Angelo DiFelice and Gordon W. Nuber

Indications

1. Proximal humerus fracture with displacement of fracture fragments greater than 1 cm or 45 degrees of fracture angulation as described by Neer (1970)

2. Unstable fracture reductions

3. Irreducible fracture dislocation

4. Displaced tuberosity fracture

5. Three- or four-part fracture in younger patients

6. Open fracture

7. Fracture with an associated vascular injury

Contraindications

1. Poor bone quality (relative)

2. Patients with a guarded overall medical condition and poor rehabilitation potential (relative)

3. Marked deltoid dysfunction (relative)

Preoperative Preparation

1. Shoulder radiographs (trauma series) to include an AP shoulder view, an AP scapular view (Grashey view), and an axillary view

2. If needed, CT scan to define articular surface defects or assess reduction of the glenohumeral joint

3. Document status of preoperative neurovascular examination.

Special Instruments, Position, and Anesthesia

1. The patient is placed in the semi-sitting position (30 degrees upright).

2. All pressure points should be padded.

3. The procedure can be done with general or inter-scalene block anesthesia.

4. Trauma fixation sets should be available. These should include small and large fragment sets, as well as modified Enders rods.

5. Fluoroscopy should be available.

Tips and Pearls

1. Be sure to drape the entire shoulder girdle and arm free.

2. Check that the fracture can be adequately evaluated with the fluoroscopy prior to prepping the patient. If needed, adjust the patient accordingly.

3. Administer intravenous antibiotics prior to beginning the operation.

What To Avoid

1. Avoid excessive stripping of fracture fragments.

Postoperative Care Issues

1. A suction-type drain can be used and normally discontinued the morning after surgery.

2. A compressive dressing should be placed at the end of surgery and is normally changed approximately 48 hours after the procedure.

3. Assessment of the patient’s distal neurovascular examination should be made the evening of surgery.