Begin by inserting sutures into the insertion fibers of subscapularis tendon (1) and the supraspinatus tendon (2) enlarge

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) enlarge

Infraspinatus tendon
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.


It is easier the further lateral of an approach is used. A) shows an deltopectoral approach and B) an anterolateral approach enlarge

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.


Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon enlarge

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 ... enlarge

Insert a preliminary traction suture into the visible part of the posterior rotator cuff …


Expose the proper location for a suture in the infraspinatus tendon insertion enlarge

… 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.


Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head enlarge

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. enlarge

Similarly, a so-called delta retractor may improve deltoid retraction.


Grabbing bone fragments with a forceps or clamp will typically increase comminution of osteoporotic bone enlarge

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.


Correct the valgus impaction by elevating the lateral aspect of the humeral head enlarge

Reduce the humeral head

Correct the valgus impaction by elevating the lateral aspect of the humeral head. 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)


 A varus force can be applied to the humeral shaft. This can be achieved by using a fulcrum in the axilla. enlarge

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.


Combination of direct manipulation and leverage for the reduction of proxial humerus fractures enlarge

D) Combination of direct manipulation and leverage.


Disimpaction of jammed bone fragments with bone punch enlarge

E) If the fragments are jammed together, disimpaction with a bone punch may be required.


Incising the periosteum enlarge

Pearl: incising the periosteum
Exposure and reduction of the humeral head may be aided by dividing any soft-tissue connections between the tuberosities and extending this incision proximally between the fibers of the supraspinatus tendon.


If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). enlarge

Note: If a cranial extension is needed, it should be carried into the supraspinatus tendon (A) and not into the rotator interval (B). This is because the typical “intertuberosity” fracture line of a four-part fracture is actually lateral to the bicipital groove, and thus through the greater tuberosity.


In displaced fractures, the medial hinge (periosteum) is often disrupted. If so, the humeral head is unstable and might ... enlarge

Pitfall: humeral head displaces medially
In displaced fractures, the medial hinge (periosteum) is often disrupted. If so, the humeral head is unstable and might displace medially upon reduction.


It might still be advantageous to secure the humeral head using 2 or 3 K-wires enlarge

Fix the humeral head temporarily

Secure the reduced humeral head temporarily using 2 or 3 K-wires. As shown, they are placed from distal to proximal.

Make sure that they are anterior enough to avoid interfering with the plate application.

If the greater tuberosity is comminuted, additional smaller K-wires may be needed to fix separated fragments.


Pull the sutures between the subscapularis and the infraspinatus tendons horizontally ... enlarge

Reduce the tuberosities

If the humeral head is properly reduced and the correct inclination of the humeral head is achieved, the tuberosities can now easily be positioned underneath the humeral head. Pull the sutures between the subscapularis and the infraspinatus tendons horizontally …


... and tie them together. enlarge

… and tie them together.


There should be no gap or step-off between the tuberosities. enlarge

Confirm reduction

After preliminary fixation check the reduction visually and by image intensification.

Visual control
There should be no gap or step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly against the shaft fragment.


Confirm the inclination of the humeral head. enlarge

Radiographic confirmation
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.


This intraoperative x-ray shows an unacceptable step-off. enlarge

This intraoperative x-ray shows an unacceptable step-off.


Check that there is no anteversion or excessive retroversion of the humeral head. enlarge

Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive retroversion of the humeral head. This view might also reveal malpositioned tuberosities.


In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and ... enlarge

In order to maintain fracture reduction in unstable situations (even with preliminary K-wire fixation) move the C-arm and not the patient’s arm when obtaining the axial/lateral.


Tighten the horizontal sutures between the subscapularis and infraspinatus tendons. enlarge

Pearl: reduction of tuberosities under humeral head
Anatomical reduction requires proper approximation of the tuberosities underneath the humeral head. Secure this by tightening the horizontal sutures between the subscapularis and infraspinatus tendons (lesser and greater tuberosities).


A common mistake in reduction of the humeral head, is its insufficient elevation in relation to the humeral shaft. enlarge

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 tuberosities from fitting properly under the humeral head. As shown, the humeral head may remain below the top of the tuberosities.

Proper reduction may be aided by incising the periosteum and supraspinatus tendon.


In osteoporotic bone, stability may be increased by leaving medial impaction of the humeral head. enlarge

Pearl: osteoporotic bone
In osteoporotic bone, stability may be increased by accepting some
medial impaction of the humeral head.