Fixation techniques enlarge

General considerations

There are several techniques to fix the greater tuberosity. The choice depends on

  • Size of the fragment
  • Bone quality (osteoporosis)
  • Degree of fragmentation

Techniques include:
A) Screw fixation (cannulated or standard screws; with or without washers)
This is mainly indicated for single large fragment with good bone quality.
B) Tension band sutures
Tension band sutures are more secure for patients with osteoporosis or comminution because they can be placed through tendon insertion sites, which may be stronger than the bone itself. The sutures can be placed in patterns that are optimal for stabilizing comminuted fractures.
Distal anchorage of tension band sutures can be through an anterior to posterior drill hole in the humerus (B1), to screws (B2), through suture anchors, or through the lateral cortex of the humerus just distal to the fracture site. Combinations of these techniques are possible.

Lag screw insertion enlarge

Lag screw

Insert a 3.5 mm lag screw. The lag screw should engage the medial cortex, distal to the articular surface. Cannulated screws may also be used.

Note: washers may make the screw heads more prominent and may result in shoulder impingement. Washers may be less problematic with more distally placed screws.

Check the fixation under image intensifier control.

Insertion of a second lag screw enlarge

If possible, insert a second lag screw in order to achieve rotational stability.

Note: make sure to avoid the axillary nerve by placing the second screw rather proximal.

Once the lag screw(s) are inserted, the K-wire(s) used for temporary fixation, and any stay sutures, should be removed.

Suture insertion into rotator cuff tendon enlarge

Tension band suture

The most secure anchorage for a tension band suture is in the rotator cuff tendon, just before it inserts into the bone. Pass the needle parallel to the bone, picking up a good bite of tendon. In osteoporotic patients, these sutures are stronger than when placed through the bone.

Hole drilled into humerus enlarge

Distal anchorage – drill hole
Distal anchorage can be done through a drill hole, typically horizontal.
Use a 2.0 mm drill bit to prepare the drill hole and a suture passer as needed.

Suture passed in figure-of-eight enlarge

The suture is passed, shown here in a figure-of-eight fashion through the bore hole and tied securely. The suture should be passed to stabilized comminution as needed.

Suture passed through a washer enlarge

Distal anchorage - screw
Pass the suture through a washer and the washer over a cortex screw. The screw is then placed into the neck region.
Note: be aware of the axillary nerve when inserting the screw.

Suture tightened and tied enlarge

The suture is then tightened and tied.

Using a screw rather than a drill hole for anchoring has the advantage of less space and a smaller approach required.

Alternative: suture deep to the fragment and over it enlarge

Alternative: intraosseous sutures
Sutures can be placed through the rotator cuff tendon, and around a small tuberosity fragment, so the suture lies deep to the fragment and over it. Distal suture anchorage is here shown with monocortical drill holes, through the humeral cortex distal to the tuberosity fragment. Several such sutures should be placed to increase stability.

Stabilization with K wires enlarge

Once the sutures are placed, the tuberosity fragment is reduced and stabilized with K-wires.

Fixation of fracture with individual sutures enlarge

Then, the sutures are tied individually to secure the fragment.
Option: the sutures could be placed as mattress sutures through the tendon proximal to the tuberosity fragment.
Note the monocortical drill holes through which the sutures are anchored distally.

Insert suture anchors enlarge

Tension band suture with proximal suture anchors

Especially in osteoporotic bone and/or multifragmentary tuberosities, additional suture anchors are helpful. If suture anchors are used, they have to be inserted prior to reduction

The suture anchor is placed directly into the margin of the fracture as close as possible to the articular cartilage.

Passing the sutures through the supraspinatus tendon enlarge

The sutures are then passed through the supraspinatus tendon, close to the medial insertion line of the supraspinatus.

Reduction and preliminary fixation of greater tuberosity enlarge

Reduce the greater tuberosity anatomically and secure it temporarily with one or two K-wires. Tighten and tie the sutures of the suture anchors.

Distal fixation of suture through washer enlarge

Distal fixation is illustrated here to a screw below the tuberosity fragment as shown previously.
Pass the sutures through the washer of a screw inserted in the metaphyseal region distal to the fragment greater tuberosity to anchor the tension ban. Tighten the suture to hold the tuberosity and fragment in place and to counteract the pull of the rotator cuff. Remove the inserted K-wires.

Tension band suturing combined with lag screw fixation enlarge

Combination of lag screw fixation and tension band suturing

The beneficial effect of tension band suturing can be combined with screw osteosynthesis.

Sutures to close rotator cuff interval enlarge

Repair of rotator cuff interval

Place several additional sutures or a running suture to close the lateral portion of the rotator cuff interval between the supraspinatus and subscapularis tendons. Any rotator cuff tear identified should also be repaired.