The displaced greater tuberosity must be reduced and fixed stably. The metaphyseal fracture also requires reduction, usually provisional reduction with K-wires and, finally, stable plating.
Deltopectoral approaches are best suited for lesser tuberosity reduction and fixation and plate application. Occasionally, an anterolateral approach provides sufficient access. For greater tuberosity fractures, a transdeltoid approach may provide easiest access.
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 fixation of the separated tuberosity
Placing and tensioning horizontal sutures helps reduce and stabilize the free tuberosity fragment.
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 fragmentary 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.
Medial calcar fragmentation
In fractures with medial metaphyseal fragmentation, it is necessary to restore the medial column as accurately as possible. Restoring a medial bony buttress helps avoid varus collapse.
It is also crucial to reduce the humeral head adequately since the combination of remaining varus displacement and medial fragmentation predisposes to secondary varus collapse and/or implant failure.
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.