Goals of reduction
The goal of reduction is to restore the normal location of all fracture components. For simple 3-part fractures, the humeral head and separated tuberosity must be reduced properly.
The optimal reduction and fixation procedure for the fracture subtypes depends on the involved tuberosity, and whether or not the calcar region is comminuted.
Proximal humeral reconstruction
Reduce and fix the lesser/greater tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
Reduce the metaphyseal fracture component to the shaft and fix it
In the following procedure, involvement of the greater tuberosity is assumed. For specific details on reduction of the lesser tuberosity see Open reduction and preliminary fixation of lesser tuberosity and humeral head.
In fractures with medial metaphyseal fragmentation, it is necessary to realign the medial column fragments as accurately as possible while preserving their soft-tissue attachments and vascularity. Once healed, the restored medial bony buttress helps prevent varus collapse. With medial fragmentation, initial fixation must be secure enough to resist 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.
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 fragmentation of osteoporotic bone. This should be avoided by using sutures as “handles” for manipulation and reduction.
Reduce the involved tuberosity
Reduce the involved tuberosity by pulling the sutures.
Tie a knot to stabilize the tuberosity to the head fragment. Thereby, the 3-part fracture is converted into a 2-part situation.
Simple 3-part fractures
Reduce the metaphyseal fracture component
The reduction of the metaphyseal fracture component depends on the intrinsic stability and displacement of the humeral head. Longitudinal traction on the arm may be necessary.
One can use sutures through the rotator cuff, or a joy stick (eg, threaded pin) to help reduce the humeral head onto the humeral shaft.
Alternative: use plate as reduction aid
Alternatively, one can fix a plate laterally to the humeral head, reduce the humeral head with the help of a plate (as a handle). The plate is then fixed to the shaft with a bicortical screw. Interfragmentary compression of the metaphyseal fracture (LCP technique or other maneuver) should be considered.
Depending on fracture morphology, one might also be able to reduce the metaphyseal fracture component by pulling the humeral shaft towards a plate that has not yet been attached to the humeral head.
Preliminary fixation with K-wires
The fracture reduction is temporarily secured using 2 or 3 K-wires. Make sure to place them from anterior in order to avoid interference with the foreseen plate position.
If necessary, an additional K-wire may be used to preliminary stabilize the greater tuberosity.
Medial calcar fragmentation
In fractures with medial calcar fragmentation, it is necessary to restore the medial column as well as possible, especially if combined with a varus displacement of the humeral head. In this case, it is also crucial to reduce the humeral head adequately since the combination of varus deformity and medial fragmentation predisposes to secondary varus collapse and/or implant failure.
The severity of the medial calcar fragmentation varies. With a single large fragment, a lag screw may be considered. It could be placed before (as illustrated) or after the plate is applied.
A multifragmentary medial cortex might be stabilized with a small plate.