The speedbridge-technique is a totally knotless transosseous fixation of greater tuberosity fractures by laminar fixation of the rotator cuff. It is performed with a Swivel Lock anchor (Arthrex) with a Screw (Bio-Corkscrew, Arthrex) and a non-absorbable suture (Fiber Chain, Arthrex). There are various configuration possibilities for this technique, such as single row, double row, the V- or W- (so called Cassiopeia) configuration. Depending on the type of fracture and/or the bone quality a stronger fixation may be needed.

For the origin speedbridge technique, two Swivel Lock anchors are placed at the medial part of the rotator cuff footprint with a distance of 1.5–3 cm depending on the fracture and corresponding rotator cuff rupture. Then the non-absorbable sutures (Fiber Tapes, Arthrex) are passed through the intact cuff attached to the greater tuberosity fragment. Fiber Tapes are crossed (Fig. 18.2) and intraosseous fixation with Bio Swivel lock anchors is performed at the lateral edge of the greater tuberosity fragment.

The bone quality of the medial part of the humeral head is often poor, complicating the screw fixation. Therefore, a V-shaped or even a Cassiopeia configuration of the speedbridge technique may be indicated. The V shape technique is an alternative for the original single row technique. In contrast to the original single row speedbridge technique all four Fiber Tapes of the medial anchors are fixed with a single Bio Swivel Lock anchor at the lateral edge of the greater tuberosity fragment (Fig. 18.3). This is of advantage in case of poor bone quality at the medial part of the humeral head.

Moreover, in case of greater tuberosity fractures with a large fragment or corresponding extensive damage or rupture of the rotator cuff, the Cassiopeia technique can be used. In contrast to the original speedbridge technique three Swivel Lock anchors are used and fixed with the rotator cuff at the medial edge of the fragment. The Fiber Tapes are crossed and fixed with two Bio Swivel Lock anchors at the lateral edge in a W-configuration (“Cassiopeia”, Fig. 18.4).

Biomechanical studies and case reports could detect a minimal advantage of the double-row suture anchor fixation and suture-bridge technique compared to the two-screw fixation technique regarding loading force of 3 and 5 mm displacement as well as maximum failure load [15, 17].

Among proximal humeral fractures, isolated fractures of the greater tuberosity are rare and fractures of the lesser tuberosity are exceedingly rare. Isolated avulsion fractures of the lesser tuberosity represent an extremely rare injury that occurs mainly in younger patients [27].

Due to the functional environment including the coracoid process and acromial edge, only marginal dislocations of fractured tuberosities should be tolerated. Due to the insertion of the rotator cuff, displacement of either tuberosity leads to biomechanical changes in the inserting tendons and consecutive degenerative changes in the corresponding muscles. Operative fixation is widely recommended in cases of 5 mm dislocation or even with 3 mm dislocation of the greater tuberosity in overhead workers and athletes. In fractures of the lesser tuberosity, operative treatment is recommended for even minor displacement [2, 26]. In general, operative therapy of the lesser tuberosity must be considered beneficial in comparison with conservative approaches [22].

Arthroscopic fracture fixation consists of diagnostic arthroscopy for detection of other pathologies (Figure 18.5). A typical intraarticular pathology is for example a lesion of the biceps pulley system. After debridement of the fracture one or two suture anchors are placed at the medial rim of the fracture. The subscapularis tendon is fixed with strong sutures (e.g. Fiber Tape, Arthrex) lateral of the fracture creating a constant surface pressure of the fragment [18].

At present, certain difficulties are associated with arthroscopic methods for reduction and fixation of greater tuberosity fractures. Results from case studies and case reports suggest that arthroscopic methods for reduction and fixation of this type of fracture are associated with the same difficulties as arthroscopic repair of rotator cuff tears. First, there are many muscles around the shoulder joint. Hence, the distance from the skin to the joint cavity is relatively long and makes arthroscopic procedures more difficult. Second, a tourniquet cannot be used in this type of surgery, so bleeding affects visualization and increases the difficulty of the procedure. This bleeding can be reduced by regulation of the blood pressure. Third, a lateral position and traction of the shoulder can increase the joint space, resulting in difficulties in identifying the anatomical position of the shoulder. Finally, arthroscopic treatment of greater or lesser tuberosity fractures requires a long learning curve. Therefore, this method should be reserved for surgeons experienced and routinized with shoulder arthroscopy and rotator cuff repair.

Generally, humeral head fractures are managed by open reduction (with a deltopectoral approach for example) and internal fixation, e.g. with a plate. With an arthroscopic approach normally, the fracture cannot be properly reduced and fixed as the operation situs is too confusing. Nevertheless, apart from the above mentioned fracture of the greater or lesser tuberosity, arthroscopy can be performed first to identify possible accompanying intra- articular pathologies. Nevertheless, there are few reports about arthroscopical management of humeral head fractures. Dawson et al. for example [7] reported about a 4-part fracture-dislocation treated by arthroscopically assisted reduction of the humeral head and percutaneous pinning. This technique avoids the need for a deltopectoral approach, preserving soft tissue coverage of the humeral head fragment. Fracture was treated by arthroscopic assisted percutaneus pinning. The authors report that the visualization obtained was sufficient to perform the entire procedure without significant fluid extravasation into the soft tissue.

A posterior and lateral arthroscopic portal was used and the glenoid served as sufficient anatomic reference to perform the procedure. Intra-articular evaluation of the joint showed the biceps tendon and the cancellous bone of the dislocated humeral head, anterior to the glenoid. Only the anterior and inferior parts of the head fragment remained with soft tissue coverage. No soft tissue was seen in the posterior portion of the head fragment. Using a lateral arthroscopic portal, a 7-mm cannulated screw was introduced being used as “joystick” to obtain reduction of the humeral head under arthroscopic assistance. Once the reduction was obtained, the screw was withdrawn. Three K-wires were percutaneously inserted from the diaphysis to the proximal humeral head, using a motor drill.

Through a small lateral approach, the greater tuberosity was reduced and fixed on the humeral head by means of a 4.0-mm cancellous screw. In this case, no signs of avascular necrosis of the head were noted at 7 months of follow-up evaluation. The arthroscopic findings of only anterior and inferior soft tissue attached to the humeral head fragment are relevant, because any attempt to reduce the humeral head using a deltopectoral approach could have damaged the limited irrigitation of it. Hepp et al. compared functional outcome and humeral head necrosis after open reduction and internal fixation by a deltopectoral (DP) or deltoid-splitting [6] approach in 83 patients. They observed one case of avascular necrosis in group DS and three in group DP [10]. Stable osteosynthesis is important, but the outcome of operatively treated proximal humeral fractures is dependent on soft tissue management as well.

Nevertheless, humeral head fractures are generally treated by open reduction and internal fixation. Arthroscopy can be beneficial regarding better intra-articular evaluation, improved soft-tissue management and detection of potential accompanying pathologies.

Malunion of the proximal humeral fracture is an often debilitating and painful injury, which is a challenge of treatment.

These deformities need to be distinguished regarding their basic pathology. One classification can be found in the current literature. Beredjiklian et al. named three subtypes which are malposition of the tuberosities (type 1), articular surface incongruity (type 2) and articular fragment malposition (type 3) [5]. Moreover, soft tissue pathologic changes play a major role in the limited movement seen in proximal humeral malunion cases. Generally, malunion of proximal humeral fractures are treated by osteotomy and open reduction through an anteriosuperior approach using screws, sutures or suture anchors. Nevertheless, many components of the pathology complex, like soft tissue changes, injuries of the rotator cuff, intraarticular changes, etc. can be better addressed arthroscopically. Arthroscopy is used as an evaluation tool to assess the soft tissue contractures and intra-articular bony abnormalities. Malposition of the tuberosities is a deformity that can and should be addressed arthroscopically as well for displacements <10 mm.