Introduction: We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate.
Step 1 preoperative planning: To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes.
Step 2 patient positioning: Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier.
Step 3 approach: The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury.
Step 4 reduction and fixation of the tuberosities the key to obtaining marionette-like control: The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like.
Step 5 fracture reduction: After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate.
Step 6 fixation implant-specific considerations: Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities.
Step 7 tenotomy or tenodesis of the long biceps tendon: Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval.
Step 8 wound closure: Do not close the deltopectoral interval.
Step 9 rehabilitation: As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol.
Results: In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.