Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus

INTRODUCTION: We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate. STEP 1: PREOPERATIVE PLANNING: To choose the right candidate, obtain a full understanding of the patient’s fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes. STEP 2: PATIENT POSITIONING: Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier. STEP 3: APPROACH: The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury. STEP 4: REDUCTION AND FIXATION OF THE TUBEROSITIES: THE KEY TO OBTAINING MARIONETTE-LIKE CONTROL: The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like. STEP 5: FRACTURE REDUCTION: After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate. STEP 6: FIXATION: IMPLANT-SPECIFIC CONSIDERATIONS: Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities. STEP 7: TENOTOMY OR TENODESIS OF THE LONG BICEPS TENDON: Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval. STEP 8: WOUND CLOSURE: Do not close the deltopectoral interval. STEP 9: REHABILITATION: As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol. RESULTS: In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively. Indications Contraindications Pitfalls & Challenges