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Key Techniques in Orthopaedic Surgery

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passive range-of-motion exercises
c. Phase 3. Once radiographic evidence of healing
is noted, resistive and stretching exercises for the
rotator cuff muscles are instituted
Operative Technique
Approach
1. Place the patient in the semi-sitting position (30
degrees upright) on the operating room table.
2. Place a small bump under the operative scapula to
help access the entire shoulder girdle.
3. Make a standard deltopectoral incision. Open the
deltopectoral interval and mobilize the cephalic
vein laterally.
4. Retract the deltoid muscle laterally. If needed, par-
tially release the deltoid at its insertion.
5. If additional exposure is required, release the cora-
coacromial ligament proximally and partially
release the pectoralis major tendon distally. The
pectoralis tendon should be repaired at the time of
wound closure with heavy nonabsorbable suture.
6. Identify the long head of the biceps. This structure
helps outline the fracture pattern and serves as a
guide to fracture reduction (Fig. 5–1).
Reduction and fixation
7. Mobilize the fracture fragments. Take care to pre-
serve bone fragment vascularity by avoiding exten-
sive soft tissue dissection.
8. Place stay sutures in the fracture fragments. Inspect
the humeral head for impaction or malposition.
9. Consider using a Cobb elevator to reduce the
humeral head into the glenoid and to clear the frac-
ture site of hematoma.
10. Reduce the fracture fragments. If needed, provision-
ally hold them in place with 0.062 K-wires.
11. After the humeral head is reduced, make two drill
holes through the anterior aspect of the humeral
shaft on each side of the bicipital groove (Fig. 5–2A).
12. Drill a 2-mm hole through the greater tuberosity
and lesser tuberosity (Fig. 5–2B).
13. Use a 14-gauge angiocath as a guide for either an
18-gauge wire or a #5 braided nonabsorbable suture.
Place the wire or suture through a hole in the ante-
rior aspect of the humeral shaft (Fig. 5–3).
14. Use a 14-gauge angiocath as a guide for passing the
previously positioned 18-gauge wire or #5 braided
nonabsorbable suture through the rotator cuff ten-
don, greater tuberosity, subscapularis, and lesser
tuberosity.
15. Ensure that the humeral head is reduced on the
shaft and the tuberosities are anatomically reduced.
Using the biceps and bicipital groove as landmarks,
fix the suture or wire in a figure eight fashion.
16. After tensioning of the suture is complete, place a
second wire or suture in a similar tension band
technique, thereby securing the tuberosities to the
humeral shaft (Fig. 5–4).
17. Ensure that the wires or sutures cross the fracture
site. This allows them to apply compression and
helps achieve a stable construct that moves as a unit
(Fig. 5–5).
Closure
18. Loosely approximate the deltopectoral interval with
an absorbable suture.
19. Close the subcutaneous tissue in layers over a suc-
tion drainage.
20. Close the skin using a subcuticular skin closure.
Apply steristrips.
3 0 S H O U L D E R A N D A R M
3 1
Greater
tuberosity
Subscapularis
muscle
Axillary
nerve
Supraspinatus tendon
Biceps
tendon
Lesser
tuberosity
Bicipital
groove
A
B
Figure 5–2 (A) Humeral drill holes. Two drill 
holes are made through the anterior aspect 
of the humeral shaft. They are positioned on 
each side of the bicipital groove. (B) Proximal
drill holes. Two drill holes are made through 
the greater tuberosity and lesser tuberosity.
Figure 5–1 Deep dissection. Note the long 
head of the biceps. This structure helps outline
the fracture pattern and serves as a guide to
fracture reduction.
3 2
First wire
placed
Crimp
ends
Second
wire
placed
Figure 5–4 Second wire passage. A second wire
or suture is passed in a similar fashion using a
tension-band technique.
Figure 5–5 Final construct. Note the wires placed
in a tension-band technique cross the fracture site.
This allows them to apply compression and helps
achieve a stable construct that moves as a unit.
Figure 5–3 Wire or suture passage. A 14-gauge
angiocath is used as a guide for either an 
18-gauge wire or a #5 braided nonabsorbable
suture. The wire or suture is passed through 
one of the holes in the anterior aspect of the
humeral shaft.
Suggested Readings
Neer CS. Displaced proximal humerus fractures. I.
Classification and evaluation. J Bone Joint Surg
1970;52A(6):1077–1089.
The shoulder. In: Hoppenfeld S, deBoer P, eds. Surgical
Exposures in Orthopaedics: The Anatomic Approach. 2nd
ed. Philadelphia, PA: J.B. Lippincott, 1994:5–13.
5 P R O X I M A L H U M E R U S F R A C T U R E ( O R I F ) 3 3
Indications
1. Four-part proximal humerus fractures and fracture
dislocations of the proximal humerus
2. Humeral head splitting fractures
3. Displaced anatomic humeral neck fractures that
cannot be adequately reduced or fixed
4. Chronic shoulder dislocations with impaction frac-
tures involving greater than 40% of the humeral
head’s articular surface
5. Selected three-part proximal humerus fractures in
older patients with osteoporotic bone
Contraindications
1. Soft tissue infection
2. Chronic osteomyelitis
3. Paralysis of the rotator cuff muscles
4. Deltoid muscle paralysis (relative)
Preoperative Preparation
1. Perform a complete history. Attempt to determine
the cause of the fracture. Obtain pertinent medical
history including history of seizures or syncope.
Consider metastatic disease.
2. Document the preoperative neurovascular status of
the limb, especially the axillary nerve.
3. Obtain radiographs (shoulder trauma series)
a. Anteroposterior (AP) in plane of scapula (“true
AP”)
b. Transscapular lateral
c. Axillary view
d. AP and lateral of the unaffected shoulder to
assist with templating
4. Templates of the prosthesis to be implanted
5. If needed, obtain computed tomography (CT) scan
to assess degree of fracture displacement or to eval-
uate the humeral head’s articular surface in head
splitting fractures or chronic dislocations.
Special Instruments, Position, 
and Anesthesia
1. Patient is placed in a modified beach chair position
with head up 20 to 30 degrees. Position patient so
the involved shoulder extends over the edge of the
table to allow free humeral extension and rotation
(Fig. 6–1). The head should be stabilized in a neu-
tral position to avoid traction on the brachial
plexus. The McConnell head holder (McConnell
Surgical Mfg., Greenville, TX) facilitates stable posi-
tioning of the patient.
2. Routine orthopaedic surgical instruments. Implant
specific instruments for prosthesis: humeral prepa-
ration, head sizing, trials, etc.
3. Small drill bits for greater tuberosity reattachment
4. Curved Mayo needles; #2 and #5 braided non-
absorbable suture
3 4
C H A P T E R 6
Proximal Humerus Fracture
Hemiarthroplasty
Mark K. Bowen and Angelo DiFelice
 
Tips and Pearls
1. Intravenous antibiotics should be given prior to the
beginning of the operation.
2. The patient must be positioned with the arm able to
hang free over the table’s side so that it can be eas-
ily hyperextended and internally and externally
rotated.
3. Restoring the proper length of the humerus is criti-
cal to proper function: if the prosthesis is left proud
stiffness will result; if the prosthesis is inserted too
deep loss of soft tissue tension may cause instability.
4. Restoring proper humeral retroversion is critical to
optimizing shoulder function and stability.
5. Achieving secure fixation of the greater and lesser
tuberosities to each other, as well as the prosthesis
and humeral shaft is the important final step in per-
forming a successful shoulder reconstruction.
What To Avoid
1. Avoid excessive operating room traffic.
2. Avoid excessive or aggressive reaming or broaching
of the humeral