Reduction enlarge

Reduction

Sequence of repair:

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

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 lesser tuberosity enlarge

Reduction of the lesser tuberosity

Direct reduction of the lesser 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 lesser tuberosity

Tighten and tie the transverse sutures in order to preliminarily fix the lesser 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.


Preliminary fixation enlarge

Preliminary fixation

After the tuberosity and humeral head have been reduced and stabilized with sutures, there may be no need for additional preliminary fixation, but it might be advantageous to use additional K-wires to secure the position of the humeral head relative to the humeral shaft. This is illustrated with 2 retrograde K-wires. Make sure to place them from anterior in order to avoid interference with the foreseen plate position.

If the greater tuberosity is multifragmentary it might become necessary to use additional small K-wires in order to fix separate fragments.

Confirmation of reduction
The correct reduction must be confirmed in both AP and lateral views using image intensifier control.