Operative management of Extra-articular Unifocal Fractures

A1 fractures

Displacement of tuberosity fragments can be properly verified and assessed with x-rays in internal and external humeral rotation. Sling immobilization must be used in case of greater tuberosity in unifocal fractures in case of no displacement or less than 5mm. displacement in younger patients; in case of less than 40° angulation of the fragments; and if there is not more than 10 mm. displacement in older patients (60 and above).

If fragments are displaced particularly the superior part of the greater tuberosity, they may intrude between the head and the acromion, because of the pull of the supraspinatus muscle, the reduction is required in such fragments. These fragments are held temporarily with K-wires running through to the medial side and then fixed with a cannulated screw. A tension-absorbing suture or tension band wire may be used distinctively or additionally if open reduction with a deltopectoral approach is essential.

Following perforation of the cuff close to its bony insertion with the help of an atraumatic curved needle carrying a size 1 or 2 resorbable suture, the fragment is reduced and held in place with a figure-of-eight loop which is tightened around a screw head or through a 2.0 mm drill hole in the lateral cortex.

Instead of wires, resorbable atraumatic sutures have been used for a long time which has indicated good results. The major issue is that wire tends to cut through the bone and there is a possibility of its breakage. It can be noticed on the x-ray and the patient may feel concerned about it.

An accurate closed reduction should be undertaken first in case of an associated glenohumeral dislocation. In case of displacement of the greater or lesser tuberosity, the closed reduction under image intensifier followed by percutaneous fixation should be preferred. And If it seems unattainable then open fixation should be aimed at.

A2 fractures

Sling immobilization should be used in surgical neck or sub-capital fractures without major displacement or less than 10 mm displacement and below 30º to 45º angulation until the pain is gone. But the patient’s age and concurrent disease must be considered before the treatment. Later, passive motion can be cautiously supported and after that active motion can be followed. If the fracture is affected with a manageable level of valgus malalignment then considering the patient’s age, after a few days, functional treatment may be given.

A3 fractures

Re-displacement occurs in these unstable fractures whether they are impacted or can be reduced closed. This leads to stiffness, immobilization, and continuous pain. Maintenance of the reduction is usually attempted by percutaneous pinning under general anaesthesia if these can be reduced. 7.0 mm or 4.5 mm cannulated screws following the optimal placing of three 1.6 mm K-wires can be used as an alternate of simple pinning. 

These screws are inserted with power after the lateral cortex has been opened with a 4.5 mm drill bit but 3.2 mm in the case of younger patients. One from anteriorly and two from the lateral cortex are moved towards the centre of the head.

Generally, one or two long cannulated cancellous screws are inserted to impact the fracture and one or two K-wires may be inserted from the greater tuberosity into the medial shaft cortex. The stability of fixation for postoperative functional treatment will be verified by passive motion under image intensification after the removal of K-wires. 

The application of intramedullary nails, generally by retrograde insertion from about 3 cm proximal to the olecranon tip is another method of fixation after closed reduction. Adequate stability is provided by unreamed interlocking nails also in the case of A3.3 fractures with metaphyseal comminution. An external fixator can be used in case of critically open, contaminated, and comminuted fractures.

The interposition of the long biceps’ tendon interposed fragments, or buttonholing through a split muscle leads to the inability to reduce the fracture by closed means. Under such conditions, a deltopectoral approach is followed to put the situation right. Up to 10º of Valgus impaction is acceptable and lag screws or plates may be used for stable fixation.

Mostly, 3-hole or 4-hole T-plate is inserted. Bone cement can be put into the drill holes if the anchorage of the screws is not reliable. Before wound closing, the image intensifier must be used to check the reduction, stability, screw position, and screw length. Following this method, pathological fractures can also be stabilized accurately.

Longer T-plates bridging the medial comminution area will be applied in multi-fragmentary fractures at the surgical neck area or fractures extending further into the shaft. In such cases, removal of the anterior part of the deltoid insertion is acceptable and sutured back.

The deltopectoral approach will be followed in open reduction. Tension-absorbing sutures or wires around the tuberosity fragments are anchored to screw heads or in plate holes. Though in type B fractures, it is very necessary not to damage the residual blood supply to the head. 

Hand Fracture Plate will be used routinely. In multi-fragmentary fractures, plates will be used. If stable fixation is not attainable in these three fractures, Hemi-arthroplasty remains a restoration procedure.