If bone quality (minimal osteoporosis and limited comminution) is adequate, angular stable plate fixation offers potential for restoring function without arthroplasty. Be cautious, however, if reduction and fixation cannot be achieved satisfactorily.
Deltopectoral approaches generally provide the best access, but depending on fracture location and preoperative planning, anterolateral or transdeltoid can be considered.
Remember that in these fractures, a significant portion of the head is a part of the greater tuberosity fragment.
Anatomic reduction and elimination of varus deformity
Anatomic (step-less) reduction of the articular surface of the humeral head fragment is an essential part of this procedure.
Elimination of the varus deformity of the humeral head is also important.
Proper stabilization of the humeral head
In order to stabilize the humeral head appropriately, sufficient calcar support (screws) is necessary, to resist recurrent varus deformity.
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.