Reduction/Fixation of the tuberosities
Sequence of repair:
Reduction/fixation of the tuberosity (thereby converting the 3-part fracture into a 2-part situation)
Reduction/fixation of the proximal humeral fragment to the shaft
For improved stability an additional (cannulated) lag screw can be placed in the lesser tuberosity.
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). This can be demanding, and may be easier with traction on the previously placed sutures, with properly placed retractors, and/or repositioning the arm.
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.
Reduction of the greater tuberosity
Direct reduction of the greater tuberosity fragment is performed by pulling the sutures or, …
… with instruments (eg, elevator) applied either through the incision (as illustrated) or through a separate stab incision.
Preliminary fix the greater tuberosity
Tighten and tie the transverse sutures in order to preliminarily fix the greater tuberosity fragment. Thereby, the 3-part fracture is converted into a 2-part situation.
Reduction of the head fragment
Distal traction, perhaps augmented with increased angulation, will help to reduce the fracture.
Use of an elevator
Sometimes, the incision allows insertion of an elevator to disimpact the humeral head, or to help to correct inclination/torsion and to restore a normal relationship of the medial fracture surface. The proximal fragment should be reduced anatomically to the shaft.
The actual process of reduction is done with image intensifier control.
Quite often, the humeral head is not stable enough and requires additional preliminary fixation using 2 or 3 K-wires.
Confirmation of reduction
The correct reduction must be confirmed in both AP and lateral views using image intensifier control.