractures. With osteoporotic bone, the tendon insertion is often stronger than the bone itself, so that sutures placed through the insertional fibers of the tendon may hold better than screws or sutures placed through bone.
These additional sutures are typically the last step of fixation.