Surgical Technique for Open Reduction–Internal Fixation of an Unstable Displaced 3- Part Proximal Humeral Fracture Using a Proximal Humeral Locking Plate  Wichan Kanchanatawan, M.D., Sunikom Suppauksorn, M.D., Thanapon Chobpenthai, M.D., Worawit Densiri-aksorn, M.D., Warongporn Pongpinyopap, M.D., Gem Dorjiee, M.D.  Arthroscopy Techniques  Volume 6, Issue 3, Pages e807-e813 (June 2017) DOI: 10.1016/j.eats.2017.02.008 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 Anteroposterior fluoroscopic images. (A) The proximal humeral locking plate is temporarily placed and fixed with a K-wire after converting the 2 parts at the humeral head (humeral articular part with attached lesser tuberosity and greater tuberosity) into 1 part (H) and leaving the humeral shaft (S) as the second part. (B) The plate assists in reduction of the head and shaft part by insertion of the compression screw (arrow). Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 Left shoulder in beach-chair position. A 6- to 8-cm incision (arrow) is made at the anterolateral aspect of the acromion (A). (C, tip of coracoid process; D, distal clavicle.) Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 Left shoulder in beach-chair position through superolateral approach. The axillary nerve (arrow) lying in the deep layer of the deltoid is identified and looped with a vascular loop. The nerve is usually located 5 cm below the acromion process. Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 Left shoulder in beach-chair position through superolateral approach. The sutures placed at the lesser tuberosity are pulled laterally to correct the retroversion of the humeral head (black arrow), whereas the sutures placed at the greater tuberosity are pulled in a downward direction to correct any varus deformity (white arrow). Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 Left shoulder in beach-chair position through superolateral approach. A gloved index finger is inserted through the rotator interval. (G, greater tuberosity; L, lesser tuberosity.) Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 6 (A, B) Arthroscopic views from the posterior portal of the left shoulder show the gloved index finger (F) entering through the rotator interval. (Bi, long head of biceps tendon; G, glenoid; H, humeral articular part; Ssc, subscapularis tendon.) Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 7 The precise plate (P) placement should be opposite the articular part of the humerus to allow maximum purchase of the diverted locking screws. (B, long head of biceps tendon.) Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 8 A fluoroscopic image of the left shoulder shows the full profile of the plate, which has been referred to as the “plate view.” The arm is placed in an internally rotated position (arrow, inset). The plate should lie opposite to and be centered over the humeral head, which will have a light-bulb appearance. Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 9 A fluoroscopic image of the left shoulder shows the maximum length of the screws, which has been referred to as the “screw view.” The arm is in an externally rotated position of approximately 20° to 30° (arrow, inset). Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 10 (A) The remaining screws are placed at the head and shaft with special attention given to the screws supporting the reduced calcar area (arrow). (B) The sutures attached to the rotator cuff are secured to the plate holes for additional stability. Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 11 A 3-dimensional computed tomography scan of the left shoulder shows a 4-part proximal humeral fracture. The articular fragment (H) is difficult to control because of the disruption of the lesser tuberosity (L). (G, greater tuberosity; S, shaft.) Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 12 A computed tomography scan of the right shoulder shows impaction of the humeral shaft into the humeral head (arrow). Bone loss is expected after reduction, and bone grafting is usually indicated. Arthroscopy Techniques 2017 6, e807-e813DOI: (10.1016/j.eats.2017.02.008) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions