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.IndicationsContraindicationsPitfalls & Challenges.