Goals of reduction

The goal of reduction is to restore the normal location of all fracture components. For B2.1 and B2.2 fractures, the humeral head and separated tuberosity must be reduced properly.

The optimal reduction and fixation procedure for the B2 fracture subtypes depends on the involved tuberosity, and whether or not the calcar region is comminuted.

Proximal humeral reconstruction

  1. Reduce and fix the lesser/greater tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
  2. Reduce the metaphyseal fracture component to the shaft and fix it

In the following procedure, involvement of the greater tuberosity is assumed. For details for proper reduction in cases of lesser tuberosity involvement, please click here.

Metaphyseal comminution
In B2.3 fractures (with medial metaphyseal comminution), it is necessary to realign the medial column fragments as accurately as possible while preserving their soft-tissue attachments and vascularity. Once healed, the restored medial bony buttress helps prevent varus collapse. With medial comminution, initial fixation must be secure enough to resist varus collapse.
It is also crucial to reduce the humeral head adequately since the combination of remaining varus displacement and medial comminution predisposes to secondary varus collapse and/or implant failure.

Rotator cuff sutures: Subscapularis and supraspinatus tendon enlarge

Place rotator cuff sutures

Subscapularis and supraspinatus tendon
Begin by inserting sutures into the subscapularis tendon (1) and the supraspinatus tendon (2). Place these sutures just superficial to the tendon’s bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities.

Infraspinatus tendon enlarge

Infraspinatus tendon
Next, place a suture into the infraspinatus tendon insertion (3). This can be demanding, and may be easier with traction on the previously placed sutures, with properly placed retractors, and/or repositioning the arm.

Stay sutures enlarge

Use of stay sutures
Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.

Preliminary traction suture enlarge

Insert a preliminary traction suture into the visible part of the posterior rotator cuff …

Pull anteriorly enlarge

… and pull it anteriorly. This will expose the proper location for a suture in the infraspinatus tendon insertion. Then the initial traction suture is removed.

Pearl: larger needles
A stout sharp needle facilitates placing a suture through the tendon insertion.

Direct reduction of the greater tuberosity enlarge

Reduction of the greater tuberosity

Direct reduction of the greater tuberosity fragment is performed by pulling the sutures or, …

Instrumentation enlarge

… with instruments (eg, elevator) applied either through the incision (as illustrated) or through a separate stab incision.

Preliminary fix the tuberosity enlarge

Preliminary fix the greater tuberosity

Tighten and tie the transverse sutures in order to preliminarily fix the greater tuberosity fragment. Thereby, the 3-part fracture is converted into a 2-part situation.

Reduction of the head fragment enlarge

Reduction of the head fragment

Distal traction, perhaps augmented with increased angulation, will help to reduce the fracture.

Using an elevator enlarge

Use of an elevator
Sometimes, the incision allows insertion of an elevator to disimpact the humeral head, or to help to correct inclination/torsion and to restore a normal relationship of the medial fracture surface. The proximal fragment should be reduced anatomically to the shaft.
The actual process of reduction is done with image intensifier control.