These are very complex, mainly four-part fractures in which the humeral head is separated from the tuberosities and the epiphyseal cancellous bone is crushed between the head displaced in valgus and the metadiaphysis (Fig. 7.2a).

In order to obtain the fracture reduction, the head should be levered up with delicate movements acting on the calcar as a hinge, which is often comminuted and weak.

After removing the fracture hematoma, the greater and the lesser tuberosities which stay over the epiphysis deviated in valgus are identified. As described above, the fragments have to be carefully prepared and bone sutures applied. An incision of the rotator cuff between the fragments of the greater tuberosity is necessary in order to expose the humeral head and push it in varus (Fig. 7.2a part). Several authors suggest to open the rotator interval rather than the cuff. Controlling the head reduction through the rotator interval in our opinion is more difficult and the surgeon’s manipulations therefore more aggressive, so this is advisable only in case that the greater tuberosity is a single large fragment separated from the lesser tuberosity. On the other side, a limited section of the supraspinatus allows to avoid surgical lesions of the pulley and of the richly vascularized area of the long head of the biceps, gaining a direct lateral view of the epiphysis and the diaphysis, which makes the reduction easier.

After placing the Lambotte forceps as described above, it is possible to proceed to the reduction, which requires a combined action. While the assistant tractions the shaft acting on the Lambotte forceps, the surgeon by a straight retractor gently elevates the head (Fig. 7.2b). The bone loss in this area often prevents the maintenance of the reduction and needs augmentation. No type of graft has proven superior to others in this setting; anyway its application is necessary [33].

The graft should be mechanically strong to support the head, correctly sized in order to get stuck in the medullary canal without sinking, easy to pass through by the screws which have to reach the humeral head, and easy to remove in case of late failure. The type of graft that best fulfills these requirements is a homologous cancellous bone wedge, to be adapted to the patient’s anatomy (Fig. 7.2b part).

The graft has to be introduced in the upper part of the medullary canal while adduction of the arm. Maneuvering the shaft below the head and adapting the size and shape of the graft allow to keep the head in the correct degree of varus (the graft can be impacted inside the canal if too proud or trimmed by a Luer or a saw if too thick). Additional small cancellous homologous grafts can be placed around the wedge for a better filling.

If the tuberosities are mechanically strong, the bone sutures can be tractioned in order to place them between the head and the shaft, overlaying the graft (Fig. 7.2c). Only at this point can the fracture be provisionally stabilized by the smaller possible number of K-wires.

These steps are quite delicate in the more comminuted fractures. If the bone sutures fail or the K-wires create additional fractures in the tuberosities or in the head, there is a high risk to have to shift to a hemiarthroplasty. It is therefore recommended to use the plate for obtaining a gradual reduction exploiting its strength and anatomic shape, as described above. Hertel [5] well describes the principles of this reduction; in his paper he suggests the use of a simple one-third tubular plate with cancellous bone screws. Nowadays the new plates have added the great advantage of the polyaxial locking screws, while the anatomic contour proves extremely useful for the reduction acting like a template.

Once the plate is fixed by one cortex screw in the oval hole, the bone sutures are provisionally knotted to the plate, some K-wires or proximal screws are inserted, and image intensifier images are obtained before definitively fixing the fracture (Fig. 7.2d).

The cuff incision has to be closed by resorbable sutures, even though tightening the tuberosities to the plate often pulls the edges so close as to make it unnecessary. It is not always possible to close the rotator interval, if it was opened and if the fracture reduction is not perfect.

This fracture pattern often occurs in younger patients. The comminution of the tuberosities is less severe; there is a better bone stock and usually a better calcar length.

The reduction however is not easier, and there is always a risk that the surgical manipulation can make the fracture more complex.

Once the fragments have been identified and the bone sutures prepared, it is useful to expose by a delicate dissection the lower part of the subscapularis to get access to the calcar. A smooth retractor can gently push the head to place it in valgus. Unfortunately this procedure can induce two risks:

It is therefore advisable to try to use the plate for obtaining the fracture reduction (Fig. 7.3).

The surgeon should try to set the tuberosities on the sides of the head deviated in varus by gentle traction on the bone sutures and to connect them to the head by K-wires (Fig. 7.3a).

The plate is then placed on the aligned fragments and provisionally fixed with other K-wires through its dedicated holes. If the anatomy reconstruction looks macroscopically and radioscopically acceptable, the fixation is performed placing the proximal screws (Fig. 7.3b), then the plate can be used like a joystick in order to move the proximal humerus in valgus and align it with the shaft. The fixation goes on with a cortex screw in the oval hole before obtaining new images with the image intensifier. The reduction can then be refined with additional bone sutures, possibly loosening and then tightening again some screws for the corrections before completing the fixation (Fig. 7.3c).

The long head of the biceps is a key structure in proximal humerus fractures. It is first of all an important landmark for anatomy comprehension during surgery. Locating it distally and following it proximally help find the lesser tuberosity and the rotator interval. Its bony groove is a crucial area for the vascular supply of the bony fragments and should be respected as much as possible. Restoring the continuity of the bicipital groove is extremely helpful for assessing the fracture reduction before radioscopic checking.

The surgical manipulation should not be extended beyond the medial edge of the long head of the biceps to minimize the risks of lesion of the anterior circumflex artery and of its branches, even though recent clinical evidences and angiographic studies suggest a major role of the posterior circumflex artery in the vascular supply of the humeral head, in contrast with what was thought [34].

At the end of the surgery, the long head of the biceps can be left in place if undamaged (the sharp edges of the bony fragments often cause severe damage) and if its bony bed has a smooth continuity. If this is not the case, a proximal tenotomy and possibly a soft tissue tenodesis (depending on the patient’s age) are advisable.

The good balance between the quality of the fracture reduction and the soft tissue damage to achieve it is the key point of the operation. The clinical results after conservative treatment of borderline fractures show that even non-perfectly reduced fractures can allow a satisfactory functional result. This balance is however quite hard to define in the form of guidelines. This is why these fractures are better treated not in emergency, not by unexpert surgeons, and not with insufficient radiographic pictures. It is better to take the time to obtain an accurate planning and to have an adequate surgical team available and the best surgical instrumentation (dedicated plates, bone grafts, and a shoulder prosthesis).

Codman realized the importance of the rotator cuff tendons in keeping proximal humerus fractures in mutual apposition. He emphasized “how tenaciously the short rotators with their periosteal prolongations cling to all the fragments, and tend to hold them together.” Plate fixation of these fractures should be intended not as a strong construct depending on the holding power of the screws in bone, but rather as a solid bridge/scaffold connecting the various bony fragments to the plate and the plate to the humeral shaft. The tension of the tendons counterbalanced by the scapular glenoid will keep the fragments “loaded.”