We recommend placing the patient in Beach chair position

Essential is an unobstructed intraoperative C-arm view of the proximal humerus

We use a TRIMANO armholder (Arthrex, Naples) in a standardized fashion, allowing for excellent intraoperative manipulation and stabilization of the arm (see Fig. 17.3).

We strongly recommend a deltopectoral approach, starting between the coracoid and the AC-Joint extending to the lateral axillary line (see Fig. 17.4). The deltopectoral interval has to be thoroughly identified, usually landmarked by the cephalic vein. The cephalic vein can be either lateralized or medialized.

The deltoid muscle is retracted either a self spanning shoulder retractor or a Brown retractor. We use a carbon Brown retractor (Innomed, Switzerland), allowing for intraoperative C-arm control without the need for instrument removal.

The medial border of the dissection is marked by the conjoined tendons

For identification of the lesser tuberosity the long head of the biceps has to be found medial to the pectoralis major insertion. In about 80 % of head fractures a signification injury of the LHB can be found, requiring tenotomy throughout the rotator interval and subpectoral tenodesis of the LHB.

Fracture hematoma is removed by irrigation, followed by blunt adhesiolysis in the subacromial (SA) space after identification of the coracoacromial (CA) ligament. Sometimes a Fukuda retractor within the SA space is useful.

The GT fragment and the facets of the supraspinatus, infraspinatus, and teres minor and the corresponding rotator cuff attachments must be identified.