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.


Reduce the humeral head split using digital pressure, periosteal elevators, and/or partially threaded pin(s) in either head ... enlarge

Reduction of the head split

Reduce the humeral head split using digital pressure, periosteal elevators, and/or partially threaded pin(s) in either head fragment.


Check the reduction by image intensification. enlarge

Check the reduction by image intensification.


The sagittal head split fracture line is typically not visible since it is covered by the rotator cuff. Since a step-less ... enlarge

The sagittal head split fracture line is typically not visible since it is covered by the rotator cuff. Since a step-less reduction is crucial, a supraspinatus-splitting incision is recommended to see the fracture line.


When anatomic, step-less reduction has been achieved, perform preliminary fixation with 2 or 3 K-wires. enlarge

Preliminarily fix the humeral head split

When anatomic, step-less reduction has been achieved, perform preliminary fixation with 2 or 3 K-wires. While lag screws may provide better fixation these may be in the way of the angular stable plate screws. Thus, K-wires, which can be easily changed, are preferable. If necessary, supplementary lag screws can be added for the humeral head fracture.


With the greater tuberosity properly reduced to the humeral head fragment, a defect remains into which the lesser tuberosity ... enlarge

Reduce the lesser tuberosity

With the greater tuberosity properly reduced to the humeral head fragment, a defect remains into which the lesser tuberosity must be reduced. This can be performed by pulling on the stay sutures in the subscapularis tendon. If the lesser tuberosity is not mobile enough, reduction can be facilitated by the additional help of a periosteal elevator.


The horizontal suture between the infraspinatus and the subscapularis tendons closes the tuberosities underneath the humeral ... enlarge

The horizontal suture between the infraspinatus and the subscapularis tendons closes the tuberosities underneath the humeral head. Confirm that the vertical fracture line is anatomical.


Reduce the shaft to the reduced proximal humerus and secure the reduction temporarily 2 or 3 K-wires. Make sure to place them .. enlarge

Reduction and preliminary fixation of the shaft

Reduce the shaft to the reduced proximal humerus and secure the reduction temporarily 2 or 3 K-wires. Make sure to place them from anterior, away from the foreseen plate position.


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.


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

Confirm the overall 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.


Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive ... 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.

To avoid redisplacing a provisionally stabilized fracture, rotate the C-arm to obtain the axial view instead of moving the patient’s upper limb.