Authors of section

Authors

Martin Jaeger, Frankie Leung, Wilson Li

Executive Editors

Peter Trafton

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ORIF - Plate fixation

1. Principles

Introduction

The lesser tuberosity fracture may result in weakness if it is not fixed. The primary task of the plate is to stabilize a metaphyseal fracture that requires disimpaction to correct significant angulation.

Suture fixation of the lesser tuberosity

Sutures in the subscapularis tendon insertion aid both reduction and fixation of the lesser tuberosity. Once reduced, lesser tuberosity sutures are tied to a similar suture in the infraspinatus tendon for provisional fixation. Ultimately, these sutures contribute significantly to primary stability of the lesser tuberosity.

Sutures in the subscapularis tendon insertion aid both reduction and fixation of the lesser tuberosity. Once reduced, lesser ...

Lesser tuberosity reduction

Proper reduction of the lesser tuberosity is difficult. Its position is hard to visualize with intraoperative image intensification.
Medial displacement of the lesser tuberosity (A) produces an intraarticular anterior step which can compromise internal rotation.
Lateral displacement of the lesser tuberosity (B) obstructs the bicipital groove and may compromise the bicipital tendon. If possible, correct reconstruction of the bicipital groove is desirable to allow sliding of the tendon. An alternative would be tenodesis of the long head of the biceps.

Lesser tuberosity, suture reduction and fixation

Tension band sutures in addition to plate and screws

Sutures placed through the insertions of each rotator cuff tendon increase stability, and should be used as well as the plate and screws, particularly for more comminuted and/or osteoporotic fractures. With osteoporotic bone, the tendon insertion is often stronger than the bone itself, so that sutures placed through the insertional fibers of the tendon may hold better than screws or sutures placed through bone.
These additional sutures are typically the last step of fixation.

Sutures placed through the insertions of each rotator cuff tendon increase stability and should also be used.

Angular stable versus standard plates

This procedure describes proximal humeral fracture fixation with an angular stable plate (A). Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf plate (B). Presently, the specific indications, advantages, and disadvantages of angular stable and standard plates are being clarified. There is some evidence that angular stable plate provide better outcomes. In addition to type and technique of fixation, the quality of reduction, the soft-tissue handling, and the characteristics of the injury and patient significantly influence the results. There is no evidence that the use of angular stable plates will overcome these other factors.

Standard plates provide an alternative option, for example the modified cloverleaf plate.

2. Patient preparation and approaches

Patient preparation

It is recommended to perform this procedure with the patient in a supine position (with the beach chair position as alternative).

Approaches

A deltopectoral approach is best suited for lesser tuberosity reduction and fixation and plate application.

Occasionally, an anterolateral approach provides sufficient access.

3. Reduction and preliminary fixation

Reduction

Sequence of repair:

  1. Reduce and fix the lesser tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
  2. Reduce the proximal humeral fragment to the shaft and fix it.

If needed, fix the lesser tuberosity with an additional (cannulated) lag screw.

Reduce and fix the lesser tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)

Proper reduction of lesser tuberosity
A common problem seen in these fractures is inaccurate reduction of the lesser tuberosity.

Medial displacement of the lesser tuberosity (A) produces an intraarticular anterior step which can compromise internal rotation.

Lateral displacement of the lesser tuberosity (B) obstructs the bicipital groove and may compromise the bicipital tendon. If possible, correct reconstruction of the bicipital groove is desirable to allow sliding of the tendon. An alternative would be tenodesis of the long head of the biceps.

The correct position of the lesser tuberosity is achieved if the fracture line between the lesser and the proximal humeral segment is closed precisely without any step or gap.

orif plate fixation

Proper reduction of humeral head segment
The humeral head with attached greater tuberosity is typically rotated externally and into a varus malposition due to the pull of the posterosuperior rotator cuff (supra- and infraspinatus tendons). This malposition of the humeral head has to be reduced in order to allow for proper reduction of the lesser tuberosity (medial fracture line aligned).
A common mistake in the treatment of these fractures is an inaccurate reduction of the humeral head.

Proper reduction of humeral head segment

Place rotator cuff sutures

Subscapularis and supraspinatus tendon
Begin by inserting sutures into the subscapularis tendon (1) and the supraspinatus tendon (2). Place these sutures just superficial to the tendon’s bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities.

Rotator cuff sutures: Subscapularis and supraspinatus tendon

Infraspinatus tendon
Next, place a suture into the infraspinatus tendon insertion (3). This can be demanding, and may be easier with traction on the previously placed sutures, or with properly placed retractors.

Next, place a suture into the infraspinatus tendon insertion (3).

Variations depending on the approach chosen
Inserting sutures into the infraspinatus tendon is easier with a lateral approach. A) shows a deltopectoral approach and B) an anterolateral (transdeltoid) approach.

It is easier the further lateral of an approach is used. A) shows an deltopectoral approach and B) an anterolateral approach.

Use of stay sutures
Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.

Anterior traction on the supraspinatus tendon helps expose the greater tuberosity and infraspinatus tendon.

Insert a preliminary traction suture into the visible part of the posterior rotator cuff …

Insert a preliminary traction suture into the visible part of the posterior rotator cuff ...

… and pull it anteriorly. This will expose the proper location for a suture in the infraspinatus tendon insertion. Then the initial traction suture is removed.

Pearl: larger needles
A stout sharp needle facilitates placing a suture through the tendon insertion.

... and pull it anteriorly.

Pearl: use of retractors
Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.

Use of blunt, curved Hohmann retractors underneath the deltoid muscle can be helpful to expose the humeral head.

Similarly, a so-called delta retractor may improve deltoid retraction.

Similarly, a so-called delta retractor may improve deltoid retraction.

Reduce the lesser tuberosity

In order to reduce the lesser tuberosity, pull the sutures between the subscapularis and the infraspinatus horizontally …

In order to reduce the lesser tuberosity, pull the sutures between the subscapularis and the infraspinatus horizontally ...

… and tie them together. Thus, reducing and fixing the lesser tuberosity to the proximal humeral segment converts the 3-part fracture into a 2-part situation.

In some cases, the lesser tuberosity is not mobile enough and therefore can not be reduced adequately. In this situation it is recommended to mobilize the lesser tuberosity using a periosteal elevator.

In some cases, due to the impacted head and displaced humeral head, there is not enough space for a proper reduction of the lesser tuberosity. In this situation, it is recommended to reduce the humeral head by disimpaction.

In cases of a multifragmentary lesser tuberosity it might become necessary to additionally fix single fragments with small K-wires.

... and tie them together.

Reduce the metaphyseal fracture component

Since these fractures involve metaphyseal impaction, pure traction alone may not be effective to reduce the fracture.

orif plate fixation

While longitudinal traction is applied to the limb, a periosteal elevator can be inserted into the fracture gap to disimpact the fracture.

A periosteal elevator can be inserted into the fracture gap to disimpact the fracture.

Preliminary fixation of the head to the shaft

After its reduction, the humeral head is preliminarily fixed to the shaft using two K-wires. Make sure to place them from anterior in order to avoid interference with the foreseen plate position.

After its reduction, the humeral head is preliminarily fixed to the shaft using two K-wires.

Confirmation of reduction
After provisional fixation, the reduction must be confirmed.
Both humeral head segment and lesser tuberosity must be correctly positioned.

Confirmation of the reduction of the lesser tuberosity can be very demanding.

The lateral fracture line might be covered by the bicipital tendon and the medial fracture line covered by the subscapularis tendon. Therefore, it is recommended to expose the lateral fracture line by slight removal of the periosteum in order to achieve visual control.

The lesser tuberosity is not visible in AP radiographic views, but is seen in profile on an axillary lateral view. Both projections should be assessed.

It is recommended to expose the lateral fracture line by slight removal of the periosteum in order to achieve visual control.

Radiographic control
On the AP x-ray, confirm the correct inclination of the humeral head. The centrum column diaphyseal (CCD) angle should be 135°.
If the humeral head is still displaced, the reduction should be corrected since it may interfere with anatomic reduction of the lesser tuberosity.

The centrum column diaphyseal (CCD) angle should be 135°.

Confirm proper rotational alignment
Correct rotational alignment must be confirmed. This can be done by matching the fracture configurations on both sides of the fracture. This would be useful in the more transverse fracture configuration as shown in the illustration.

Pearl: check retroversion
The bicipital groove might be a good indicator for correct rotation. In case of correct rotation, no gap/angulation is visible at the level of the fracture.

Remember that the humeral head is normally retroverted, facing approximately 25° posteriorly (mean range: 18°-30°) relative to the distal humeral epicondylar axis. This axis is perpendicular to the forearm with the elbow flexed to 90°.

Confirmation of overall reduction
The correct reduction must be confirmed by image intensification in both AP and lateral views.

Confirm proper rotational alignment

Pearl: reduction of the lesser tuberosity
The lesser tuberosity must be reduced and fixed in its proper location. This is most easily done with a suture passed through the subscapularis tendon insertion on the lesser tuberosity fragment. Once achieved, reduction can be stabilized by tying this suture to another, placed through the infraspinatus tendon as shown.

Pearl: Reduction of the lesser tuberosity

Pearl: osteoporotic bone
In osteoporotic bone, stability may be increased by accepting some
medial impaction of the humeral head.

In osteoporotic bone, stability may be increased by leaving slight medial impaction of the humeral head

4. Plate position

Correct plate position

The correct plate position is:

  1. about 5-8 mm distal to the top of the greater tuberosity
  2. aligned properly along the axis of the humeral shaft
  3. slightly posterior to the bicipital groove (2-4 mm)
Correct plate position

Confirmation of correct plate position
The correct plate position can be checked by palpation of its relationship to the bony structures and also confirmed by image intensification.

To confirm a correct axial plate position insert a K-wire through the proximal hole of the insertion guide. The K-wire should rest on the top of the humeral head.

To confirm a correct axial plate position insert a K-wire through the proximal hole of the insertion guide.

Pitfall 1: plate too close to the bicipital groove
The bicipital tendon and the ascending branch of the anterior humeral circumflex artery are at risk if the plate is positioned too close to the bicipital groove. (The illustration shows the plate in correct position, posterior to the bicipital groove).

Pitfall: plate too close to the bicipital groove

Pitfall 2: plate too proximal
A plate positioned too proximal carries two risks:

  1. The plate can impinge the acromion
  2. The most proximal screws might penetrate or fail to securely engage the humeral head
Pitfall: plate too proximal

5. Plate fixation

Attach plate to humeral shaft

Attach the plate to the humeral shaft with a bicortical small fragment 3.5 mm screw inserted through the elongated hole.

Pearl 1: fine tuning of plate position
If the first screw is inserted only loosely in the center of the elongated hole, fine-tuning of the plate position is still possible. With the plate in proper position, tighten this screw securely.

Attach the plate to the humeral shaft with a bicortical small fragment 3.5 mm screw inserted through the elongated hole.

Pearl 2: preliminary plate fixation with K-wires
For x-ray confirmation of plate position, one can fix the plate preliminarily to the bone with several 1.4 mm K-wires inserted through the small plate holes, before placing any screws.

Pearl: preliminary plate fixation with K-wires

Pearl 3: insert K-wires through appropriate guiding sleeves.

Alternative provisional plate fixation: K-wires inserted through their appropriate K-wire sleeves.

Fix plate to the humeral head

Drill holes
Use an appropriate sleeve to drill holes for the humeral head screws. Do not drill through the subchondral bone and into the shoulder joint.

Use an appropriate sleeve to drill holes for the humeral head screws.

Avoiding intraarticular screw placement
Screws that penetrate the humeral head may significantly damage the glenoid cartilage. Primary penetration occurs when the screws are initially placed. Secondary penetration is the result of subsequent fracture collapse. Drilling into the joint increases the risk of screws becoming intraarticular.

Two drilling techniques help to avoid drilling into the joint.

Pearl 1: “Woodpecker”-drilling technique (as illustrated)
In the woodpecker-drilling technique, advance the drill bit only for a short distance, then pull the drill back before advancing again. Keep repeating this procedure until subchondral bone contact can be felt. Take great care to avoid penetration of the humeral head.

Pearl 2: Drilling near cortex only
Particular in osteoporotic bone, one can drill only through the near cortex. Push the depth gauge through the remaining bone until subchondral resistance is felt.

“Woodpecker”-drilling technique

Determine screw length
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 integrity of the subchondral bone can be confirmed by palpation or the sound of the instrument tapping against it. Typically, choose a screw slightly shorter than the measured length.

Determine screw length

Insert screw
Insert a locking-head screw through the screw sleeve into the humeral head. The sleeve aims the screw correctly. Particularly in osteoporotic bone, a screw may not follow the hole that has been drilled.

Insert a locking-head screw through the screw sleeve into the humeral head.

Number of screws and location
Place a sufficient number of screws (often 5) into the humeral head. The optimal number and location of screws has not been determined. Bone quality and fracture morphology should be considered. In osteoporotic bone a higher number of screws may be required.

Place a sufficient number of screws (often 5) into the humeral head.

Insert additional screws into the humeral shaft

Insert one or two additional bicortical screws into the humeral shaft.

Any K-wires placed during the procedure may now be removed.

Insert one or two additional bicortical screws into the humeral shaft.

6. Fixation of lesser tuberosity

Fixation of the lesser tuberosity including anchorage of the subscapularis tendon is primarily done with sutures placed through the tendon insertions. Provisional reduction and stabilization are accomplished with such a suture. Definitive fixation should include a secure suture to appropriate plate holes.

Supplementary fixation of the lesser tuberosity with lag screws or absorbable polymer pins might be considered. If the stability of lesser tuberosity fixation is questionable, it can be checked clinically by rotating the arm. If there is any micro movement visible or palpable one should consider additional fixation.

Fixation of the lesser tuberosity including anchorage of the subscapularis tendon is primarily done with sutures placed ...

7. Supplementary rotator cuff tendon sutures

Secure the tendons of the rotator cuff (subscapularis, supraspinatus, infraspinatus) with additional tension band sutures through the small holes in the plate.

Secure the tendons of the rotator cuff with additional tension band sutures through the small holes in the plate.

8. Use of standard plates

If no angular stable plate is available, a standard plate provides an alternative. The described procedure (reduction, preliminary fixation, and rotator cuff sutures) is essentially the same for standard plates, except for the screws. A good choice from the standard plates is the small fragment cloverleaf plate, with its tip cut off, and contoured as necessary. This plate allows multiple small fragment screws for the humeral head.

Be aware that angular stable implants provide better fixation, especially in osteoporotic bone. On the other hand, even angular stable plates are not a substitute for good surgical technique and judgment. Advances in fracture classification, understanding of the blood supply, use of rotator cuff tendon sutures, anatomical fracture reduction, and provisional fixation, represent improvements in care. When combined with optimal implants, these contributions offer the best chance of a good outcome.

If no angular stable plate is available, a standard plate provides an alternative. The described procedure (reduction, ...

9. Final check of osteosynthesis

Using image intensification, carefully check for correct reduction and fixation (including proper implant position and length) at various arm positions. Ensure that screw tips are not intraarticular.

Carefully check for correct reduction and fixation (including proper implant position and length) at various arm positions.

Also obtain an axial view.

Also obtain an axial view.

In the beach chair position, the C-arm must be directed appropriately for orthogonal views. Position arm as necessary to confirm that reduction is satisfactory, fixation is stable, and no screw is in the joint.

In the beach chair position, the C-arm must be directed appropriately for orthogonal views.

10. Overview of rehabilitation

The shoulder is perhaps the most challenging joint to rehabilitate both postoperatively and after conservative treatment. Early passive motion according to pain tolerance can usually be started after the first postoperative day - even following major reconstruction or prosthetic replacement. The program of rehabilitation has to be adjusted to the ability and expectations of the patient and the quality and stability of the repair. Poor purchase of screws in osteoporotic bone, concern about soft-tissue healing (eg tendons or ligaments) or other special conditions (eg percutaneous cannulated screw fixation without tension-absorbing sutures) may enforce delay in beginning passive motion, often performed by a physiotherapist.

The full exercise program progresses to protected active and then self-assisted exercises. The stretching and strengthening phases follow. The ultimate goal is to regain strength and full function.

Postoperative physiotherapy must be carefully supervised. Some surgeons choose to manage their patient’s rehabilitation without a separate therapist, but still recognize the importance of carefully instructing and monitoring their patient’s recovery.

Activities of daily living can generally be resumed while avoiding certain stresses on the shoulder. Mild pain and some restriction of movement should not interfere with this. The more severe the initial displacement of a fracture, and the older the patient, the greater will be the likelihood of some residual loss of motion.

Progress of physiotherapy and callus formation should be monitored regularly. If weakness is greater than expected or fails to improve, the possibility of a nerve injury or a rotator cuff tear must be considered.

With regard to loss of motion, closed manipulation of the joint under anesthesia, may be indicated, once healing is sufficiently advanced. However, the danger of fixation loosening, or of a new fracture, especially in elderly patients, should be kept in mind. Arthroscopic lysis of adhesions or even open release and manipulation may be considered under certain circumstances, especially in younger individuals.

Progressive exercises

Mechanical support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture is sufficiently consolidated that displacement is unlikely.

Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function.
The three phases of nonoperative treatment are thus:

  1. Immobilization
  2. Passive/assisted range of motion
  3. Progressive resistance exercises

Immobilization should be maintained as short as possible and as long as necessary. Usually, immobilization is recommended for 2-3 weeks, followed by gentle range of motion exercises. Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending upon the injury and its repair. If greater or lesser tuberosity fractures have been repaired, it is important not to stress the rotator cuff muscles until the tendon insertions are securely healed.

nonoperative

Special considerations

Glenohumeral dislocation: Use of a sling or sling-and-swath device, at least intermittently, is more comfortable for patients who have had an associated glenohumeral dislocation. Particularly during sleep, this may help avoid a redislocation.

Weight bearing: Neither weight bearing nor heavy lifting are recommended for the injured limb until healing is secure.

Implant removal: Implant removal is generally not necessary unless loosening or impingement occurs. Implant removal can be combined with a shoulder arthrolysis, if necessary.

Shoulder rehabilitation protocol

Generally, shoulder rehabilitation protocols can be divided into three phases. Gentle range of motion can often begin early without stressing fixation or soft-tissue repair. Gentle assisted motion can frequently begin within a few weeks, the exact time and restriction depends on the injury and the patient. Resistance exercises to build strength and endurance should be delayed until bone and soft-tissue healing is secure. The schedule may need to be adjusted for each patient.

Phase 1 (approximately first 3 weeks)

  • Immobilization and/or support for 2-3 weeks
  • Pendulum exercises
  • Gently assisted motion
  • Avoid external rotation for first 6 weeks

Phase 2 (approximately weeks 3-9)

If there is clinical evidence of healing and fragments move as a unit, and no displacement is visible on the x-ray, then:

  • Active-assisted forward flexion and abduction
  • Gentle functional use week 3-6 (no abduction against resistance)
  • Gradually reduce assistance during motion from week 6 on

Phase 3 (approximately after week 9)

  • Add isotonic, concentric, and eccentric strengthening exercises
  • If there is bone healing but joint stiffness, then add passive stretching by physiotherapist