Anatomical fracture reduction, provisional K-wire fixation, and stable plating are appropriate for simple 2- or 3-part fractures. If the lesser tuberosity is fractured it may require suture fixation, with possibility of plating the surgical neck.
Use the deltopectoral incision for open glenohumeral or lesser tuberosity reduction. Anterolateral or transdeltoid approaches offer less invasive access to the greater tuberosity, chosen according to fracture location.
The first priority is prompt reduction of the glenohumeral dislocation. One should be aware of the need of an open reduction.
Once the dislocation is reduced the fracture pattern may be reassessed and appropriate treatment may be planned.
Definitive management includes anatomical reduction and secure fixation of fractured tuberosities.
In the following, the treatment is described for a fracture with displaced greater tuberosity. For specific details on reduction of the lesser tuberosity - once the glenohumeral joint has been replaced - see Open reduction and preliminary fixation of lesser
tuberosity and humeral head.
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 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.