Open reduction and internal fixation of two- and three-part proximal humerus fractures

Results of open reduction and internal fixation of two- and three-part proximal humerus fractures can be maximized with a thorough understanding of shoulder anatomy, accurate fracture classification based on quality radiographs in three planes, strict attention to detail, and minimizing further injury to the soft tissues at the time of surgery. Almost all of these fractures can be managed by one of two surgical approaches, the deltoid-splitting or deltopectoral, both of which leave the deltoid origin intact. Minimal osteosynthesis fixation in the form of heavy, nonabsorbable suture or wire incorporating the strong rotator cuff tendons, tuberosities, and shaft is a sound method of achieving both rigid fixation and fracture healing. Ender nails used in conjunction with figure-of-eight suture or wire in a tension band configuration gives additional longitudinal and rotational stability in surgical neck fractures, especially if comminution exists. The use of this limited internal fixation minimizes the complications of soft-tissue stripping and loss of fixation in osteoporotic bone seen with the use of plates and screws, while allowing an early passive rehabilitation program. A physician-supervised rehabilitation program for at least 1 full year is required for optimum results.