The displaced greater tuberosity must be reduced and fixed stably. The metaphyseal fracture may be left impacted, unless severe deformity must be corrected. This disimpacts the metaphyseal fracture, which will be fixed with the plate.
For longer plates consider a deltopectoral incision. Otherwise, choose anterolateral or transdeltoid approach according to which is closest to the patient’s tuberosity fracture.
The greater tuberosity is typically displaced posterosuperiorly due to the pull of the rotator cuff. The humeral head is typically rotated posteriorly due to the pull of the subscapularis tendon on the intact lesser tuberosity. Both aspects of deformity have to be corrected precisely. If there is a valgus/varus malposition of the humeral head this has to be corrected to allow a proper reduction of the greater tuberosity.
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.
Tension band sutures in addition to plate and screws
Sutures placed through the insertions of each rotator cuff tendon increase stability, and should be used as well as the plate 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.
Angular stable versus standard plates
This procedure describes proximal humeral fracture fixation with an angular stable plate (A). Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf plate (B). Presently, the specific indications, advantages, and disadvantages of angular stable and standard plates are being clarified. There is some evidence that angular stable plate provide better outcomes. In addition to type and technique of fixation, the quality of reduction, the soft-tissue
handling, and the characteristics of the injury and patient significantly influence the results. There is no evidence that the use of angular stable plates will overcome these other factors.