Fig. 4.1
A two-part fracture pattern. The fragments are dislocated by the pectoralis major and deltoid muscle (a, anterolateral view), by the supraspinatus and subscapularis tendon (b, anterolateral view), and by the infraspinatus tendon (c, posterior view)
However, it has been demonstrated that this description does not fully correspond to the real fracture morphology. The greater tuberosity is typically posteriorly and laterally dislocated, not superiorly. This can be explained by the work carried out by Mochizuki, who included 113 shoulders in his cadaver study; he demonstrated that the supraspinatus always inserted into the anteriormost area of the highest impression on the greater tuberosity, while the infraspinatus extended to the anterolateral area of the highest impression of the greater tuberosity [10].
Before performing surgery it is mandatory to study and thoroughly understand the pattern of fracture, but sometimes this cannot be achieved even with the use of imaging. Traditional X-ray imaging is almost always insufficient, even when particular tricks are employed [11, 12]. The CT scan is very helpful [13], and also 3D imaging reconstruction can greatly improve the quality of preoperative planning [14]. However, the correct analysis of the fracture is not easy, and even expert surgeons can remain at variance at the end of the preoperative phase. Nevertheless, we believe it is crucial to always evaluate the fracture with a standard X-ray view, a transthoracic lateral view, an axillary view and, where possible, a CT scan.
4.2 Which Type of Fracture?
4.3 Closed Reduction Technique
Proper positioning of the patient is vital. Several authors describe the lateral [19], the beach-chair [20–24], and the supine [15, 17, 25, 26] positions. The image intensifier positioning is also very important because it must provide good X-ray views without hindering the surgeons’ work: it can be placed behind the patient’s head [22, 23, 27, 28], on the side being operated on [29], or contralateral to the fracture. The surgical site must be prepared with attention to common landmarks such as the acromion, the coracoid, and the acromioclavicular joint which need to be easily palpable. The patient must be perfectly stable on the operating table, and the head should be secured with a proper head positioner.
Various authors describe the closed reduction maneuver in different ways. Several surgeons usually refer to the techniques previously described by Jaberg [15], who suggests carrying out the procedure with the shoulder abducted to 70–80°; then progressive longitudinal traction is performed to position the diaphysis slightly lateral to the humeral head; downward pressure against the anterior aspect of the arm completes the maneuver.
Some authors use devices to make the reduction easier. Calvo et al. [17], in medially translated fractures, used a post connected to the surgical table as a fulcrum in the medial side of the fracture while the arm was in adduction to help the reduction of the displaced humeral shaft. Williams and Wong [29] suggests the association of flexion, adduction, and slight internal rotation to relax the pectoralis major tendon; then a longitudinal traction of the arm is applied along with a posteriorly directed force. Seyhan et al. [24] believes that traction of the adducted arm is enough. Herscovici et al. [30] recommends that the forearm be kept supinated and the elbow extended while performing the longitudinal traction; a 45° abduction completes the maneuver. Other authors describe different maneuvers for each type of fracture. Magovern and Ramsey [16] differentiates between five possible situations:
Two-part surgical neck fractures: the humeral head lies in a neutral position or is slightly varus dislocated because cuff tendons are intact; the shaft is medially and anteriorly dislocated and internally rotated because of the action of the pectoralis major tendon, while the humeral head is more retroverted than it is normally. Flexion together with adduction allows the surgeon to deal with the force of the pectoralis major tendon; traction and a posteriorly directed force applied to the arm complete the reduction maneuver.
Two-part greater and lesser tuberosity fractures: a tuberosity percutaneous pin inserted just before starting the maneuver is needed (the greater tuberosity is typically more involved than the lesser, which is difficult and dangerous to fix with a pin); the following arm rotation helps to fully reduce the fracture.
Three-part greater tuberosity fractures: the diaphysis is dislocated as mentioned above, so the maneuver implies flexion, adduction, and internal rotation followed by traction and a posteriorly directed force applied to the arm; once the surgical neck fracture has been fixated, the arm is externally rotated to achieve greater tuberosity reduction.
Three-part lesser tuberosity fractures: the humeral head is abducted and externally rotated; the surgical neck fracture is reduced thanks to flexion and external rotation; external rotation and abduction follow traction and the posteriorly directed force applied to the arm.
Four-part valgus impacted fractures: they need pins or blunt elevators inserted through mini-incisions.
Other authors suggest that mini-incisions be performed (also called “reduction portals”) so that instruments which can help the surgeon may be inserted, in particular in cases of complex fractures [31].
No complications are reported in the literature after a closed reduction maneuver.
4.3.1 Authors’ Preferred Technique
Whenever we have planned a closed reduction, we prefer the supine position . The image intensifier is contralateral to the fracture. As a consequence we can obtain both a good AP view and a good axial view without rotating the arm; moreover the C-arm does not get in the surgical team’s way and the surgeons have enough room to perform the reduction maneuver and the following fixation. A proper shoulder operating table is very useful in obtaining good intraoperative X-rays (Fig. 4.2).
Fig. 4.2
(a) The C-arm position to achieve the AP view. (b) The C-arm position to achieve the axial view
A two-part varus impacted fracture (Fig. 4.3) has been taken as an example. The closed reduction procedure is clearly illustrated step-by-step in the following sequence of photographs (Fig. 4.4):
Fig. 4.3
A two-part varus impacted fracture
