Surgical Discussion

Patient positioning:  The patient was positioned supine with the head of the bed elevated to 45 degrees to accommodate ongoing intracranial pressure management.

Anatomical surgical approach:  The surgical approach utilized an extended deltopectoral incision. A biceps tenotomy was performed to facilitate reduction of the humeral head into the glenoid. A Schanz pin was carefully placed into the calcar or humeral head, with manual protection of the axillary artery and vein during insertion. Following reduction, direct anatomic reduction of the fracture was achieved with interfragmentary compression using 2.7mm lag screws. The greater tuberosity was reduced using sutures in the rotator cuff, held in place with wires, and potentially mini fragment fixation if the fragment size permitted. A laterally based locking plate was applied, ensuring all screws were safely positioned, and cuff sutures were tied to the plate. Biceps tenodesis was performed.

The surgeon noted the importance of careful placement of the Schanz pin to avoid vascular injury and emphasized the necessity of achieving anatomic reduction to minimize the risk of avascular necrosis (AVN). The use of sutures and wires for greater tuberosity fixation was highlighted as a critical step in restoring native anatomy.

Postoperative protocol:   Postoperative rehabilitation included immobilization in a sling with passive range of motion exercises initiated as tolerated, progressing to active-assisted and active range of motion exercises over several weeks. Weight-bearing restrictions were maintained until radiographic evidence of healing.

Follow up:   Not specified.

Orthopaedic implants used:   Laterally based locking plate, 2.7mm lag screws, Schanz pin, sutures for rotator cuff fixation, wires for greater tuberosity fixation.