Degree of head split fragmentation
These fractures vary with regard to the degree of head fragmentation. In less fragmented cases one may try to perform a reconstruction in the younger patient. Such a case is illustrated here. In more fragmented, non-reconstructible head splitting situations, a primary arthroplasty might be considered.
Anatomic (step-less) reduction of the humeral head fragments is key in this procedure.
Problems in achieving an anatomic reduction are:
limited visual and radiological control of the reduction
limited possibilities to fix the humeral head fragments
Nevertheless, a reconstruction of the head split fracture should be attempted in young patients at least to achieve a proper ingrowth of the tuberosities. This may result in a better situation for secondary prosthetic replacement – if necessary.
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.