The glenohumeral dislocation should be reduced promptly. If closed reduction is successful, definitive treatment of the proximal humeral fracture can be delayed for a few days, if necessary.
Reduction of the humeral head may be difficult. Anesthesia with good muscle relaxation may be necessary. Open reduction/internal fixation may begin with an attempt at closed reduction, typically under anesthesia. Alternatively, the surgeon may proceed directly to open reduction.
With longitudinal traction applied to the arm, the dislocated humeral head may be reduced using direct digital pressure pushing it back into position.
Once the dislocation is reduced the fracture pattern may be reassessed and appropriate treatment may be planned.
Option: bone hook
A bone hook can be placed carefully around the calcar avoiding damage to the articular cartilage. The head can then be pulled laterally and guided into position. Note: avoid neurovascular injury.
Place rotator cuff sutures
Subscapularis and supraspinatus tendon
Once the shoulder is reduced, insert 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 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 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.
Reduce the metaphyseal fracture component
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.
After preliminary fixation of the reduction confirm the result visually and by image intensification.
There should be no gap and no step-off between the tuberosities. The inferior spike of the greater tuberosity should fit snugly into the fracture gap.
Moreover, one should pay attention to the correct rotational alignment. This can be assessed by the course of the bicipital groove.
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°.