Standardized Reduction Technique in Proximal Humerus Fractures

For plate fixation of proximal humerus fractures, postoperative varus malunion, screw penetration into the joint, avascular necrosis, and loss of reduction are the most common complications. Intraoperative anatomic reduction and maintenance are the keys to successful fixation.

To address this issue, we describe a standardized, stepwise reduction and fixation technique.

Procedure:

A standard deltopectoral approach is used. No. 5 nonabsorbable sutures are placed through the rotator cuff tendons at the tendon–bone junction, primarily to assist with reduction.

• Three 2.0 mm K-wires are percutaneously inserted in retrograde fashion into the humeral shaft, directed toward the fracture line (B).
• The humeral head fragment is anatomically reduced, with special attention paid to restoring the integrity of the medial buttress. The K-wires are then advanced into the subchondral bone to provide stability (C).
• Next, the greater tuberosity fragment is reduced. After anatomic reduction, an angular stable locking plate is applied and temporarily fixed with 1.6 mm K-wires **(D)**.
• Position is assessed fluoroscopically. Before inserting locking screws, the plate is secured with 3.5 mm cortical screws. The K-wires are removed, the nonabsorbable sutures are tensioned, and definitive screw fixation is performed (E and F).

K-wires may be inserted from different directions:

(A) Manual fracture reduction with temporary K-wire fixation from both caudal and cephalad directions.

(B) Fixation of the medial calcar fragment using a one-third tubular plate, with temporary K-wire fixation of the locking plate.

(C and D) Final fixation.

This technique relies on the surgeon’s ability to maintain reduction while fixing the fragments with K-wires before definitive fixation. Passing nonabsorbable sutures through the rotator cuff tendons and securing them to the plate assists in reduction and maintains stable fixation of the tuberosities.