Proper reduction of the humeral head fragment is key. This may require an glenohumeral arthrotomy, via either an osteotomy of the lesser tuberosity or tenotomy of the subscapularis tendon, to improve visualization and manipulation.
It is recommended to perform this procedure with the patient in a beach chair position (with the supine position as alternative).
Reduction of the humeral head may be possible with digital pressure without open exposure. If this is unsuccessful, one could use a periosteal elevator or a bone hook inserted into the glenohumeral joint through a small incision of the rotator cuff.
Prolonged attempts at closed reduction are not encouraged. Proceed with open reduction through an anterior shoulder arthrotomy. For a description of the anterior shoulder arthrotomy see the deltopectoral approach.
One or two threaded pins in the humeral head may be used as “joy-sticks”, to aid the reduction.
Secure the reduced humeral head temporarily using 2 or 3 K-wires. As shown, they are placed from distal to proximal.
Make sure that they are anterior enough to avoid interfering with the screw application.
Check the position of the humeral head in the axial/lateral view and be sure that there is no anteversion or excessive retroversion of the humeral head.
Remember that the C-arm should be placed so that AP and axial views can both be obtained by C-arm repositioning without motion of the patient’s arm.
Cannulated or non-cannulated screws can be used according to the surgeon’s preference. We illustrate the use of 3.5 mm cannulated screws. A larger diameter screw may be preferred for larger bone fragments, particularly in the surgical neck region.
Since interfragmentary compression is desired, use a lag screw technique, with partially threaded screws, or lateral overdrilling, to compress the fracture.Guide wire insertion
Note: beware the axillary nerve and the bicipital tendon.
Insert 3.5 mm cannulated screws of correct length over the guide wires. The screw must not perforate the articular cartilage. Use washers only in osteoporotic bone.
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.
Also obtain an axial view.
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.
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:
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.
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.
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)
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:
Phase 3 (approximately after week 9)