Since the fracture is not exposed, the surgeon should be skilled at closed reduction maneuvers before considering minimally invasive plate osteosynthesis MIPO.
Distal traction, perhaps augmented with increased angulation, will help to disimpact the fracture.
Use of an elevator
Sometimes, the incision allows insertion of an elevator to disimpact the fracture. This also helps 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.
Threaded pins or K-wires may be inserted into the proximal fragment and used as joy sticks for fracture reduction. However, this technique may be less effective in osteoporotic bone.
Pearl: use of retractors
Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.
Similarly, a so-called delta retractor may improve deltoid retraction.
The reduction of the humeral head is temporarily secured using 2 to 3 K-wires. Make sure to place the K-wires such that they will not interfere with the later plate position.
Confirm the reduction by image intensification in two planes.
Attention should be paid on the correct alignment of the proximal humerus in all planes. Particularly varus malposition has to be corrected. The medial “calcar” region should be well opposed.
A slight impaction can be tolerated in the elderly, and it may increase stability.