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Intra-articular Fractures:
What Have We Learnt?

Intra-articular Fractures: What Have We Learnt?

Bhavuk Garg, Rajesh Malhotra

Introduction
Life is movement, Movement is life. This sentence has always been cited as the steering
principle of fracture care.1 This principle is more than vital in the management of intra-
articular fractures: fractures that extend or involve the articular cartilage. It is an irony
that junior most orthopedic surgeons operate most of the intra-articular fractures like
patellar fractures, malleolar fractures, neck femur fractures, olecranon fractures, etc.
(Fig. 1.1).
Intra-articular fractures, if not properly treated, inevitably lead to stiffness, pain or
osteoarthritis (post-traumatic). In his famous book on conservative management of
fractures entitled, “The Closed Treatment of Common Fractures”, Sir John Charnley

Figure 1.1: Common intra-articular fractures, which are usually

managed by junior most orthopedic surgeons
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advocated nonoperative management of intra-articular fractures.2 Several other authors
including Neer et al3 and Stewart et al4 also advocated the same. The main reason for
this favor for conservative management was unavailability of proper internal fixation
devices as well as lack of proper understanding of orthopedic surgical principles.
After foundation of AO group in 1958 at Biel, Switzerland, a lot of improvements in
orthopedic internal fixation devices as well as an improved understanding of orthopedic
surgical principles prevailed. AO/ASIF group reported better outcome of intra-articular
fractures with open reduction and internal fixation.5 Several other authors echoed similar
Intra-articular Fractures

results.6,7 It was also observed that intra-articular fractures that underwent ORIF as
well as immobilization had much more stiffness and worse outcome than fractures,
which were either, treated with ORIF and early motion, or, immobilization alone.8 AO
group also advocated that intra-articular fractures behave in a different biological and
functional manner as compared to diaphyseal fractures.

Principles of Intra-articular Fracture Management

Müeller et al1 enunciated the AO principles of intra-articular fracture care that anatomical
reduction as well as absolute stability is vital to the optimum healing of articular
fractures. These factors also enable the patient for early motion, leading to best outcome
for intra-articular fractures. Mitchell and Shepard9 reported that articular cartilage
regenerate after intraarticular fractures provided anatomical reduction and absolute
stability. Salter et al10 showed that continuous passive motion stimulates articular
cartilage healing as well as regeneration. Schatzker et al 11 pointed out following
principles of intra-articular fracture treatment:
1. Immobilization of intra-articular fractures leads to stiffness of joint.
2. Immobilization combined with ORIF of intra-articular fractures causes much more
stiffness.
3. Depressed and impacted articular fragments will not reduce by closed manipulation
or ligamentotaxis.
4. Big articular defects do not fill by fibrocartilage, resulting in instability due to their
displacement.
5. Anatomical reduction and as well as absolute stability is vital to the optimum healing
of articular fractures (Fig. 1.2).
6. Metaphyseal voids should be bone grafted (Fig. 1.3) (however, with use of current
locking plates, this has become controversial).
7. Any metaphyseal and diaphyseal displacements should be reduced to prevent extra
load on the joint (This reduction need not to be anatomical).
8. It is extremely important to restore the joint congruity as well as axial alignment.
9. Early motion is essential for optimal healing of articular cartilage and best outcome.
Stable internal fixation is a must for this.

Basic Sciences Facts about Intra-articular Fractures

Articular cartilage is an aneural structure with no blood or lymphatic supply and is
dependent upon diffusion from surrounding tissues for nutrition. The cartilage matrix
has got hypoxic environment and depends on anaerobic glycolysis and mainly consists
of type-2 collagen and proteoglycans important for the joint. This structure makes
articular cartilage very sensitive to injury and confers to it poor reparative potential.
Relationship between articular cartilage injury and subsequent development of
osteoarthritis is a complex phenomenon. Articular cartilage healing leads to formation
of fibrocartilage, however it does not restore the structural and mechanical properties
of a normal articular cartilage.12 Larger the defect, larger is the alteration of mechanical
properties; larger is the risk of progression to osteoarthritis.12 Severity of articular
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Intra-articular Fractures: What Have We Learnt?

Figure 1.2: A depressed intra-articular fracture of proximal tibia managed by anatomical reduction,
stable fixation and early motion. Patient had excellent functional result

Figure 1.3: Bone grafting

should be done in cases of
metaphyseal voids, particu-
larly in osteoporotic bones
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cartilage injury has also been linked to the outcome of intra-articular fractures. Marsh
et al13 reported that development of post-traumatic osteoarthritis correlate with the
severity of articular damage. Several other authors have also reported the same
findings.14,15
Effect of step-off defects and development of post-traumatic osteoarthritis has also
been studied in detail. The thickness of articular cartilage varies from joint to joint and
is also variable at different sites in a single joint 16 (Ankle 1.0–1.62 mm, Knee
1.69–2.55 mm, Patella 1.76–2.59 mm). Articular cartilage step-offs do remodel but have
Intra-articular Fractures

limited capability.17 Articular step-offs that exceeds the full thickness of articular cartilage
usually do not remodel completely. These step offs lead to localized and altered
mechanical peak pressures, leading to rapid progression of osteoarthritis.18 Usually a
step-off of less than 2 mm is acceptable.12 Extra-articular deformities also affect the
development of osteoarthritis after intra-articular fractures by virtue of altered
mechanical axis and eccentric joint loading.19 Management of soft tissue surrounding
joint is also very important in determining the optimal outcome following intraarticular
fractures.20,21 Joint immobilization causes raised joint pressure leading to loss of nutrition
and chondrocyte death. There is also liberation of several enzymes like proteases, which
lead to articular surface degeneration. Motion promotes healing of full thickness articular
cartilage defects with hyaline articular “cartilage like” material.

Imaging of Intra-articular Fractures

A detailed radiographic work-up is essential to understand the fracture anatomy of
intra-articular fractures. Anteroposterior and lateral X-rays alone are usually not
sufficient. Computed tomography is very useful for delineating the fracture configuration
and has proved invaluable in current planning and management of intra-articular
fractures (Fig. 1.4). This is more important in certain complex fractures like acetabular
fractures, distal humerus fractures, distal tibia fractures, etc. CT gives detailed description
of articular gap and step offs.22,23 According to a study by Tornetta,24 surgical plan
changed in 64% cases after CT and additional information was available in 82% cases.
Recently intraoperative 3D fluoroscopy has been introduced, which usually provides
inferior quality images than intraoperative CT but is much cheaper and has similar
clinical value. Several studies26,27 have proved the usefulness of this investigation and
have led the surgeons to change their implant placement during surgery.

Timing to Operate
Intra-articular fractures rarely require urgent ORIF except in open fractures, fractures
with neurovascular complications, associated compartment syndrome and irreducible
fracture dislocations. Proper management of intra-articular fractures requires
appreciation of fracture anatomy as well as soft tissue injury. Usually complex intra-
articular fractures are associated with significant trauma to surrounding soft tissue.
Surgical approach through such traumatized soft tissue envelop, if done early, will
cause additional trauma to soft tissue envelope, leading to problems related to wound
healing and infection (Fig. 1.5). So it is prudent to wait for soft tissue healing before
embarking upon the surgery. This can vary from days to weeks.11 In between the time,
one can use bridging external fixators also known as traveling fixators (Fig. 1.6) with
definitive fixation later on. Several indirect reduction techniques and biological fixation
concepts have also come to reduce trauma to the soft tissue envelope.
It is also important to assess the resources of surgeon as well as of the institution
and cases should be referred to higher centers if facilities are inadequate.

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Intra-articular Fractures: What Have We Learnt?

Figure 1.4: CT gives much
detailed description of intra-
articular fracture anatomy.
Die-punch component (arrow)
was easily identified on CT in
this case

Figure 1.5: Infection and wound healing problems are

common if surgery is done early through traumatic
soft tissue envelope

Surgical Principles (Figs 1.7A to E)

An atraumatic surgical approach should be used. Both minimally invasive and open
approaches are available, however all articular fragments must be reduced anatomically
and preferably under vision. Ligamentotaxis will only work for fragments with ligament
attachment (i.e. some split fractures of the tibial plateau).
Surgical reconstruction begins with anatomical reduction of the articular surface.
Quite often the depressed fragments need to be elevated. Bone graft or bone substitute
is used to support this elevated fragment if necessary. This articular reduction is then
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Intra-articular Fractures

Figure 1.6: Traveling temporary fixator

Figures 1.7A to E: (A) AP and lateral X-rays of intra-

articular distal humerus fracture; (B) Exposure of
fracture; (C) Reduction of articular surface; (D) Provi-
sional fixation of fracture with K wires; (E) Postope-
rative X-rays showing definitive fixation with plates
and screws

secured with K-wires or screws and then this articular block is fixed to the metaphysis
with the help of definitive implant. Nowadays, periarticular anatomical locking plates
have become indispensable in the management of these fractures. All measures are
taken to minimize trauma to the surrounding soft tissue.

Postoperative Rehabilitation
Several studies29-31 have reported beneficial effects of early motion in intra-articular
fractures. Active assisted exercises are preferable, muscles and joints both are rehabili-
tated. Continuous passive motion (CPM) does not prevent muscle atrophy, however; it
is still a useful tool in the management of intra-articular fractures. Sometimes, stability
of fixation can be of concern. Some sort of additional stability can be provided with
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ROM-splints. Plaster immobilization should not be used after ORIF of intra-articular
fractures as it leads to more stiffness. Patients are kept non-weight bearing until articular
fracture is healed.

Emerging Technologies
T1-rho MRI mapping, which measure relaxation times in cartilage can assess specific
components of articular cartilage biochemistry and ultra-structure. It has shown to be

Intra-articular Fractures: What Have We Learnt?

more sensitive to cartilage degradation than conventional MRI techniques.32-34
Recently virtual operative plan can be made preoperatively with the help of electronic
templating. Electronic templating is also useful in planning of implant needs as well as
positioning over the bone fragments. Superior softwares are being introduced to improve
the efficacy as well as extent of application of this technology.35
Navigation is another important breakthrough which helps in the management of
complex intra-articular fractures like acetabular fractures. Both CT based as well as
fluoroscopy based navigations are available in today’s world.36,37
New technologies are being added to orthopedics day by day. Some technologies
like nanotechnology have the potential to change the current orthopedic practice
completely.

References
1. Muller ME, Allgower M, Schneider K, Willenegger H. Manual of internal fixation, 2nd edn.
Springer, Berlin Heidelberg, New York, 1979.
2. Charnley J. The closed treatment of common fractures. Livingstone, Edinburgh, 1961.
3. Neer C, Graham SA, Shelton ML. Supracondylar fracture of the adult femur. J Bone Joint
Surg. 1967;49 A:591-613.
4. Stewart M, Sisk D, Wallace SL. Fractures of the distal third of the femur. J Bone Joint Surg.
1966;48A:784-807.
5. Wenzl H, Casey PA, Hebert P, Belin J. Die operative Behandlung der distalen Femurfraktur.
AO Bulletin, Bern. 1970.
6. Mize RD, Bucholz RW, Grogan DP. Surgical treatment of displaced comminuted fractures of
distal end of femur. J Bone Joint Surg. 1982;64A:871-9.
7. Schatzker J, Lampert DC. Supracondylar fractures of the femur. Clin Orthop. 1979;138:77-
83.
8. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience. Clin
Orthop. 1979;138:94-104.
9. Mitchell N, Shepard N. Healing of articular cartilage in intra-articular fractures in rabbits.
J Bone Joint Surg. 1980;62A:628-34.
10. Salter RB, et al. The biological effects of continuous passive motion on the healing of full
thickness defects in articular cartilage: an experimental investigation in the rabbit. J Bone
Joint Surg. 1980;62A:1232-51.
11. Schatzker J, Tile M. The rationale of Operative Fracture Care, 3rd edn, Springer, Berlin
Heidelberg, New York, 2005.
12. Dirschl DR, Marsh L, Buckwalter JA, et al. Articular fractures. J Am Acad Orthop Surg.
2004;12:416-23.
13. Marsh JL, Buckwalter J, Brown T, et al. Articular fractures: Does an anatomic reduction
really change the result? J Bone Joint Surg Am. 2002;84:1259-71.
14. Crutchfield EH, Seligson D, Henry SL, Warnholtz A. Tibial pilon fractures: A comparative
clinical study of management techniques and results. Orthopedics. 1995;18:613-7.
15. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intra-
articular calcaneal fractures: Results using a prognostic computed tomography scan
classification. Clin Orthop. 1993;290:87-95.
16. Shepherd DET, Seedhom BB. Thickness of human articular cartilage in joints of the lower
limb. Ann Rheum Dis. 1999;58:27-34.
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17. Lovász G, Llinás A, Benya PD, Park SH, Sarmiento A, Luck JV Jr. Cartilage changes caused
by a coronal surface stepoff in a rabbit model. Clin Orthop. 1998;354:224-34.
18. Brown TD, Anderson DD, Nepola JV, Singerman RJ, Pedersen DR, Brand RA. Contact stress
aberrations following imprecise reduction of simple tibial plateau fractures. J Orthop Res.
1988;6:851-62.
19. Rasmussen PS. Tibial condylar fractures as a cause of degenerative arthritis. Acta Orthop
Scand. 1972;43:566-75.
20. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the
Intra-articular Fractures

treatment of pilon fractures. J Orthop Trauma. 1992;6:195-200.

21. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of
severe tibial pilon fractures: A study of three techniques. J Orthop Trauma. 2001;15:153-60.
22. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intra-
articular calcaneal fractures: Results using a prognostic computed tomography scan
classification. Clin Orthop. 1993;290:87-95.
23. Cole RJ, Bindra RR, Evanoff BA, Gilula LA, Yamaguchi K, Gelberman RH. Radiographic
evaluation of osseous displacement following intra-articular fractures of the distal radius:
Reliability of plain radiography versus computerized tomography. J Hand Surg [Am].
1997;22:792-800.
24. Tornetta P, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res.
1996;323:273-6.
25. Kendoff D, Citak M, Gardner MJ, Stübig T, Krettek C, Hüfner T. Intraoperative 3D imaging:
value and consequences in 248 cases. J Trauma. 2009;66(1):232-8.
26. Kendoff D, Citak M, Gardner M, Kfuri M Jr, Thumes B, Krettek C, et al. Three-dimensional
fluoroscopy for evaluation of articular reduction and screw placement in calcaneal fractures.
Foot Ankle Int. 2007;28(11):1165-71.
27. Kendoff D, Gardner MJ, Citak M, Kfuri M Jr, Thumes B, Krettek C, et al. Value of 3D
fluoroscopic imaging of acetabular fractures comparison to 2D fluoroscopy and CT imaging.
Arch Orthop Trauma Surg. 2008;128(6):599-605.
28. Kendoff D, Pearle A, Hüfner T, Citak M, Gösling T, Krettek C. First clinical results and
consequences of intraoperative three-dimensional imaging at tibial plateau fractures. J
Trauma. 2007;63(1):239-44.
29. Salter RB. Continuous passive motion: from origination to research to clinical applications.
J Rheumatol. 2004;31(11):2104-5.
30. Salter RB. History of rest and motion and the scientific basis for early continuous passive
motion. Hand Clin. 1996;12(1):1-11.
31. Salter RB. The physiologic basis of continuous passive motion for articular cartilage healing
and regeneration. Hand Clin. 1994;10(2):211-9.
32. Souza RB, Stehling C, Wyman BT, Hellio Le Graverand MP, Li X, Link TM, et al. The effects
of acute loading on T1rho and T2 relaxation times of tibiofemoral articular cartilage.
Osteoarthritis Cartilage. 2010;18(12):1557-63.
33. Zarins ZA, Bolbos RI, Pialat JB, Link TM, Li X, Souza RB, et al. Cartilage and meniscus
assessment using T1rho and T2 measurements in healthy subjects and patients with
osteoarthritis. Osteoarthritis Cartilage. 2010;18(11):1408-16.
34. Bolbos RI, Ma CB, Link TM, Majumdar S, Li X. In vivo T1rho quantitative assessment of
knee cartilage after anterior cruciate ligament injury using 3 Tesla magnetic resonance
imaging. Invest Radiol. 2008;43(11):782-8.
35. Pilson HT, Reddix RN Jr, Mutty CE, Webb LX. The long lost art of preoperative planning—
resurrected? Orthopedics. 2008;31(12).
36. Hoffmann M, Schröder M, Lehmann W, Kammal M, Rueger JM, Herrman Ruecker A. Next
generation distal locking for intramedullary nails using an electromagnetic X-ray-radiation-
free real-time navigation system. J Trauma Acute Care Surg. 2012;73(1):243-8.
37. Oberst M, Hauschild O, Konstantinidis L, Suedkamp NP, Schmal H. Effects of three-
dimensional navigation on intraoperative management and early postoperative outcome
after open reduction and internal fixation of displaced acetabular fractures. J Trauma Acute
Care Surg. 2012 Jun 14. [Epub ahead of print].

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2 Glenoid Fractures

Glenoid Fractures
Vikram A Mhaskar, J Maheshwari

Introduction
Scapular fractures comprise of approximately 1% of all fractures. Of these, one-third
affect the glenoid process, including the fractures of glenoid cavity and neck. More
than 90% of glenoid fractures are minimally displaced and can be managed
nonoperatively, the other 10% need surgery. The displaced fractures may affect stability
of the shoulder if they involve glenoid rim or result in substantial tilt of the glenoid.
These fractures can occur in isolation, in association with other scapular fractures, and
as a part of glenohumeral dislocations. They often occur due to high-energy trauma, or
fall on an out-stretched arm.

Relevant Anatomy
Glenoid inclination is variable. On an average, it is inclined 4.25 degrees superiorly and
is in retroversion of 1.23 degrees. Any significant change in inclination may result in an
unstable shoulder. The glenoid width averages 28.8 + 1.6 mm in males and 23.6 +
1.5 mm in females. Its height averages 37.5 + 2.2 mm in males and 32.6 + 1.8 mm in
females.
The shallowness of the fossa and relatively loose articulation between the shoulder
and the rest of the body allows the arm to have tremendous mobility at the expense of
being much easier to dislocate than most other joints in the body. The head of the
humerus is approximately 4 times the size of the glenoid fossa, and hence loss of
glenoid surface may become a reason for recurrent dislocation.

Clinical Features
Common presentation of a glenoid fracture is in association with an acute anterior
dislocation of the shoulder, which has the tendency to re-dislocate after reduction. On
X-rays, one can see a fracture of the anterior glenoid rim. Posterior glenoid fractures
often result in persistent posterior dislocation. Glenoid fossa fractures have few
symptoms. Often these injuries are associated with a multiply injured patient, and are
associated with serious chest injury. For this reason such injuries are commonly missed.
One must look for brachial plexus and vascular injuries, sometimes associated with
‘high-velocity’ trauma.

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Intra-articular Fractures

Figure 2.1: Classification of glenoid fractures

Radiographic Features
Trauma series including a true AP of the shoulder and axillary (mostly possible) form
the basic views. Computed tomography (CT) scan, particularly a 3-D CT scan with
‘end-on glenoid’ with head removed, gives the best idea about the type of fracture.
Magnetic resonance imaging (MRI) is sometimes done to assess for the associated rotator
cuff injuries.

Classification
Ideberg and Goss classified1 these fractures into six types (Fig. 2.1):
Type I: Fractures of the glenoid rim, subdivided into type Ia (anterior rim), and type
Ib (posterior rim) fractures.
Type II: Transverse or oblique fractures through the glenoid fossa extending into the
lateral border of the scapula so that the inferior triangular fragment, if
displaced, may result in inferiorly subluxated humeral head.
Type III: Oblique fracture through the glenoid fossa that exits at the mid superior
border of the scapula, often associated with acromion/clavicular fracture or
acromioclavicular joint dislocation.
Type IV: Horizontal fracture line extending through and through to the medial border
of the scapula.
Type V: Combination of type IV with a fracture separating inferior (Va), superior
(Vb) or both halves (Vc) of the glenoid.
Type VI: Severe comminuted fracture of the glenoid fossa.

Management
Non-surgical: Minimally displacement (less than 5 mm step and less than 5 mm
separation) is acceptable as it does not cause long-term issues. Usually a sling for 2 to
3 weeks is adequate. Most fractures heal in 6 weeks.
Surgical: Surgical indications of glenoid fossa fractures broadly depend upon the
following:
a. Articular step of more than 5 mm
b. Separation of fragments enough to cause non-union (more than 5 mm)
c. Fracture pattern that allows displacement of the head out of the glenoid (type I
and II)

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Depending upon the type of fracture, the treatment is as follows:
Type I a,b Open reduction required if fracture involves more than 1/4th of the glenoid
fossa, and is associated with shoulder instability. Fixation is done via anterior
approach for type Ia and posterior approach for type Ib fractures.
Type II Excellent results are obtained with open reduction and internal fixation,
usually from posterior approach.
Type III Goss recommends open reduction internal fixation for a step off of 5 mm

Glenoid Fractures
or more involving the articular surface. Rockwood 2 recommends
arthroscopic evaluation and assisted reduction with limited open surgery,
by using a heavy pin in the coracoid to manipulate the upper glenoidal
aspect.
Type IV Open reduction only recommended in a separated fracture or that with a
step off, mainly when the superior fragment of the glenoid is displaced
laterally.
Type V Conservative treatment, if humeral head is well centered.
Type VI Best treatment is early motion.

Approaches
Thorough knowledge of the surgical anatomy is necessary to adequately stabilize a
glenoid fracture. It is important is to decide from which side can the fracture be best
approached—anterior, posterior, superior or combined. Anterior rim fracture can be
approached from front (deltopectoral approach). Posterior rim fractures and all the
other fractures are best approached from behind. In some, an additional exposure from
superiorly is required to control the superior fragment. Basic orthopedic and shoulder
instruments are required. K-wires, 4 mm cannulated screws, and small fragment recon
plates form the mainstay of implants required to fix these fractures.
Deltopectoral approach: This approach is used essentially for anterior glenoid rim fractures.
The approach is similar to that used for any anterior surgery on the shoulder, and
consists of the following steps (Fig. 2.2).
The patient is positioned in beech-chair position. The bony landmarks are marked,
particularly the coracoid. A 10 cm skin incision is made extending from lateral third of
the clavicle, going over the coracoid, towards insertion of the deltoid (Fig. 2.2A). The
cephalic vein is identified (Fig. 2.2B), and mobilized laterally. The deltopectoral interval
is opened (Fig. 2.2C). The tip of the coracoid can be felt in the superior part of the
incision. Coracoid is the ‘light house’ of anterior shoulder exposure. Undersurface of
the deltoid and pectoralis are mobilized to be able to retract them. A self-retaining
retractor is handy at this stage (Fig. 2.2C). The conjoint tendons attaches on the tip of
the coracoid, and is covered with clavipectoral fascia. The clavipectoral fascia lateral to
the conjoint tendon is cut to retract the conjoint tendon medially. The self-retaining
retractor is now shifted between conjoint tendon medially and deltoid laterally. The
shoulder is externally rotated at this stage. The fibers of underlying subscapularis come
to vision, running medial to lateral, getting attached to the lesser tuberosity (Fig. 2.2D).
The bursa covering the muscle is removed by blunt dissection. The tendinous upper
border of the subscapularis can be felt at the base of the coracoid. The lower border of
the subscapularis corresponds to a leash of vessels running transversely from medial to
lateral (Fig. 2.2D), commonly termed as ‘three sisters’. These vessels are carefully ligated.
Once the attachment of the subscapularis and its upper and lower borders are identified,
its tendon is cut 2.5 mm from the attachment. 3 to 4 stay sutures are placed in the cut
edge of the subscapularis for later closure (Fig. 2.2E). The plane between the subscap
and anterior capsule is developed. The muscle is retracted medially. The underlying
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Intra-articular Fractures

Figures 2.2A to G: Deltopectoral approach for glenoid exposure

anterior capsule is likewise cut from the lessor tuberosity, and retracted medially.
The anterior part of the glenoid rim can now be seen and tilt (Fig. 2.2F). A special
humeral head retractor (Facuda) comes handy in keeping the head out of the way
(Fig. 2.2G). Often one needs to carefully dissect the capsule from lower pole of the
glenoid to adequately expose the fracture extending to the lower pole. Great care needs
to be taken while doing this as the axillary nerve is close. The fracture is reduced under
direct vision. It is temporarily fixed with one or two K-wires. It is best to use 4 mm
cannulated screws to fix the fracture. One needs to be careful while drilling and fixing
the anterior rim as the axillary nerve is close. Attention is required to drill in mediolateral
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Glenoid Fractures
Figures 2.3A to F: Posterior approach for glenoid exposure (A) Bony anatomy of the shoulder
from behind; (B) Skin incision; (C) Posterior approach muscles under the deltoid; (D) Internervous
plane between infraspinatus and teres minor; (E) Capsule over the joint; (F) Exposing of glenoid

direction to avoid putting the screw intra-articular. An osteotomy of the coracoid may
be required for better exposure.
Posterior approach (Figs 2.3A to F): With the patient in lateral decubitus position, bony
landmarks are drawn (Fig. 2.3A). A curved skin incision is made starting at lateral
prominence of acromion, going medially along scapular spine and distally to the inferior
angle of scapula (Fig. 2.3B). The deltoid is detached sharply from the scapular spine
alongwith some periostium. Interval between the posterior deltoid and underlying
infraspinatus muscle is created by careful blunt dissection with finger. The detached
deltoid is retracted laterally. Under the deltoid one would find the bellies of infraspinatus
and teres minor (Fig. 2.3C). A plane can be identifies more easily between the two at the
lateral end where they attach to the posterior part of the greater tuberosity. Further
dissection is between the infraspinatus and teres minor (Fig. 2.3D), as these muscles are
suplied by two different nerves (suprascapular and axillary nerves respectively). Under
the muscles, one will find the posterior capsule covering the head, which can
appropriately expose the glenoid (Fig. 2.3E). The exposure can be further improved by
detaching the origin of triceps from infragenoid tubercle, and by placing a head retractor
to expose the glenoid (Fig. 2.3F).
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For more extensile exposure, particularly to expose superior part of the glenoid and
lateral border of the scapula, infraspinatus or teres minor is detached from the greater
tuberosity. These can subsequently be reattached at the end of the operation with suture
anchors. Long head of the triceps from inferior glenoid tubercle may have to be removed
to gain access to inferior rim of the glenoid, and to the lateral boarder of the scapula.
Suprascapular nerve medially and axillary nerve inferiorly are at risk in this exposure.
Superior approach: This may be required as an additional approach to control the superior
Intra-articular Fractures

glenoid fragment. It is a direct approach to the superior part of the glenoid, which can
be reached by splitting the fibers of trapezius and supraspinatus.
Tips in reduction and fixation:
• Adequate exposure, and knowledge of structures at risk, particularly axillary nerve
and suprascapular nerve
• Reduction, either direct or indirect using thick K-wires as joy sticks
• Temporary fixation with thin K-wires over which cannulated screws can be fixed
• Exact size and placement of the screw is important, particularly to avoid intra-
articular placement of the screw.

Postoperative Management and Rehabilitation

The shoulder area does not respond too well to the operative treatment.
It is important to device a rehabilitation protocol that will allow adequate healing of
the fracture as well as preserve motion at the shoulder joint. Passive movements should
be performed from day one, at least in selected directions. Initially, near full time wearing
of a shoulder brace which keeps the shoulder 20 degree abduction and in neutral rotation.
Early supervised range of motion exercises is recommended.
If full subscapularis take down is done, brace is worn in 0 degree external rotation
for 4 weeks. 30 degrees of internal rotation and 90 degrees of elevation is allowed.
External rotation movement is limited to 30 degrees for 3 weeks.
Active resisted exercises started at 3 weeks when muscle healing has occurred.
Activities against resistance are started only after radiological evidence of healing is
seen. It is very important to strengthen the muscle groups around the shoulder for
optimal rehabilitation.

COMPLICATIONS
1. Shoulder stiffness: Some degree of shoulder stiffness may always be present but can
be largely prevented with appropriate operative mobilization. Some patients may
need manipulation under anesthesia if expected ROM is not achieved.
2. Secondary degenerative arthritis: Though incidence of osteoarthritis is less in upper
limb fractures, but gross malreduction, significant step at the fracture site and undue
shearing force due to the tilt of the glenoid may result in early osteoarthritis. Pain is
the main symptom. Some patients may ultimately require a shoulder replacement.
3. Axillary nerve injury: Axillay nerve is pretty close to the inferior pole of the glenoid
and can be easily damaged as a result of traction or direct injury. It can be prevented
with appropriate surgical approach.
4. Failure of fixation: Often it may not be possible to achieve adequate fixation of
fragments. It is prudent in such cases to go slow with rehabilitation.
5. Infection: This is an uncommon a complication as in other operations. A contused
skin due to injury itself, at the site of the incision, may lead to wound healing
problems. Infection can be prevented by meticulous surgery. Maintaining asepsis
and use of appropriate perioperative antibiotics can minimize this complication.
6. Instability: Appropriate treatment of associated injuries to the rotator cuff and other
14 stabilizing structures may prevent this complication.
 2
RESULTS
Glenoid fossa fractures are rare. The indication for conservative or surgical treatment is
controversial, especially because of limited reports in the literature. Many authors prefer
conservative treatment for most type of glenoid fractures. 3 Kligman and Roffman
reported on a small series of four patients with displaced, intra-articular glenoid fossa,
who were treated either surgically or conservatively. After an average 7-year follow-
up, clinical and radiographic results were satisfactory in all patients. Kraus et al3 reported

Glenoid Fractures
good results of type 1b fractures treated conservatively in elderly patients.
More recently, several authors have shown good results with open reduction and
fixation of some of these fractures. They used Ideberg classification in planning the
surgical approach. Schandelmaier et al published 10 year follow-up of glenoid fractures
treated by operation, with good to excellent results in majority. Anavian et al4 also
suggested surgical treatment for complex, displaced intra-articular glenoid fractures
with or without involvement of the scapular neck. Mayo et al5 published results of
surgical treatment in twenty-seven patients at mean follow-up 43 months from surgery.
Anatomic reconstruction was achieved in 24 (89%) patients. They concluded that
anatomic surgical reconstruction with a low complication rate and good functional
outcome can be obtained for most patients of glenoid fractures treated surgically. Leung
et al6 reported the results of treating 14 glenoid fractures with open reduction and
stable internal fixation, with an average follow-up period of 30.5 months. They concluded
that the operative treatment for these fractures gives good and predictable results.
The recent trend is to do arthroscopic assisted reduction and percutaneous fixation
of glenoid fractures. Methods of indirect reduction using a thick K-wire as joy stick,
and safe corridors for percutaneous internal fixation under arthroscopic vision have
been described.7 Sugaya et al8 reported successful results by treating anterior glenoid
rim fractures, with average 27% bone loss, arthroscopically.

Illustrative Case
This 30-year-old man fell from a bike and sustained injury to his right (dominant)
shoulder. It was diagnosed as shoulder dislocation. The attending surgeon made an
attempt at closed reduction. He noticed that, though it could be easily reduced, but it
was dislocating with equal ease. The X-ray showed fracture of the anterior rim of the
glenoid (Fig. 2.4A). CT scan confirmed the presence of a significant fracture of the
anterior rim of the glenoid. A further study with 3D CT showed the exact size of the
glenoid fragment, constituting nearly 40% of the glenoid (Fig. 2.4B).
Arthroscopic reduction and fixation of the fragment was carried out. Arthroscopic
surgery was done with the patient in lateral position, and arm in traction. Standard
posterior viewing portal was made. Instruments were introduced from anteroinferior
(instrument) portal. Hematoma was cleaned using a shaver, and the fracture evaluated.
Reduction of the fracture was achieved by manipulating the fragment using a probe. In
order to get a direct access to the anterior rim of the glenoid an additional 5’o clock
portal was made through the subscapularis (Fig. 2.4C). Two guide wires were passed
into the anterior glenoid fragment to fine tune the reduction, and also to temporarily
stabilize it. After careful drilling over the guidewires, two 4 mm cannulated lag screws
were passed to fix the fracture (Fig. 2.4D). The stability of the reduction was checked
and found satisfactory. The patient was kept in a sling with intermittent mobilization
for 4 weeks, after which active assisted exercises were started. CT scan done at 2 months
showed that the shoulder is well reduced and glenoid fragment is well in position
(Fig. 2.4E). The patient continued physiotherapy and became nearly normal with
minimal scars (Fig. 2.4F).

15
 2
Intra-articular Fractures

A B C

D E F

Figures 2.4A to F: (A) Preoperative X-ray showing fracture of the anterior glenoid rim; (B)
Preoperative 3D CT scan with en-face view showing the extent of the fracture; (C) Showing 5’O
clock portal used for passing screws; (D) Pictorial representation of the fixation of the glenoid;
(E) Showing well reduced and fixed glenoid fracture; (F) Showing minimal scars

References
1. Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am. 1993;74:299-305.
2. Butters KP. The scapula. In: Rockwood CA, Matsen FA II (Eds). The shoulder. Philadelphia:
WB Saunders. 1990;I:335-6.
3. Kraus N, Gerhardt C, Haas N, Scheibel M. Conservative therapy of anteroinferior glenoid
fractures. Unfallchirurg. 2010;113(6):469-75.
4. Anavian J, Gauger EM, Schroder LK, Wijdicks CA, Cole PA. Surgical and functional outcomes
after operative management of complex and displaced intra-articular glenoid fractures. J
Bone Joint Surg Am. 2012;94(7):645-5.
5. Mayo KA, Benirschke SK, Mast JW. Displaced fractures of the glenoid fossa. Results of open
reduction and internal fixation. Clin Orthop Relat Res. 1998;(347):122-30.
6. Leung KS, Lam TP, Poon KM. Operative treatment of displaced intra-articular glenoid
fractures. Injury. 1993;24(5):324-8.
7. Marsland D, Ahmed HA. Arthroscopically assisted fixation of glenoid fractures: a cadaver
study to show potential applications of percutaneous screw insertion and anatomic risks. J
Shoulder Elbow Surg. 2011;20(3):481-90.
8. Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid fractures using suture anchors.
Arthroscopy. 2005;21(5):635.

16
 3

Proximal Humeral Fractures:

3 Open Reduction and

Proximal Humeral Fractures: Open Reduction and Internal Fixation

Internal Fixation
Bhavuk Garg, Prakash P Kotwal

Introduction
Proximal humeral fractures account for around 4 to 5% of all fractures. It is the second
most common fracture type of upper extremity and 3rd most common fracture in patients
> 65 years. Most of proximal humeral fractures (80–85%) are minimally displaced. These
fractures have a bimodal distribution. In the younger age group, proximal humeral
fractures usually occur because of high energy injury, while in elderly, low energy
injuries are usually the culprit due to underlying osteoporosis.1
Disabilities associated with proximal fractures are often underestimated and are
due to loss of motion, loss of reduction, avascular necrosis (AVN), heterotopic bone
formation and injuries to rotator cuff, nerves (axillary, brachial plexus), vascular
structures, scapula, clavicle, etc.
Both conservative and surgical options are used for proximal humeral fractures;
however, the operative indications are expanding because of:
• Better understanding of multiple fracture patterns
• Higher patient expectations
• Improvements in internal fixation techniques.

Classification
The decision to operate and the selection of the appropriate surgical modality for
proximal humerus fractures are largely based on the fracture pattern. Understanding
the particular fracture pattern in each case is complicated. Because of the increase in
treatment methods as well as understanding of proximal humeral fractures, a variety
of classification systems have been devised. The Neer’s 4-part classification2 (Fig. 3.1) is
still the most widely used classification and is based on pathoanatomy of proximal
humerus fractures. AO/ASIF3 classification system (Fig. 3.2) considered vascularity also
in addition to patho-anatomy. In 2004, Edelson et al4 published a CT based classification,
which has shown potential to improve as well as modify the surgical procedures. This
classification divides proximal humerus fractures into 5 major patterns:
1. Two part
2. Three part
3. Shield fractures and variants
4. Isolated greater tuberosity #
5. Fracture dislocations
17
 3
Intra-articular Fractures

Figure 3.1: Neer classification system

18 Figure 3.2: AO classification system

 3
The shield was defined as the section of bone circling the head composed of the
greater and lesser tuberosities and held together by the bicipital groove. The shield
fracture pattern involves the superior bicipital groove and the lesser tuberosity, with
the shield fragment itself usually being comminuted.

IMAGING WORKUP1

Radiographs

Proximal Humeral Fractures: Open Reduction and Internal Fixation

The standard trauma series (Fig. 3.3) for proximal humerus fracture includes true AP,
axillary lateral and scapular Y view. The trauma series evaluates the glenohumeral
joint and proximal humerus in three perpendicular planes. The axillary radiograph
best shows displacement of the lesser and greater tuberosities and splits and dislocations
of the humeral head. If the patient is unable to tolerate the axillary view because of
pain, a Velpeau axillary view can be substituted. The axillary view is the most frequently
omitted image and is a common reason for missed dislocations and fractures.
Other radiographic projections1 are useful for specific fracture types, such as humeral
head indentations (so-called Hill-Sachs and reverse Hill-Sachs lesions) or glenoid rim
fractures, but are not needed in most cases. The Stryker notch view1 is used to evaluate
for Hill-Sachs lesions in dislocations and fracture dislocations of the glenohumeral
joint. The Didiee view1 is an excellent radiographic view for visualization of the anterior
inferior glenoid rim. The Hill-Sachs radiograph is an AP radiograph taken with the
humerus in internal rotation revealing posterolateral head impaction fractures. The
internal rotation view allows for better visualization of the lesser tuberosity. The West
Point axillary lateral view provides tangential imaging of the anterior glenoid rim.

Figure 3.3: Standard radiographic workup

for proximal humerus fractures
19
 3
Computed Tomography
Computed tomography (CT) has enhanced tremendously our ability to image and
understand complex proximal humerus fractures. CT represents an invaluable tool
in the preoperative planning and execution of internal fixation for these complex
fractures. Most authors recommend the systematic use of CT scans for preoperative
planning, especially for fractures including the greater or lesser tuberosities, humeral
head impaction, head splitting, or any other fracture with intra-articular fragments.
Intra-articular Fractures

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) can be a useful diagnostic tool in assessing osseous
abnormalities about the proximal humerus potentially leading to improved patient
evaluation and treatment. MRI may help identify occult fractures and detect associated
rotator cuff tears. In general, MRI is rarely used in the standard preoperative imaging
protocol of proximal humerus fractures.

Radiographic Assessment of Bone Density1 (Fig. 3.4)

Bone mineral density can be roughly determined by radiographic evaluation and can
have a considerable effect on treatment options. Tingart and colleagues5 identified a
reliable and reproducible predictor of bone mineral density of the proximal humerus.
They compared the cortical thickness of the proximal humeral diaphysis with the bone
mineral density of the proximal humerus. They noted that a cortical thickness (defined
as the sum of the cortical thickness of the medial and lateral cortex of the proximal
humerus) less than 4 mm was highly predictive of low bone mineral density. Additionally
the radiographic images must be evaluated for the presence of an intact medial buttress
because this has been theorized to be important in strength of fixation, especially
regarding current locking plate technology.

Radiographic Evaluation of Vascularity6,7 (Fig. 3.5)

Another consideration in the radiographic classification of proximal humeral fractures
is the vascularity of the humeral head. Avascular necrosis is known as sequela of

Figure 3.4: Bone density assessment of

proximal humerus (at level 2) Figure 3.5: Assessment of vascularity in proximal humerus fractures
20
 3
proximal humeral fractures and has been reported at rates of 21 to 75%. The vascularity
of the humeral head segment in conjunction with the state of the articular surface and
other mitigating patient factors help to determine optimum treatment. Hertel and
colleagues7 devised a series of criteria that could be predictive of humeral head ischemia
after fracture. Fractures that were predictive of ischemia were those of the anatomic
neck, four-part displaced and all three-part fractures configurations except one. The
exception three-part fracture that maintained perfusion involved a fracture at the

Proximal Humeral Fractures: Open Reduction and Internal Fixation

anatomic neck and a fracture below the tuberosities at the surgical neck; however, the
tuberosities did not have a fracture between them. Additional elements, such as length
of the posteromedial metaphyseal extension (<8 mm associated with vascular compro-
mise) and the integrity of the medial hinge, were also key in predicting vascular
disruption.
Tamai and colleagues8 suggested that the orientation of the articular surface is
important in predicting humeral head vascularity. The absence of displacement or medial
displacement of the humeral head with respect to the humeral shaft was predictive of
maintained vascularity to the humeral head.

INDICATIONS FOR CONSERVATIVE MANAGEMENT (FIG. 3.6)

In this operative era, there is still a role of conservative management. The indications
for closed treatment are:
• Minimally displaced 2 part fracture (or positional reduction of significant
displacement)
• Greater tuberosity fracture displacement <5 mm
• Minimally displaced 3- and 4-part fractures.

INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION (ORIF)9–11

Indications for ORIF can be summarized as follows:
• Displaced greater tuberosity fracture (>5 mm)
• Lesser tuberosity fracture with involvement of articular surface
• Displaced or unstable surgical neck fracture
• Displaced anatomic neck fracture in young patient
• Displaced, reconstructible 3- and 4-part fractures.

Figure 3.6: Conservative management of

proximal humerus fracture
21
 3
Table 3.1: Choice of surgical approach

Surgical approach Fracture pattern

Deltopectoral Surgical neck, Lesser tuberosity, 3 part, 4 part/surgeon choice

Deltoid splitting Greater tuberosity, Some Surgical neck if using IM fixation
Posterior Scapula, glenoid, occasional posterior articular fracture
Percutaneous Fractures amenable to pinning or nailing
Intra-articular Fractures

The last indication is variable for different surgeons depending upon their skills
and experience.

Surgical Approaches
A variety of surgical approaches have been described for proximal humeral fractures.
Choice of surgical approach depends upon fracture pattern (Table 3.1).

Current Techniques of Open Reduction and

Internal Fixation (ORIF)
A variety of ammunition is present in an orthopedic surgeon’s armamentarium to deal
with proximal humeral fractures. They can be discussed in brief as follows:

PERCUTANEOUS PINNING12 (FIG. 3.7)

This is best suited for limited 2 or 3 part fractures when other techniques are not
favorable. This is usually done in beach-chair position under C arm control. After closed
reduction, bidirectional pins are used, which are preferably terminally threaded.
Associated problems include pin migration, axillary nerve injury, pin loosening and
infection. Another major disadvantage is that no early motion can be instituted leading
to shoulder stiffness.

SUTURE OR K-WIRE/TENSION BAND13 (FIG. 3.8)

This is best suited for isolated greater tuberosity, lesser tuberosity, or both, or both
tuberosities associated with undisplaced surgical neck fracture. Associated problems
include cuff constriction, limited head fixation to shaft and wire migration.

Figure 3.7: Percutaneous pinning of proximal Figure 3.8: Tension band wiring
22
humerus fracture (schematic diagram)
 3

Proximal Humeral Fractures: Open Reduction and Internal Fixation

Figure 3.9: Flexible nailing of proximal Figure 3.10: Locked nailing for proximal
humerus fracture humerus fracture (schematic diagram)

INTRAMEDULLARY NAILING14
Two types of intramedullary nails are available: Flexible (Fig. 3.9) and locked rigid
nails (Fig. 3.10). They are best suited for two part surgical neck fractures. Associated
problems are limited head fixation, migration into subacromial space, cuff violation,
etc. Locked nails provide enhanced proximal fixation with twisted blades or multiple
screws.

PLATING
Buttress plate technique (Fig. 3.11) is usually applied lateral to the bicipital groove to
minimize vascular damage. This is rarely used now a days due to impingement and
poor head fixation. This is best suited for low 2-part surgical neck fracture alone or
associated with greater tuberosity fracture. These plates have high failure rate due to
impingement and poor screw purchase.
To obviate the screw fixation problem, Hintermann et al15 recommended blade plate
fixation (Fig. 3.12) regardless of age. However, Meier et al16 reviewed 36 cases with

Figure 3.11: Buttress plate fixation

23
 3
Intra-articular Fractures

Figure 3.12: Blade plate fixation

blade plate fixation and found that 8 patients out of 36 had blade plate perforation and
recommended alternate fixation if possible.
Locking plates came as a boon to solve all these problems. They provide near-
anatomic reduction and stable fixation leading to good results. They also provide good
fixation in osteoporotic bones. They also bail out the surgeon who can switch to
arthroplasty if he is unable to obtain adequate reduction/fixation. They have combined
properties of versatile adaptability of buttress plate and angular stability of blade plate.
PHILOS® by AO group also provides suture holes to neutralize muscle forces. All these
features allow for early postoperative mobilization, essential for good functional results.17
Locking plate fixation is currently the most commonly employed technique for
displaced but salvageable two-, three-, and four part fractures.

Surgical Technique for Locking Plate

Fixation of Proximal Humerus
POSITIONING AND ANESTHESIA (FIG. 3.13)
General anesthesia is used. The patient is positioned on the operating room table in a
semi-sitting beach-chair position; the head is rotated to the opposite side. To prevent

24 Figure 3.13: Positioning of patient

 3
the patient from sliding down the operating room table, a pillow is placed behind the
knees and a seat belt across the patient’s thighs. The shoulder is positioned off the edge
of the table so that the arm can be extended and imaged properly when needed
intraoperatively.

Surgical Approach and Exposure

A standard deltopectoral approach is used. The incision is around 10 to 15 cm in length

Proximal Humeral Fractures: Open Reduction and Internal Fixation

starting from the coracoid process to deltoid insertion (Fig. 3.14). Interval between
pectoralis major and deltoid is easily identified by the presence of cephalic vein
(Fig. 3.15), which is reflected laterally. This is an extensile approach and can be extended
distally as an anterolateral approach if there is a diaphyseal extension. The insertion of
the pectoralis major is partially released for exposure. Abducting the humerus during
the procedure aids in relaxing the deltoid. If excessive deltoid tension is present, a
transverse division of the anterior 1 cm of the deltoid insertion distally improves
exposure and, more importantly, avoids damaging the deltoid.

Figure 3.14: Standard deltopectoral approach skin

marking

Figure 3.15: Cephalic vein is the landmark for delto-

pectoral interval
25
 3
Intra-articular Fractures

Figure 3.16: Identification of fracture fragments

Identification of Fracture Fragments

The long head of the biceps tendon serves as the key landmark in separating the greater
and lesser tuberosity segments. In three and four part fractures, the split in the
tuberosities is located just posterior to the bicipital groove. The space formed by this
fracture line is developed to gain access to the humeral head and glenohumeral joint
(Fig. 3.16).
The displaced greater tuberosity with its attached supraspinatus tendon lies laterally
and posteriorly to the humeral head, and there is displacement between the humeral
head and shaft. The articular surface of the humeral head usually lies posteriorly, directed
away from the glenoid fossa, often facing lateral. It is necessary to disimpact the humeral
head by blunt dissection and confirm that the head does not have a rare impaction or
head-splitting fracture.18

Mobilization of Fracture Fragments

Nonabsorbable intraosseous or intratendinous (in case of osteoporotic bone) sutures
are passed through both tuberosities (Fig. 3.17). It is important to open the rotator
interval to inspect the articular surface for any loose fragments or defects. If humeral
head is dislocated, it is reduced first before performing any reduction maneuver.

Reduction of Fracture Fragments (Fig. 3.18)

Humeral head is reduced over the shaft in all the three planes (coronal, sagittal and
horizontal) either manually or with the help of K-wires, periosteal elevator or osteotomes.
Lateralizing the shaft also helps shaft reduction, as it is usually displaced anteromedially
due to the pull of pectoralis major. This can be achieved either by reduction forceps or
by indirect pressure in the axilla through customized bolster. Aligning of fracture spikes
as well as bicipital groove also help in ensuring optimum alignment. Tuberosities are
also reduced with the help of holding sutures.

Provisional Stabilization
Once reduction is achieved, it is held with the help of K-wires (Figs 3.19 and 3.20).
Bone graft or bone substitutes may be used if there is extensive metaphyseal defect
26
 3

Proximal Humeral Fractures: Open Reduction and Internal Fixation

Figure 3.17: Passing of holding sutures through
tuberosities

Figure 3.18: Reduction of fracture fragments

Figure 3.19: Provisional stabilization with K-wires

27
 3
Intra-articular Fractures

Figure 3.20: Reduction is confirmed under C-arm

Figure 3.21: Bone substitute is added in case of

metaphyseal void

(Fig. 3.21). Gardner et al19 emphasized the importance of medial buttress in proximal
humerus fractures and recommended restoration of the medial buttress with reduction.
If it is not possible, then it should be substituted with oblique locking (kickstand) screw
or a fibular strut graft.

Definitive Plate Fixation

We routinely use the PHILOS® (Synthes) locking plate for proximal humerus fractures.
Plate length is chosen optimally to insert 3 to 4 screws distal to fracture and 4-6 screws
in the humeral head depending upon the bone quality. The correct plate position is
about 8 mm distal to the top of the greater tuberosity, aligned properly along the axis of
the humeral shaft and slightly posterior to the bicipital grove (2–4 mm) (Fig. 3.22).
Inserting a K-wire through the proximal hole of the insertion guide can confirm the
correct plate position. The K-wire should rest on the top of the humeral head (Fig. 3.23).
Placing the plate at too high a level increases the risk of subacromial impingement.
28
 3

Proximal Humeral Fractures: Open Reduction and Internal Fixation

Figure 3.22: Lateral placement of plate

Figure 3.23: Always ensure optimum height of plate

Placing the plate too low can prevent the optimal distribution of screws in the humerus
head. The plate may also be used as a reduction tool.
Hold the appropriate Metaphyseal Jig over the plate. Before inserting the screws,
check the subsequent position of the screws using Kirschner wires. Do not drill through
the subchondral bone and into the shoulder joint. The drill is inserted using “wood-
pecker technique” at low speed where we advance the drill bit only for a short distance,
then pull the drill back before advancing again. This procedure is repeated until
subchondral bone contact can be felt. The intact subchondral bone should be felt with a
depth gauge or blunt pin to ensure that the screw stays within the humeral head. The
screw length is measured and is around 40 to 50 mm in most of the cases (Fig. 3.24).
Medial buttress screw (kickstand screw) is placed through the plate if required.
Once proximal fixation is achieved, a bicortical non-locking screw is inserted through
the elongated hole into the distal shaft. Make sure to insert the screw perpendicular to
the humeral shaft. By tightening this screw in the humeral shaft, the humeral head will

29
 3
Intra-articular Fractures

Figure 3.24: Insertion of proximal screws

Figure 3.25: Placement of all screws. Note the

position of biceps tendon with respect to plate
positioning

be aligned to the humeral shaft, thus achieving a correct reduction. Additional screws
are then inserted (Fig. 3.25).
It is advisable to check all screws under image intensifier to rule out any intra-
articular penetration of the screw tips (Fig. 3.26).

Tuberosity Fixation
The function of plate is to connect the humeral head to the shaft. Tuberosity fragments
must be fixed separately. Tuberosities are secured with tension band sutures through
the small holes in the plate (Fig. 3.27). Check the sutures to ensure that they do not
rupture during motion.

30
 3

Proximal Humeral Fractures: Open Reduction and Internal Fixation

Figure 3.26: Always check in
multiple views or under fluoro-
scopy to rule out anterior intra-
articular placement of screws

Figure 3.27: Tuberosity fixation through plate holes

with nonabsorbable sutures

31
 3
Intra-articular Fractures

Figure 3.28: Wound closure

Wound Closure
After a thorough wash, wound is closed in layers (Fig. 3.28). A drain may or may not be
used depending upon surgeon’s preference.

POSTOPERATIVE REHABILITATION
Usually a shoulder immobilizer is used for 2 to 4 weeks depending upon the stability
of fixation. Pendulum exercises and elbow ROM exercises are started immediately as
soon as the pain subsides. Sequentially active assisted and active exercises are initiated.
However, full load is exerted only after fracture has consolidated, usually at 6 months.

COMPLICATIONS
These locking plates have their own set of complications. Plate breakage and locking
screw backout are two major problems (Figs 3.29A to D). Also humeral diaphyseal split
fractures have been reported with use of short proximal humerus locking plates. Simple
fractures at the surgical neck may run with an increased risk of a fatigue failure of the
plate. In a recent systemic review,20 fixation of proximal humerus fractures with proximal
humerus locking plates was found to be associated with a high rate of complications
and reoperation and the authors suggested that the surgical technique should be used
carefully and only in well-selected patients.

RESULTS OF LOCKING PLATES IN PROXIMAL HUMERUS FRACTURES

Saudan et al21 presented first results of locking plates in proximal humerus fractures
and recommended ORIF of 2, 3-part fractures regardless of age, ORIF of 4-part fractures
in younger patients and hemiarthroplasty for elderly 4-part fractures. Fankhauser
et al22 reported that results of locking plate are inversely proportional to the severity of
injury. Koukakis et al23 reported better results in younger patients as compared to
elderly patients. Now longer plates are also available to deal with diaphyseal extension
of proximal humerus fractures. Results have been very encouraging as most authors
report a very high union rate combined with satisfactory functional results.24-29

32
 3

Proximal Humeral Fractures: Open Reduction and Internal Fixation

A B

Figures 3.29A to D: Complications of

C D locking plate

Summary
A lot has changed in our understanding and management of proximal humerus fractures.
Surgical treatment of proximal humeral fractures continues to be a challenge especially
in osteoporotic patients. Locking plates have been used with satisfactory results but the
previous reported complications have not been substantially reduced. Most of the
existing studies involve a small number of patients followed up for a rather short
period of time. Since proximal humeral fractures constitute a heterogeneous group of
complex fractures in an even more heterogeneous population, no single fixation method
is a panacea. Choice of implant and method of fixation should be selected according to
individual patient and fracture pattern characteristics based on clearly defined
indications and contraindications.

Illustrative Case
A 45-year-old male sustained bilateral proximal humerus fractures during a road traffic
accident. He sustained a 4-part fracture on right side and a three-part fracture on left
side (Fig. 3.30). Both sides were managed with proximal humerus locking plate fixation.
He made an excellent recovery with almost full range of motion at the end of 6 months.
His postoperative X-rays at 3 years follow-up are shown in Figure 3.31.

33
 3
Intra-articular Fractures

Figure 3.30: Preoperative X-rays and CT scan

of bilateral proximal humerus fracture

Figure 3.31: Postoperative X-rays

showing excellent healing and
remodeling of the same patient at
3 years

References
1. Robinson C, et al. Classification and Imaging of Proximal Humerus Fractures. Orthopedic
Clinics of North America. 2008;39(4):393-403.
2. Neer CS. Displaced proximal humeral fractures. Part I: classification and evaluation. J Bone
Joint Surg Am. 1970;52:1077-89.
3. Müeller ME, Nazarian S, Koch P, et al. The comprehensive classification of fractures of long
34 bones. Springer, New York; 1990. pp. 54-63.
 3
4. Edelson G, Kelly I, Vigder F, et al. A three-dimensional classification for fractures of the
proximal humerus. J Bone Joint Surg Br. 2004;86(3):413-25.
5. Lee CK, Hansen HR. Post-traumatic avascular necrosis of the humeral head in displaced
proximal humeral fractures. J Trauma; 1981. pp. 788-91.
6. Hertel R, Hempfing A, Stiehler M, et al. Predictors of humeral head ischemia after
intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427-33.
7. Tingart MJ, Apreleva M, von Stechow D, Zurakowski D, Warner JJ. The cortical thickness of
the proximal humeral diaphysis predicts bone mineral density of the proximal humerus.

Proximal Humeral Fractures: Open Reduction and Internal Fixation

J Bone Joint Surg Br. 2003;85:611-7.
8. Tamai K, Hamada J, Ohno W, et al. Surgical anatomy of multipart fractures of the proximal
humerus. J Shoulder Elbow Surg. 2002;11(5):421-7.
9. Naranja RJ Jr, Iannotti JP. Displaced three- and four-part proximal humerus fractures:
Evaluation and management. J Am Acad Orthop Surg. 2000;8:373-82.
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