Reconstruction of Proximal Humerus Three-Part Fracture Without Complications By Dr. Pothireddy Surendranath Reddy, Orthopaedic Surgeon

Table of Contents

Introduction

Anatomy of Proximal Humerus

Definition of 3-Part Fracture

Pathomechanics

Clinical Evaluation

Imaging: X-Ray, CT, 3D CT

Indications for Surgery

Pre-Operative Planning

Choosing the Surgical Approach

Deltopectoral Approach – Detailed Steps

Reduction Techniques

Rotator Cuff–Assisted Tuberosity Manipulation

Importance of Medial Calcar Support

Locking Plate Fixation: Step-by-Step

Screw Trajectory and Avoiding Joint Penetration

Techniques to Prevent AVN

Suture Fixation of Tuberosities

Intraoperative Fluoroscopy

Post-Operative Rehabilitation

Complication Prevention

Case Examples

Final Outcomes

Summary

References (linked websites)

1. Introduction

Proximal humerus fractures account for nearly 5% of all fractures and are particularly common in elderly patients with osteoporosis. Among the fracture types described by Neer, a three-part fracture involves fracture and displacement of:

The surgical neck

The greater tuberosity

The lesser tuberosity (or head-shaft displacement depending on the pattern)

A three-part fracture is complex because tuberosities and humeral head orientation must be restored accurately to regain shoulder biomechanics. Inadequate reduction or fixation can lead to:

Malunion

Stiffness

Avascular necrosis (AVN)

Loss of tuberosity function

Screw penetration

Chronic pain

Dr. Pothireddy Surendranath Reddy explains a structured, anatomical, complication-free method for reconstructing these fractures using modern principles, strong tuberosity fixation, and minimally traumatic surgical handling.

2. Anatomy of the Proximal Humerus

Understanding anatomy is crucial for avoiding complications.

Key Structures

Greater tuberosity (supraspinatus, infraspinatus insertion)

Lesser tuberosity (subscapularis insertion)

Bicipital groove

Articular head

Medial calcar → critical for stability

Humeral neck (surgical/anatomical)

Blood Supply

Preserving blood supply prevents AVN.

Main arterial supply:

Posterior humeral circumflex artery (PHCA)

Anterior humeral circumflex artery (AHCA)

Relevant reading:
🔗 AO Foundation – Proximal Humerus Anatomy
https://surgeryreference.aofoundation.org

3. What is a Three-Part Proximal Humerus Fracture?

According to Neer classification, a fracture is considered displaced when:

1 cm displacement

45° angulation

A “three-part” fracture typically includes:

Displaced surgical neck

Displaced greater tuberosity

Humeral head attached to either lesser tuberosity or shaft

These fractures are unstable and are best treated surgically in active patients.

Reference:
🔗 Orthobullets – Proximal Humerus Fractures
https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures

4. Pathomechanics

Proximal humerus fractures result from:

Falls on an outstretched hand

Direct trauma

High-energy accidents (young adults)

Low-energy osteoporosis trauma (elderly)

Muscle forces pull fracture parts:

Supraspinatus → pulls greater tuberosity superoposteriorly

Subscapularis → pulls lesser tuberosity medially

Pectoralis major → medial displacement of shaft

Understanding these vectors helps during reduction.

5. Clinical Evaluation

Symptoms

Severe pain

Swelling

Arm held in adduction

Limited movement

Crepitus

Examination includes:

Neurovascular status

Axillary nerve assessment

Rotator cuff integrity

Skin tenting or open wounds

Associated injuries

Reference:
🔗 AAOS OrthoInfo – Shoulder Fractures
https://orthoinfo.aaos.org

6. Imaging

X-rays (mandatory)

AP view

Scapular Y view

Axillary view

CT Scan

– Essential for three-part fractures
– Helps assess tuberosity displacement
– Useful for pre-op planning

3D CT

Gives a better understanding for surgical reduction.

Reference:
🔗 Radiopaedia – Proximal Humerus Fracture
https://radiopaedia.org

7. Indications for Surgery

Surgery is indicated in:

Young active individuals

Markedly displaced fractures

Tuberosity displacement (>5 mm)

Head-shaft angulation >45°

Varus fractures with medial comminution

Failure of conservative treatment

8. Pre-Operative Planning

Dr. Reddy emphasizes:

✔ Template plate positioning before surgery

✔ Plan number and direction of screws
✔ Evaluate bone density
✔ Assess rotator cuff involvement
✔ Prepare suture anchors if required
✔ Decide on approach
✔ Anticipate complications such as varus collapse

Preoperative planning reduces operative time → reduces complications.

9. Choice of Surgical Approach

Two approaches are commonly used:

Deltopectoral approach (preferred by Dr. Reddy)

Deltoid-split approach (risk to axillary nerve)

Why Deltopectoral?

Preserves blood supply

Allows excellent visualization

Provides access for plate positioning

Least muscle damage

10. Deltopectoral Approach – Step-by-Step

Landmarks

Coracoid process

Deltopectoral groove

Steps

Incision 8–12 cm from coracoid downward

Identify deltopectoral interval

Retract cephalic vein laterally

Retract deltoid laterally and pectoralis major medially

Identify fracture hematoma

Gently expose tuberosities

Maintain periosteal attachments

Use stay sutures to control tuberosities

Key principle:

Minimal stripping → Reduced AVN → Better healing

11. Reduction Techniques

Primary goal: Anatomical reduction of humeral head + tuberosities

Correct head alignment:

Valgus

Retroversion (20–30°)

Height restoration

Rotator cuff sutures

Pass strong sutures (Ethibond, Fibrewire) through:

Supraspinatus

Infraspinatus

Subscapularis

These sutures act as handles to manipulate tuberosities.

12. Rotator Cuff–Assisted Reduction

Stay sutures allow:

Traction

Rotation

Control of displacement

Greater Tuberosity Reduction:

Pull superiorly and posteriorly

Align with bicipital groove

Lesser Tuberosity:

Align medially

Confirm with bicipital groove orientation

Check reduction with fluoroscopy.

13. Importance of Medial Calcar Support

Varus malalignment is the main cause of failure.

Dr. Reddy emphasizes:

✔ Medial calcar screws MUST be placed

✔ Inferomedial buttress is critical
✔ Prevents head collapse
✔ Increases construct stability

Relevant reading:
🔗 PubMed – Importance of Calcar Screws in Proximal Humerus
https://pubmed.ncbi.nlm.nih.gov

14. Locking Plate Fixation: Step-by-Step

Plate Position

8–10 mm distal to the greater tuberosity

Slight posterior offset

Align plate with bicipital groove

Fixation Steps

Fix plate temporarily with K-wires

Insert proximal locking screws

Insert calcar screws

Check screw length

Fix shaft screws

Tie sutures from cuff tendons to plate holes

Confirm stability in all planes

15. Screw Trajectory & Avoiding Joint Penetration

Prevent Screw Cut-Out:

Use three-plane fluoroscopy

AP in neutral, internal, external rotation

Avoid excessively long screws

Posteromedial screws should be shorter

Check subchondral bone purchase

16. Techniques to Prevent AVN

Avoid excessive soft tissue stripping

Preserve PHCA

Gentle handling

Avoid multiple drilling attempts

Avoid over-distraction

Minimize operative time

17. Suture Fixation of Tuberosities

Tuberosities are key to shoulder function.

Technique:

Pass high-strength sutures through cuff tendons

Pull them to footprint

Tie them through designated plate holes

This reduces secondary displacement.

18. Intraoperative Fluoroscopy

Views needed:

AP

Internal rotation

External rotation

Axillary view

Scapular Y

Check for:

Plate position

Screw length

Tuberosity reduction

Neck-shaft angle

Implant alignment

19. Post-Operative Rehabilitation

A structured protocol reduces stiffness and complications.

Day 1–2

Arm sling

Pendulum exercises

Wrist & elbow ROM

Week 2–4

Passive shoulder ROM

Wall climbing exercises

Week 4–6

Active-assisted movements

Scapular stabilization

Week 8–12

Strength training

Rotator cuff strengthening

After 3 months

Return to overhead activities

Reference:
🔗 AAOS Shoulder Rehab Guidelines
https://orthoinfo.aaos.org

20. Complication Prevention

Dr. Reddy explains the major complications and how to avoid them:

1. Varus Collapse

Correct plate height

Calcar screws

Avoid medial comminution without support

2. Screw Penetration

Triple-view fluoroscopy

Correct screw length

3. Tuberosity Non-union

Strong suturing

Anatomical reduction

4. Avascular Necrosis

Minimal soft tissue stripping

PHCA preservation

5. Stiffness

Early physiotherapy

Avoid immobilization >2 weeks

6. Malunion

Ensure correct head orientation

Confirm with fluoroscopy

21. Case Examples (Illustrative Summary)

Case 1: 55-year-old male

Three-part fracture with GT displacement

CT shows intact medial calcar

Locking plate + suture fixation

Full ROM regained by 10 weeks

Case 2: 72-year-old woman

Osteoporotic bone

Comminuted GT

Additional fiber tape augmentation

Healed without varus collapse

Case 3: 40-year-old male (high-energy injury)

Severe displacement

Strong cuff sutures required

Excellent outcome with stable fixation

22. Expected Outcomes

With proper reconstruction:

90% regain functional ROM

Pain-free activity

Tuberosity healing

Minimal malunion

Low AVN rates

Fast return to work

Modern locking techniques + anatomical reduction produce predictable, excellent outcomes.

23. Summary

A proximal humerus three-part fracture requires:

Precise anatomical reduction

Stable locking plate fixation

Strong tuberosity suturing

Preservation of blood supply

Medial calcar support

Early rehabilitation

Dr. Pothireddy Surendranath Reddy highlights that most complications are preventable with careful surgical planning, correct implant positioning, fluoroscopy guidance, and systematic postoperative rehab.

24. References and Relevant Links

Below are authoritative orthopaedic resources used in this article:

Orthobullets – Proximal Humerus Fractures
https://www.orthobullets.com/trauma/1015/proximal-humerus-fractures

AAOS OrthoInfo – Shoulder Fractures
https://orthoinfo.aaos.org/en/diseases--conditions/proximal-humerus-fractures

AO Trauma – Proximal Humerus Surgery Reference
https://surgeryreference.aofoundation.org

Radiopaedia – Proximal Humerus Fracture
https://radiopaedia.org/articles/proximal-humeral-fracture

PubMed – Medial Calcar Screw Importance
https://pubmed.ncbi.nlm.nih.gov

Cleveland Clinic – Humerus Fractures Overview
https://my.clevelandclinic.org/health/diseases

Other topicd from Authors

1. https://pothireddysurendranathreddy.blogspot.com/2025/11/this-image-has-empty-alt-attribute-its.html neck pain

2. https://pothireddysurendranathreddy.blogspot.com/2025/11/biodegradable-screws-in-orthopaedics.html bio degradable screws

3. https://pothireddysurendranathreddy.blogspot.com/2025/11/robotics-in-orthopaedic-surgery-expert.html Robotics in Orthopaedic surgery

Dr. Pothireddy Surendranath Reddy – Official Links

Comments