The plate has small holes for temporary stabilizing wires to be placed through it into the head. Two of these are helpful in preventing the plate from small shifts in position while placing the screws. A drill is then placed through the plate into the head to a depth of approximately 8–10 mm (Fig. 6.2) from the articular surface. Confirmation of direction and depth is done with the C-arm. A locking screw of measured length is inserted into the head through the drilled track, and depth and direction are confirmed via C-arm. A second screw is placed along the calcar after drilling, and direction and depth are confirmed with several C-arm views in different planes.

Bicortical screws can then be placed through the plate and the shaft to secure the distal part of the plate and allow removal of the clamp. These screws need not be locking screws unless the bone appears to be of poor quality. After there are at least two screws in the head and two in the shaft, the clamp is removed. The rest of the screws are inserted into both areas. It is preferable to have at least five or six screws in the head with two or three of these along the calcar (Fig. 6.3).

Three-part fractures usually involve the surgical neck and greater tuberosity. There are two common types: those with the head in valgus (Fig. 6.4) and those with the head in varus (Fig. 6.5). The options for surgical approach are the same as described. Dissection for these fractures, like the two part, must be gentle with the careful use of an elevator or a finger. The long head of the biceps can often be a useful guide to the orientation and position of the fragments. Placement of the previously described traction suture through the tendon bone junction of the cuff and the greater tuberosity is important for control of this fragment. If the head is in valgus, it is very gently pried up to face the glenoid. This is done very carefully in order not to disrupt the stable medial periosteal cortical hinge of the head. Once this is done, there is a noticeable defect behind the head laterally into which the greater tuberosity usually fits quite nicely. If the head is in varus, it is a more difficult challenge. The head fragment must be tilted upward into its anatomic position, often by using a finger or elevator on its inferior aspect to lift it into the proper position. The greater tuberosity can then be placed behind the plate positioned as noted earlier, and temporarily stabilized through the tuberosity to the head with the stabilizing wires. The greater tuberosity position must be confirmed by C-arm. The tip of the greater tuberosity should be between 6 and 10 mm below the top of the reduced humeral head (Fig. 6.6a). If it is higher than the top of the head, it will restrict abduction. If the tuberosity is lower than described it will create a significant glenohumeral joint displacement upward and alter joint mechanics, potentially leading to degeneration [4]. Another C-arm shot is taken to ensure that not only is the tuberosity in the proper position but the tip of the plate is also below the tip of the greater tuberosity. The shaft is then reduced to the head/tuberosity fragments, aligning the medial cortex of the shaft with the medial inferior edge of the head and the lateral cortex of the shaft with the inferior edge of the greater tuberosity. The shaft is then clamped to the plate (Fig. 6.6a, b) and placement of the screws into the head through the plate and tuberosity, and subsequently into the shaft, is carried out as described above. Any tear in the rotator cuff is repaired. In treatment of the two- and three-part fractures, the biceps is tenodesed to the transverse humeral ligament or simply released by tenotomy.