Preoperative evaluation includes a thorough clinical examination, focused
on the presence of any neurovascular deficit, and a standard radiographic
trauma series of the shoulder (an anteroposterior radiograph in the scapular
plane as well as lateral and axillary radiographs)
(Fig. 1). In order to minimize
discomfort, the axillary radiograph is usually done with the patient in a
supine position, under the supervision of the attending physician. Additional
radiographic views (anteroposterior in external rotation or in internal
rotation with 15° of cephalic tilt) and computed tomography can be useful
in selected patients.
After induction of general anesthesia, the patient is placed in the
beach-chair position with at least 60° of flexion at the waist. Two folded
sheets are placed beneath the medial border of the scapula to bring the
shoulder girdle forward, facilitating access to the glenohumeral joint. A
second-generation cephalosporin is administered preoperatively and for the
first postoperative day. The entire upper extremity is prepared and draped in
a manner that allows full and unrestricted positioning of the arm during the
procedure.
The fractured area is exposed with use of the lateral transdeltoid
approach, by developing an interval between the anterior and middle portions
of the deltoid muscle. The skin incision is made from the anterolateral tip of
the acromion, extending laterally and distally for approximately 6 to 7 cm
(Fig. 2). With use of blunt
dissection, the deltoid is split for 4 to 5 cm distal to the acromion
(Fig. 3). Rotation and
abduction of the proximal part of the humerus in this surgical window allows
adequate visualization of both tuberosities and the metaphyseal area, thus
minimizing the risk of iatrogenic injury to the axillary nerve. In patients
with metaphyseal extension of the fracture, the nerve is identified and
protected by the surgeon's finger.
Fixation of Four-Part Valgus Impacted Fractures
Soft-tissue attachments to the fracture fragments are carefully preserved
to prevent devascularization of the humeral head. The fracture lines between
the tuberosities are identified and gently separated, facilitating access to
the humeral head. Invariably, the humeral head is facing superiorly with the
tuberosities displaced to either side of it
(Fig. 4). While the impacted
valgus position of the humeral head fragment is preserved, two heavy
nonabsorbable sutures are passed through the bone of the head fragment, 1 cm
proximal to the fracture line at both the medial and the lateral border of the
articular surface. Additional sutures are then passed through each tuberosity
fragment (or near the site of tendon insertion into the fragment in
osteoporotic bone or when intensive comminution is present), and the rotator
cuff tendons are mobilized (Fig.
5). Finally, two additional pairs of sutures are inserted
laterally and medially through 2.7-mm drill holes in the diaphysis
(Fig. 6). These sutures are
then passed through the opposite tuberosity, near the musculotendinous
junction, and on to the neighboring area of the articular segment (i.e., from
the medial diaphysis toward the greater tuberosity and from the lateral
diaphysis toward the lesser tuberosity as well as to the adjacent articular
fragment). Once all sutures are in place, the tuberosities are approximated to
the diaphysis and recessed just below the top of the head fragment. Then each
suture is tied individually and to each other in a cruciate arrangement that
allows stable fixation of all parts of the fracture to all others
(Fig. 7). Any further loosening
of the sutures, because of fracture compression, is corrected by tying
additional knots between the free suture ends once more in a cruciate manner.
A schematic representation of the surgical technique in a four-part valgus
impacted fracture is shown in Figure
8 with the appropriate order of suture passage and the final
knot-tying. When completed, eight sutures will have been placed. Each
tuberosity contains four suture ends (two distinct sutures, one to each side
of the shaft fragment, and two shared sutures to the neighboring tuberosity),
and the head fragment contains two distinct sutures (both going through the
proximal holes in the shaft fragment) (Fig.
8, c). Any associated tears of the rotator cuff tendons
are also repaired with nonabsorbable sutures.
Fixation of Three-Part Fractures
(Fig. 9)
The same principles of fixation are used for three-part fractures. In this
type of fracture, the humeral head is typically rotated either internally or
externally, and care must be taken to achieve an adequate reduction in both
the frontal and sagittal planes. Initially, two sutures are placed through the
displaced greater tuberosity and then through the intact lesser tuberosity.
Two additional pairs of sutures are inserted laterally and medially through
2.7-mm drill holes in the diaphysis. These sutures are directed into the
opposite tuberosity (i.e., the medial diaphysis toward the greater tuberosity
and the lateral diaphysis toward the intact lesser tuberosity). When
completed, six sutures will have been placed, with each tuberosity containing
four suture ends (two distinct sutures to the opposite side of the shaft
fragment and two shared sutures to the neighboring tuberosity)
(Fig. 9, c). Once all
the sutures are in place, they are tied individually and then to each other in
a cruciate arrangement that allows stable fixation of all parts, one to the
other. Loosening of the sutures, because of fracture compression, is corrected
by tying additional knots between the free suture ends in a cruciate manner.
Associated rotator cuff tears are repaired with nonabsorbable sutures.
Fixation of Two-Part Fractures of the Greater Tuberosity
(Fig. 10)
When anterior dislocation of the shoulder accompanies fracture of the
greater tuberosity, the patient is lightly sedated in the emergency department
to facilitate reduction. Only one or two efforts are made to reduce the
dislocation by closed means. If closed reduction fails, the patient is
transferred to the operating room for open reduction under general anesthesia.
In our series, twenty-nine (52%) of the fifty-six patients with two-part
fractures of the greater tuberosity had a characteristic longitudinal tear in
the rotator interval. Complete avulsion of the supraspinatus tendon was seen
in five patients; complete avulsion of the infraspinatus tendon, in three; and
combined avulsion of both tendons, in two patients. To repair the fractures,
two sutures are passed from the upper part of the greater tuberosity through
the lower part of the metaphysis (through a corresponding drill hole) and into
the upper part of the cortical bed of the humeral head, near the fracture
line. Three additional sutures are passed through the lower part of the
tuberosity fragment and directed to the upper, middle, and lower parts of the
cortical bed and metaphyseal area. When completed, five sutures will have been
placed. Two distinct sutures connect the upper tuberosity fragment to the bed
of the head and shaft, while three sutures secure the lower part of the
tuberosity fragment to different fixation points in the shaft and metaphysis
(Fig. 10, c). Once
all sutures are in place, the cortical edge of the tuberosity fragment is
reduced to align with the edge of the fracture bed on the proximal part of the
humerus and the sutures are carefully tied in a cruciate fashion with care
being taken to prevent overreduction and to avoid further comminution. The
longitudinal tears in the rotator cuff are repaired with nonabsorbable
sutures.
Once the fracture has been repaired, gentle mobilization of the humerus of
up to 90° of abduction and 30° of external and internal rotation is
tested intraoperatively. The intraoperative impression of a stable construct
that moves as a single unit in all directions presumes the adequacy of
fixation and avoids the need for intraoperative radiographic examination. The
deltoid flaps are then reapproximated with use of absorbable sutures in a
figure-of-eight manner. The subcutaneous tissue is closed with absorbable
sutures, and the skin is closed with a subcuticular technique. A Velpeau
dressing secures the arm to the chest wall. It is converted to a simple sling
on the second postoperative day. Postoperative radiographs in the recovery
room document the adequacy of reduction and fixation
(Fig. 11).
A closely monitored, three-phase rehabilitation program is administered to
all patients. Initially, this consists of pendulum exercises starting on the
second postoperative day and continuing until the third or fourth
postoperative week. The second phase includes active-assisted range-of-motion
exercises for a period of five to ten weeks. In the final phase, commencing at
approximately three months after surgery, active dynamic shoulder motion and
strengthening exercises are prescribed until the sixth postoperative
month.
CRITICAL CONCEPTSINDICATIONS:According to the classification of proximal humeral fractures proposed by
Neer4, the following
types of fractures are appropriate for transosseous suture fixation:Two-part fractures of the greater tuberosity with or without an associated
shoulder dislocationThree-part fractures or three-part fracture-dislocationsFour-part valgus impacted fractures (with no more than 45° of
rotational deformity and <6 to 7 mm of lateral displacement of the head on
the anteroposterior radiograph)CONTRAINDICATIONS:Displaced four-part fractures or four-part fracture-dislocationsTwo-part surgical neck fractures (relative contraindication)Head-splitting or anatomical neck fracturesPOTENTIAL RISKS AND PITFALLS:The axillary nerve, which is the major anatomical structure in danger, is
located approximately 5 to 6 cm distal to the tip of the acromion. With the
transdeltoid approach, the deltoid split ends well proximal to the nerve since
only 1 to 2 cm of metaphyseal exposure is required to place the drill holes in
the shaft fragment. We believe that the main advantage of the lateral approach
compared with the more standard deltopectoral approach is the preservation of
the remaining blood supply of the humeral head, especially in four-part valgus
impacted
fractures5.From a technical point of view, the passage of all sutures prior to
fracture reduction is essential, as doing so can balance the deforming forces
of the rotator cuff tendons and facilitate mobilization of the tuberosity
fragments. The sutures are always tied in a cruciate fashion with use of a
specific order of knot-tying. Loosening of the knots because of fracture
compression is mitigated by tying additional knots between the free sutures
also in a cruciate manner. We prefer heavy number-5 nonabsorbable sutures
passed through 2.7-mm drill holes. The sutures are cut at the end of the
procedure onlyafter a stable construct has been achieved. With osteoporotic or
severely comminuted tuberosity fragments, the sutures are passed near the
musculotendinous junctions.The displaced tuberosities in four-part valgus impacted fractures are
always pulled down below the top of the head fragment with the shoulder in the
adducted position and are sutured not only to each other but also to the head
fragment as well as to the medial and lateral aspects of the diaphysis in a
manner that we believe neutralizes the deforming muscular forces. We avoid
disimpacting the head fragment from its valgus impacted position, thus
minimizing the risk of further disruption of the vulnerable blood supply of
the posteromedial hinge. Despite this "incomplete" fracture
reduction, it seems that the residual disturbance of normal anatomy does not
affect shoulder joint mechanics. The moment arm of the rotator cuff muscles is
preserved by suturing the tuberosities below the top of the impacted head. Use
of this approach is supported by the very low rate of early degenerative
arthritis seen in our series.In three-part fractures of the greater tuberosity, the sutures are passed
through the intact lesser tuberosity. This provides a stable construct and
restores the normal functional balance of the involved tendons, thus allowing
for early shoulder joint motion. In isolated two-part fractures of the greater
tuberosity, the displaced tuberosity is reduced to its anatomical position,
thus avoiding a mechanical block to abduction of the shoulder or obstruction
of external rotation because of posterior displacement of the greater
tuberosity. Our preference is for suture fixation of the greater tuberosity
fragment in patients with associated dislocation of the shoulder, regardless
of the extent of its postreduction
displacement6. Our
decision to internally fix the greater tuberosity in its anatomical position
is based on the nature of the injury rather than the degree of postreduction
displacement. Recently proposed guidelines of 5 or 10 mm of greater tuberosity
displacement as an indication for internal fixation cannot be followed because
displacement often exceeds 20 mm at the time of dislocation. Associated tears
of rotator cuff tendons, noted in the majority of our patients, are an
additional indication for early surgical intervention.Regarding two-part surgical neck fractures, we believe that the optimal
treatment is with plate-and-screw osteosynthesis. We do not recommend
transosseous suture fixation in this type of fracture as rotational
instability between the large proximal fragment and the narrow diaphysis can
often be problematic. In such patients, stable fixation can be achieved only
if the humeral head fragment is impacted to the diaphysis.Finally, integral to obtaining the optimum outcome is completion of the
full rehabilitation program. An important variation of our current regimen
over previous protocols is the early initiation of pendulum exercises on the
second postoperative day and their continuation for the first three to four
weeks. A full range of motion is restored in this manner without exerting
stress on the fixation.AUTHOR UPDATE:No changes or modifications of the original technique have been made since
its publication.
CRITICAL CONCEPTS
INDICATIONS:
According to the classification of proximal humeral fractures proposed by
Neer4, the following
types of fractures are appropriate for transosseous suture fixation:
Two-part fractures of the greater tuberosity with or without an associated
shoulder dislocationThree-part fractures or three-part fracture-dislocationsFour-part valgus impacted fractures (with no more than 45° of
rotational deformity and <6 to 7 mm of lateral displacement of the head on
the anteroposterior radiograph)
Two-part fractures of the greater tuberosity with or without an associated
shoulder dislocation
Three-part fractures or three-part fracture-dislocations
Four-part valgus impacted fractures (with no more than 45° of
rotational deformity and <6 to 7 mm of lateral displacement of the head on
the anteroposterior radiograph)
CONTRAINDICATIONS:
Displaced four-part fractures or four-part fracture-dislocationsTwo-part surgical neck fractures (relative contraindication)Head-splitting or anatomical neck fractures
Displaced four-part fractures or four-part fracture-dislocations
Two-part surgical neck fractures (relative contraindication)
Head-splitting or anatomical neck fractures
POTENTIAL RISKS AND PITFALLS:
The axillary nerve, which is the major anatomical structure in danger, is
located approximately 5 to 6 cm distal to the tip of the acromion. With the
transdeltoid approach, the deltoid split ends well proximal to the nerve since
only 1 to 2 cm of metaphyseal exposure is required to place the drill holes in
the shaft fragment. We believe that the main advantage of the lateral approach
compared with the more standard deltopectoral approach is the preservation of
the remaining blood supply of the humeral head, especially in four-part valgus
impacted
fractures5.From a technical point of view, the passage of all sutures prior to
fracture reduction is essential, as doing so can balance the deforming forces
of the rotator cuff tendons and facilitate mobilization of the tuberosity
fragments. The sutures are always tied in a cruciate fashion with use of a
specific order of knot-tying. Loosening of the knots because of fracture
compression is mitigated by tying additional knots between the free sutures
also in a cruciate manner. We prefer heavy number-5 nonabsorbable sutures
passed through 2.7-mm drill holes. The sutures are cut at the end of the
procedure onlyafter a stable construct has been achieved. With osteoporotic or
severely comminuted tuberosity fragments, the sutures are passed near the
musculotendinous junctions.The displaced tuberosities in four-part valgus impacted fractures are
always pulled down below the top of the head fragment with the shoulder in the
adducted position and are sutured not only to each other but also to the head
fragment as well as to the medial and lateral aspects of the diaphysis in a
manner that we believe neutralizes the deforming muscular forces. We avoid
disimpacting the head fragment from its valgus impacted position, thus
minimizing the risk of further disruption of the vulnerable blood supply of
the posteromedial hinge. Despite this "incomplete" fracture
reduction, it seems that the residual disturbance of normal anatomy does not
affect shoulder joint mechanics. The moment arm of the rotator cuff muscles is
preserved by suturing the tuberosities below the top of the impacted head. Use
of this approach is supported by the very low rate of early degenerative
arthritis seen in our series.In three-part fractures of the greater tuberosity, the sutures are passed
through the intact lesser tuberosity. This provides a stable construct and
restores the normal functional balance of the involved tendons, thus allowing
for early shoulder joint motion. In isolated two-part fractures of the greater
tuberosity, the displaced tuberosity is reduced to its anatomical position,
thus avoiding a mechanical block to abduction of the shoulder or obstruction
of external rotation because of posterior displacement of the greater
tuberosity. Our preference is for suture fixation of the greater tuberosity
fragment in patients with associated dislocation of the shoulder, regardless
of the extent of its postreduction
displacement6. Our
decision to internally fix the greater tuberosity in its anatomical position
is based on the nature of the injury rather than the degree of postreduction
displacement. Recently proposed guidelines of 5 or 10 mm of greater tuberosity
displacement as an indication for internal fixation cannot be followed because
displacement often exceeds 20 mm at the time of dislocation. Associated tears
of rotator cuff tendons, noted in the majority of our patients, are an
additional indication for early surgical intervention.Regarding two-part surgical neck fractures, we believe that the optimal
treatment is with plate-and-screw osteosynthesis. We do not recommend
transosseous suture fixation in this type of fracture as rotational
instability between the large proximal fragment and the narrow diaphysis can
often be problematic. In such patients, stable fixation can be achieved only
if the humeral head fragment is impacted to the diaphysis.Finally, integral to obtaining the optimum outcome is completion of the
full rehabilitation program. An important variation of our current regimen
over previous protocols is the early initiation of pendulum exercises on the
second postoperative day and their continuation for the first three to four
weeks. A full range of motion is restored in this manner without exerting
stress on the fixation.
The axillary nerve, which is the major anatomical structure in danger, is
located approximately 5 to 6 cm distal to the tip of the acromion. With the
transdeltoid approach, the deltoid split ends well proximal to the nerve since
only 1 to 2 cm of metaphyseal exposure is required to place the drill holes in
the shaft fragment. We believe that the main advantage of the lateral approach
compared with the more standard deltopectoral approach is the preservation of
the remaining blood supply of the humeral head, especially in four-part valgus
impacted
fractures5.
From a technical point of view, the passage of all sutures prior to
fracture reduction is essential, as doing so can balance the deforming forces
of the rotator cuff tendons and facilitate mobilization of the tuberosity
fragments. The sutures are always tied in a cruciate fashion with use of a
specific order of knot-tying. Loosening of the knots because of fracture
compression is mitigated by tying additional knots between the free sutures
also in a cruciate manner. We prefer heavy number-5 nonabsorbable sutures
passed through 2.7-mm drill holes. The sutures are cut at the end of the
procedure onlyafter a stable construct has been achieved. With osteoporotic or
severely comminuted tuberosity fragments, the sutures are passed near the
musculotendinous junctions.
The displaced tuberosities in four-part valgus impacted fractures are
always pulled down below the top of the head fragment with the shoulder in the
adducted position and are sutured not only to each other but also to the head
fragment as well as to the medial and lateral aspects of the diaphysis in a
manner that we believe neutralizes the deforming muscular forces. We avoid
disimpacting the head fragment from its valgus impacted position, thus
minimizing the risk of further disruption of the vulnerable blood supply of
the posteromedial hinge. Despite this "incomplete" fracture
reduction, it seems that the residual disturbance of normal anatomy does not
affect shoulder joint mechanics. The moment arm of the rotator cuff muscles is
preserved by suturing the tuberosities below the top of the impacted head. Use
of this approach is supported by the very low rate of early degenerative
arthritis seen in our series.
In three-part fractures of the greater tuberosity, the sutures are passed
through the intact lesser tuberosity. This provides a stable construct and
restores the normal functional balance of the involved tendons, thus allowing
for early shoulder joint motion. In isolated two-part fractures of the greater
tuberosity, the displaced tuberosity is reduced to its anatomical position,
thus avoiding a mechanical block to abduction of the shoulder or obstruction
of external rotation because of posterior displacement of the greater
tuberosity. Our preference is for suture fixation of the greater tuberosity
fragment in patients with associated dislocation of the shoulder, regardless
of the extent of its postreduction
displacement6. Our
decision to internally fix the greater tuberosity in its anatomical position
is based on the nature of the injury rather than the degree of postreduction
displacement. Recently proposed guidelines of 5 or 10 mm of greater tuberosity
displacement as an indication for internal fixation cannot be followed because
displacement often exceeds 20 mm at the time of dislocation. Associated tears
of rotator cuff tendons, noted in the majority of our patients, are an
additional indication for early surgical intervention.
Regarding two-part surgical neck fractures, we believe that the optimal
treatment is with plate-and-screw osteosynthesis. We do not recommend
transosseous suture fixation in this type of fracture as rotational
instability between the large proximal fragment and the narrow diaphysis can
often be problematic. In such patients, stable fixation can be achieved only
if the humeral head fragment is impacted to the diaphysis.
Finally, integral to obtaining the optimum outcome is completion of the
full rehabilitation program. An important variation of our current regimen
over previous protocols is the early initiation of pendulum exercises on the
second postoperative day and their continuation for the first three to four
weeks. A full range of motion is restored in this manner without exerting
stress on the fixation.
AUTHOR UPDATE:
No changes or modifications of the original technique have been made since
its publication.