Sequence of repair:
Reduce and fix the greater tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
Reduce the proximal humeral fragment to the shaft and fix it.
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.
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, or with properly placed retractors.
Variations depending on the approach chosen
Inserting sutures into the infraspinatus tendon is easier with a lateral approach. A) shows a deltopectoral approach and B) an anterolateral (transdeltoid) approach.
Use of stay sutures
Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.
Insert a preliminary traction suture into the visible part of the posterior rotator cuff …
… 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.
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.
Pitfall: use of forceps or clamps in osteoporotic bone
Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone. This should be avoided by using sutures as “handles” for manipulation and reduction.
Reduce the humeral head
Correct the valgus impaction by elevating the displaced proximal humeral segment. The required force may vary according to the degree of impaction.
Various techniques can be used to lift the humeral head such as:
A) Digital pressure
B) Use of a blunt periosteal elevator (as illustrated)
C) Leverage. A varus force can be applied to the humeral shaft. This can be achieved by using a fulcrum (eg, the surgeons fist, as shown, or a roll of towels) in the axilla.
D) Combination of direct manipulation and leverage.
E) If the fragments are jammed together, disimpaction with a bone punch may be required.
Reduce the greater tuberosity
Pull the sutures in the supra- and infraspinatus tendons in order to reduce the greater tuberosity.
Pearl: a periosteal elevator might be helpful in order to manipulate the greater tuberosity.
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.
After preliminary fixation check the reduction visually and by image intensification.
All fracture lines should be closed without any step or gap especially between the greater and lesser tuberosities.
The AP x-ray should show the correct relationship between the humeral head and the tuberosities.
Superolaterally, the humeral head and the greater tuberosity should be flush without a step-off or gap. In particular, make sure that the greater tuberosity is not above the humeral head.
Confirm the inclination of the humeral head. The centrum collum diaphyseal angle (CCD) is illustrated. It is the angle between the axis of the humeral diaphysis, and the axis of the humeral neck, best identified as a perpendicular to the base of the humeral head. The CCD should be approximately 135°.
Valgus displacement of the humeral head must be corrected so there is enough room laterally for the tuberosities to be reduced.
Note: In fractures with apex anterior angular deformity, the axial alignment has to be checked with a lateral image, rather than the AP view.
Confirm proper rotational alignment
Correct rotational alignment must be confirmed. This can be done by matching the fracture configurations on both sides of the fracture. This would be useful in the more transverse fracture configuration as shown in the illustration.
Pearl: check retroversion
The bicipital groove might be a good indicator for correct rotation. In case of correct rotation, no gap/angulation is visible at the level of the fracture.
Remember that the humeral head is normally retroverted, facing approximately 25° posteriorly (mean range: 18°-30°) relative to the distal humeral epicondylar axis. This axis is perpendicular to the forearm with the elbow flexed to 90°.
Quite often, the situation after reduction of the humeral head is stable and does not require additional preliminary fixation with K-wires. Nevertheless, in some cases it might be advantageous to use additional K-wires to secure the position of the humeral head. Therefore, use 2 or 3 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.
Pearl: reduction of tuberosities under humeral head
Anatomical reduction requires proper approximation of the greater tuberosity underneath the humeral head. Secure this by tightening the horizontal sutures between the subscapularis and infraspinatus tendons (lesser and greater tuberosities).
Pitfall: insufficient reduction of humeral head
A common mistake in reduction of the humeral head is insufficient elevation of the humeral head laterally, in relation to the humeral shaft. This keeps the greater tuberosity from fitting properly under the humeral head. As shown, the humeral head may remain below the top of the tuberosities.
Pearl: osteoporotic bone
In osteoporotic bone, stability may be increased by accepting some medial impaction of the humeral head.