Positioning wires (for plate location)
To ensure appropriate plate position, somewhat obscured by a small incision, it helps to place temporary K-wires that can be used for radiographically controlled guidance.
Insert 2 positioning K-wires, one at the lateral border the bicipital groove and the other at the tip of the greater tuberosity. (These positioning wires can be used for provisional tuberosity fixation.)
The anterior positioning K-wire sets the location for the anterior edge of the plate, 2-4 mm lateral to the bicipital groove.
The proximal positioning K-wire determines the proximal edge of the plate, 5-8 mm distal to the tip of the greater tuberosity.
Identify the axillary nerve by palpating on the undersurface of the deltoid muscle. This helps protect it during plate insertion.
Insert the plate, assembled on an aiming device, under the deltoid muscle, and slide it distally under the deltoid and along the humerus. Always keep the plate in contact with bone.
Pearl: suturing the deltoid muscle To prevent extending the deltoid muscle split and increasing risk of axillary nerve injury, place a suture at the distal end of the split.
Attach plate to humerus
Position the plate in the planned and marked location on the proximal humerus. Fix it temporarily to the bone with K-wires. Proximally, two wires are placed through specific holes in the aiming device. Distally, use a percutaneously placed K-wire sleeve.
Confirm correct plate position with x-ray.
Fix plate to the humeral head
Use the aiming device with drill sleeves to drill holes for the proximal screws. Make sure not to perforate the humeral head.
Follow the manufacturers technique guide.
Avoiding intraarticular screw placement
Screws that penetrate the humeral head may significantly damage the glenoid cartilage. Primary penetration occurs when the screws are initially placed. Secondary penetration is the result of subsequent fracture collapse. Drilling into the joint increases the risk of screws becoming intraarticular.
Two drilling techniques help to avoid drilling into the joint.
Pearl 1: “Woodpecker”-drilling technique (as illustrated)
In the woodpecker-drilling technique, advance the drill bit only for a short distance, then pull the drill back before advancing again. Keep repeating this procedure until subchondral bone contact can be felt. Take great care to avoid penetration of the humeral head.
Pearl 2: Drilling near cortex only
Particular in osteoporotic bone, one can drill only through the near cortex. Push the depth gauge through the remaining bone until subchondral resistance is felt.
Determine screw length
The intact subchondral bone should be felt with an appropriate depth gauge or blunt pin to ensure that the screw stays within the humeral head. The integrity of the subchondral bone can be confirmed by palpation or the sound of the instrument tapping against it. Typically, choose a screw slightly shorter than the measured length.
Insert a locking-head screw through the screw sleeve into the humeral head.
All four proximal screws should be inserted as previously described.
Remember the plate lies deep to the axillary nerve. Screws should not be place through the danger zone where the nerve may be injured.
Insert screws into humeral shaft
Insert two to three screws into the humeral shaft, below the danger zone, with aiming device and appropriate, percutaneously placed screw insertion sleeves.
The illustration shows the completed osteosynthesis.
Additional fixation of the lesser tuberosity (if involved)
Lag screw fixation of the lesser tuberosity might be considered.
This may be unnecessary if a secure subscapularis suture has been placed. If in doubt, it is recommended to check the fixation stability of the lesser tuberosity clinically by rotating the arm. If there is any micro movement visible or palpable one should consider insertion of an additional lag screw.
Supplementary tension band sutures
In minimally invasive plate fixation, it is wise to increase stability by adding supplementary tension band sutures to attach the rotator cuff tendons to the plate.