High Yield Overview

SHOULDER HEMIARTHROPLASTY FOR ACUTE PROXIMAL HUMERUS FRACTURE

Deltopectoral approach - TRUE INTERNERVOUS PLANE. Fracture hematoma facilitates plane development. | advanced

Critical Danger Structures

Axillary Nerve

Location: Exits quadrangular space 5-7cm below acromion, travels with posterior circumflex humeral artery

At Risk: Fracture injury (5-10%), retractor placement, during tuberosity reduction

Protection: Document preop function, gentle retractors, stay anterior during exposure

Musculocutaneous Nerve

Location: Enters conjoint tendon 5-8cm distal to coracoid tip (variable 3-10cm)

At Risk: Aggressive medial retraction, dissection along conjoint

Protection: Gentle retractors on conjoint, avoid vigorous medial pull, palpate nerve entry

Cephalic Vein

Location: Lies in deltopectoral interval, variable course

At Risk: Often disrupted by fracture hematoma, can be divided if necessary

Protection: Take laterally with deltoid or medially with pectoralis - avoid injury if preserving

Anterior Circumflex Vessels

Location: Ascending branch travels along lateral bicipital groove to supply humeral head

At Risk: Usually disrupted in fracture (causes AVN), further injury during dissection

Protection: Identify and ligate if bleeding, avoid excessive stripping of proximal humerus

Long Head Biceps

Location: Bicipital groove between tuberosities - KEY VERSION LANDMARK

At Risk: Avulsion from tuberosity fragments, can be used as tissue marker

Protection: Preserve if intact for version reference, tag for identification, consider tenotomy if damaged

Mnemonic

HEIGHTSHEIGHTS - Prosthetic Height Landmarks

Mnemonic

FIXATIONFIXATION - Tuberosity Repair Technique

Positioning and Preparation

Patient Position: Beach chair position at 60-80° (typically 70°), head secured in horseshoe headrest, bump/bolster under medial scapular border to position glenoid vertically, arm draped completely free including hand. Fluoroscopy C-arm available from contralateral side. Fracture table NOT needed. Mayo stand over chest for instruments.

Surgical Approach: Deltopectoral approach - TRUE INTERNERVOUS PLANE (between deltoid [axillary nerve] and pectoralis major [medial and lateral pectoral nerves]). Fracture hematoma often disrupts normal planes but facilitates dissection.

Incision: 15-18cm extensile incision from clavicle/AC joint extending distally past deltoid insertion onto arm - significantly longer than elective arthroplasty (which is 10-12cm) to access widely displaced fracture fragments and allow extensive soft tissue repair work.

Anesthesia: General anesthesia with interscalene block for postoperative analgesia. Avoid indwelling catheters (phrenic nerve palsy risk).

Indications for Hemiarthroplasty

Traditional Indications (now evolving):

3-part or 4-part proximal humerus fractures in elderly patients >70-75 years
Head-splitting fractures (>40% articular surface involvement or severe impaction)
Fracture-dislocation with valgus impacted head and predicted high AVN risk
Failed ORIF with humeral head collapse or AVN
Impression fractures >40% of articular surface (large Hill-Sachs or reverse Hill-Sachs)

Modern Evolution: RSA (Reverse Shoulder Arthroplasty) now increasingly preferred over hemiarthroplasty for acute fractures in elderly patients because:

Better functional outcomes (mean forward elevation 120-130° vs 90-100° for hemi)
NOT dependent on tuberosity healing (RSA function preserved even with tuberosity nonunion)
Lower revision rates (5-10% vs 15-20% for hemi at 5 years)
More predictable pain relief

Hemiarthroplasty Still Considered For:

Younger patients 65-75 years with reconstructable tuberosities and good bone quality
Patients with intact or reparable rotator cuff function
Anatomic reconstruction preferred by patient/surgeon
Contraindications to RSA (active deltoid dysfunction, infection concern)

Neer Classification (Historical but Still Used)

1-Part: All fragments displaced <1cm or angulated <45° - NONOPERATIVE treatment 2-Part: One fragment displaced >1cm or angulated >45°:

Surgical neck (most common 2-part)
Greater tuberosity (second most common) - ORIF if displaced >5mm
Lesser tuberosity (rare)
Anatomic neck (rare, high AVN risk)

3-Part: Two fragments displaced (third fragment is head):

Greater tuberosity + surgical neck (most common 3-part)
Lesser tuberosity + surgical neck (less common)
AVN risk 15-25%

4-Part: All three fragments (GT, LT, shaft) displaced from head:

Head completely free, no soft tissue/vascular attachment
AVN risk 75-90%
Classic indication for arthroplasty vs RSA

Preoperative Planning

Imaging Review:

AP in scapular plane, Scapular Y, Axillary lateral X-rays
CT scan with 3D reconstruction ESSENTIAL - defines fragment size, displacement, comminution, head involvement
Identify: GT fragment size/quality, LT fragment, shaft comminution, head split/impaction
Measure contralateral normal shoulder for reference (head size, height landmarks)

Patient Assessment:

Age, functional demand, hand dominance
Bone quality assessment (DEXA if available, cortical thickness on CT)
Rotator cuff quality (chronic tears suggest RSA over hemi)
Medical optimization (diabetes control, smoking cessation, nutritional status)
CRITICAL: Document preoperative neurovascular exam, especially axillary nerve function

Implant Planning:

Head size from CT measurements (typically 43-49mm)
Stem length - standard vs long (long stem if metaphyseal comminution extends >5cm)
Cemented vs uncemented (cemented preferred in fracture setting for immediate stability)
Have revision options available (longer stems, RSA conversion if needed)

Step 1: Patient Positioning & Preoperative Planning

Patient Positioning & Preoperative Planning: Beach chair at 70°. Bump under scapula. Entire arm free. Review CT scan and 3D reconstruction preoperatively to understand fracture pattern (Neer 3-part vs 4-part), fragment displacement, head involvement. Document axillary nerve function preoperatively (unable to assess if unconscious - document limitation). Mark fragments on skin using fluoroscopy. Plan tuberosity reduction strategy. Have RSA implants available as backup if tuberosities non-reconstructable.

Exam Pearl

Technical Tip: EXAM KEY: 'I position the patient in beach chair with the arm completely free. Before draping, I review the CT scan carefully to understand the fracture pattern and plan my approach. I document axillary nerve function preoperatively - this is critical medicolegally as 5-10% of proximal humerus fractures have axillary nerve injury at presentation. I use fluoroscopy to mark the greater tuberosity fragment on the skin. I ensure RSA implants are available as a backup in case I encounter non-reconstructable tuberosities intraoperatively.'

Dangers at this step

Not documenting preoperative nerve status - medicolegal issues if postop deficit
Not reviewing imaging - miss fracture pattern complexity, inadequate implant planning
Inadequate positioning - difficult exposure, C-arm positioning issues
No RSA backup available - cannot convert if needed

Step 2: Extensile Deltopectoral Incision

Extensile Deltopectoral Incision: 15-18cm incision from AC joint/clavicle extending distally past deltoid insertion (significantly longer than elective arthroplasty 10-12cm). Deepen through subcutaneous tissue. Identify cephalic vein in deltopectoral interval - often disrupted by fracture hematoma, may ligate if necessary. Develop deltopectoral interval taking cephalic vein laterally with deltoid or medially with pectoralis. Evacuate fracture hematoma systematically. Explore full extent of fracture. Identify fragments by muscle attachments: GT (supraspinatus/infraspinatus), LT (subscapularis), shaft.

Exam Pearl

Technical Tip: EXAM KEY: 'I make a generous incision, 15-18cm long, from the AC joint extending distally past the deltoid insertion. This is longer than elective arthroplasty because I need to access widely displaced fracture fragments and perform extensive soft tissue repair. I develop the deltopectoral interval - the cephalic vein is often disrupted by hematoma so I may need to ligate it. I evacuate the fracture hematoma systematically. I identify fragments by their soft tissue attachments - the greater tuberosity has supraspinatus and infraspinatus, the lesser tuberosity has subscapularis attached.'

Dangers at this step

Incision too short - inadequate fragment access, difficult tuberosity reduction
Not identifying all fragments early - poor reconstruction planning
Aggressive stripping of soft tissue from fragments - devascularization, nonunion risk
Injury to musculocutaneous nerve with medial retraction

Step 3: Identify & Tag All Fracture Fragments

Identify & Tag All Fracture Fragments: CRITICAL STEP: Identify and TAG all fragments before removing anything. GREATER TUBEROSITY: Contains supraspinatus (superior facet), infraspinatus (middle facet), teres minor (inferior facet). Often displaced posterosuperiorly by muscle pull. Place heavy non-absorbable suture (Ethibond #2 or #5) through tendon substance as TAG - minimum 2 sutures. LESSER TUBEROSITY: Contains subscapularis. Displaced medially. Tag with 2 heavy sutures. HUMERAL HEAD: Often free floating in 4-part fractures. Preserve for bone graft - DO NOT DISCARD. SHAFT: Identify and protect. Tag biceps tendon if intact (version landmark). Document fragment sizes, quality, comminution.

Exam Pearl

Technical Tip: EXAM KEY: 'The most critical step is identifying and tagging all fracture fragments before proceeding. I place heavy non-absorbable sutures through the tuberosities with their cuff attachments - I use at least 2 sutures per tuberosity. The greater tuberosity has supraspinatus, infraspinatus, and teres minor - this is essential for abduction and external rotation. The lesser tuberosity has subscapularis - essential for internal rotation and anterior stability. I tag the long head of biceps if intact as this marks the bicipital groove which is my version reference point. In 4-part fractures, the head is often completely free without soft tissue - I carefully preserve this for bone graft later. I assess fragment quality - severe comminution or osteoporosis may indicate conversion to RSA.'

Dangers at this step

Not tagging fragments early - fragments lost in operative field, cannot reconstruct
Stripping soft tissue from tuberosities during tagging - devascularization, nonunion
Discarding head fragment prematurely - lose valuable autograft bone
Not identifying bicipital groove - version errors during stem implantation
Missing severe comminution - proceed with hemi when should convert to RSA

Step 4: Remove Humeral Head & Assess Fragments

Remove Humeral Head & Assess Fragments: Remove humeral head fragment (usually free/mobile in 3-part and 4-part). DO NOT DISCARD - set aside on back table for autograft bone. Assess head for: (1) AVN signs (dark, purple, no bleeding from bone) - expected in 4-part. (2) Size measurement with sizing template - typically 43-49mm diameter. (3) Articular cartilage integrity and head shape. Clear fracture site of small fragments and hematoma. Identify bicipital groove on shaft (if visible) or on head fragment (for version reference). Measure head diameter carefully. Assess tuberosity fragment quality, size, comminution, bone quality. Determine if reduction and stable fixation possible - if severely comminuted/osteoporotic, consider conversion to RSA.

Exam Pearl

Technical Tip: EXAM KEY: 'I remove the humeral head fragment and carefully preserve it for autograft bone - this is critical for tuberosity healing. I assess it for signs of AVN and measure its size to select the appropriate prosthetic head diameter, typically 43-49mm. I identify the bicipital groove which is my key landmark for version - the normal humeral retroversion is 30-40 degrees, and I aim for 20-30 degrees in the prosthesis. I carefully assess the tuberosity fragments - their quality determines the functional outcome and whether I should proceed with hemiarthroplasty or convert to RSA. If tuberosities are severely comminuted or bone quality is very poor (severe osteoporosis), I have a low threshold to convert to RSA which has better outcomes and is not dependent on tuberosity healing.'

Dangers at this step

Discarding head fragment - lose autograft bone for tuberosity-shaft junction
Not measuring head size - wrong prosthesis diameter selection
Loss of bicipital groove reference - version errors (excessive retroversion or anteversion)
Not assessing fragment quality realistically - proceed with doomed reconstruction
Missing indication for RSA conversion - commit to inferior procedure

Step 5: Prepare Humeral Canal

Prepare Humeral Canal: Identify humeral shaft. Clear soft tissue from proximal 3-4cm of shaft exposing metaphyseal bone. CRITICAL: Use bicipital groove as version reference (normal anatomic retroversion 30-40°). Goal is 20-30° retroversion in prosthesis. Open canal with box chisel or curved awl starting in CENTER of metaphysis (NOT lateral - causes varus stem position). Sequential reaming/broaching to cortical contact. In fracture cases, metaphyseal bone is often weak/comminuted - extend stem into diaphysis for stability. May need longer stem (standard 80-100mm or long 150mm+) for adequate fixation. Cemented fixation strongly preferred in fracture setting due to weak bone and need for immediate stability.

Exam Pearl

Technical Tip: EXAM KEY: 'I prepare the humeral canal using the bicipital groove as my version reference. I aim for 20-30 degrees of retroversion in the prosthesis - slightly less than the normal anatomic 30-40 degrees. In fracture cases, the metaphyseal bone is often weak and comminuted, so I typically use a longer stem extending 5-7cm into the diaphysis for stability, and I use cemented fixation for immediate stability to allow early passive motion. I start the canal in the center of the metaphysis to avoid varus stem alignment. The starting point is critical - too lateral causes varus malalignment which leads to superior migration and glenoid erosion. I sequentially broach until I achieve cortical contact, feeling the rasp engage strong diaphyseal bone.'

Dangers at this step

Starting point too lateral - varus stem position, superior migration, glenoid erosion, poor outcomes
Excessive retroversion >35° - loss of internal rotation, limits function
Excessive anteversion <15° - posterior instability risk
Short stem in severely comminuted metaphysis - early loosening, subsidence
Iatrogenic humeral shaft fracture during preparation - need longer stem or cerclage
Uncemented fixation in osteoporotic bone - micromotion, loosening

Step 6: Determine Prosthetic Height & Head Size

Determine Prosthetic Height & Head Size: MOST CRITICAL DECISION: Prosthetic height determines tuberosity tension and healing. Goal: RESTORE NORMAL ANATOMY. Use anatomic landmarks: (1) Superior edge of pectoralis major insertion is 5.5-6cm distal to top of head - GOLD STANDARD landmark. (2) Distance from top of head to greater tuberosity typically 8-10mm. (3) Measure from native head if available. (4) Use contralateral shoulder radiograph for reference. Insert trial stem to planned depth. Place trial head. Assess: Tuberosities should reduce to anatomic position WITHOUT TENSION when head is on. If too high = excessive tension on tuberosity reduction, leads to nonunion and stiffness. If too low = instability, superior migration, cuff dysfunction. Head size from native head measurement (typically 43-49mm, most common 45-47mm).

Exam Pearl

Technical Tip: EXAM KEY: 'Determining prosthetic height is one of the most critical and difficult decisions in fracture hemiarthroplasty - it determines whether tuberosities will heal. I use multiple references: The superior edge of the pectoralis major insertion is 5-6cm distal to the top of the head - this is my primary landmark. The greater tuberosity sits 8-10mm below the top of the head. I measure the native head if available and I use the contralateral shoulder X-ray for reference. During trialing, the tuberosities must reduce to their anatomic position without tension - if there is tension the prosthesis is too high and I need to seat it deeper or use a shorter head offset. The most common error is placing the prosthesis too high which causes tuberosity nonunion and stiffness. It is better to err slightly low than high. I verify height by attempting passive forward elevation to 90-100° during trialing - if there is excessive resistance, the prosthesis is too high.'

Dangers at this step

Prosthesis too HIGH - stiffness, tuberosity under tension, nonunion (MOST COMMON ERROR - 40% of failures)
Prosthesis too LOW - instability, superior migration, cuff dysfunction, glenoid erosion
Wrong head size - overstuffing (stiffness) or understuffing (instability, eccentric loading)
Not using contralateral shoulder for reference - no anatomic baseline
Not trialing before cementing - cannot adjust height after cementation

Step 7: Trial Reduction of Tuberosities

Trial Reduction of Tuberosities: Before cementing final stem, perform comprehensive trial reduction to confirm height and plan fixation. Using tagged sutures, reduce greater tuberosity to posterior-superior position on prosthetic head. Should sit ~8-10mm below top of head in anatomic position. Reduce lesser tuberosity to anterior position on prosthesis, medial to bicipital groove. Hold tuberosities with tagged sutures. Assess: (1) NO TENSION on reduction - fragments should reduce easily. (2) Adequate bone-to-bone contact with shaft and prosthesis. (3) Ability to secure with sutures/cerclage - assess fixation points. (4) Closure of rotator interval between GT and LT. If tuberosities don't reduce easily or spring away, prosthesis is likely too HIGH - must revise height before cementing. Check passive ROM with tuberosities held - should achieve 90-100° elevation, 20-30° ER without excessive tension.

Exam Pearl

Technical Tip: EXAM KEY: 'Before cementing the final stem, I perform a comprehensive trial reduction of the tuberosities. I reduce the greater tuberosity to the posterior-superior aspect and the lesser tuberosity anteriorly using the tagged sutures. They should reduce easily without tension and sit stably against the prosthesis and shaft. If there is tension or they spring away from the prosthesis, the prosthetic height is too high and I must revise it - this is why trialing is critical. Once the stem is cemented, height cannot be easily adjusted. I check passive range of motion with the tuberosities held - I should achieve 90-100 degrees of forward elevation without excessive tension. I assess the fixation points and plan my suture technique - identifying where I will place vertical mattress sutures through the shaft, horizontal cerclage sutures, and side-to-side sutures. This trial step prevents the most common technical error.'

Dangers at this step

Cementing stem before trialing tuberosities - cannot adjust height, committed to wrong height
Accepting tension on tuberosity reduction - leads to 40% nonunion rate and poor outcomes
Not checking ROM during trial - miss stiffness/impingement until too late
Proceeding despite poor tuberosity contact - setup for nonunion
Not planning suture fixation strategy - disorganized fixation, weak construct

Step 8: Cement Final Humeral Stem

Cement Final Humeral Stem: After satisfactory trial with tuberosity reduction, prepare for final cementation. Remove trial components and irrigate canal. Prepare cement (PMMA - high-viscosity with antibiotic, typically gentamicin or vancomycin). Dry canal with gauze or suction. Optional: Use distal cement restrictor (placed 1-2cm below planned stem tip). Pressurize cement into humeral canal with finger packing, then cement gun or syringe for distal canal. Insert final stem in correct VERSION (20-30° retroversion using bicipital groove reference) and HEIGHT (determined from trialing with pectoralis major landmark). Hold stem in position with steady axial pressure until cement sets (~8-10 minutes for high-viscosity cement). Avoid mallet strikes on stem (can fracture cement). Ensure stem fully seated to planned depth using proximal landmark (pectoralis insertion). Remove excess cement before complete polymerization. Do NOT assemble head yet - need access to fix tuberosities first.

Exam Pearl

Technical Tip: EXAM KEY: 'I cement the final humeral stem after satisfactory trialing. I use antibiotic-loaded high-viscosity cement - typically gentamicin 1-2g per batch - and I pressurize it into the canal for a good cement mantle, which improves fixation and reduces infection risk. I insert the stem at 20-30 degrees of retroversion using the bicipital groove as my reference landmark, and at the precise height I determined during trialing using the pectoralis major insertion as my guide. I hold it steady with axial pressure until the cement fully polymerizes - usually 8-10 minutes. I never strike the stem with a mallet as this can fracture the cement mantle. I do NOT place the final head yet because I need access to fix the tuberosities first - the head goes on last after all tuberosity sutures are placed. I verify the stem is fully seated to the planned depth by checking the relationship to the pectoralis major insertion.'

Dangers at this step

Wrong version - functional limitation (excessive retroversion → loss of IR, excessive anteversion → instability)
Wrong height - cannot correct after cementation, leads to tuberosity failure or instability
Cement extrusion into soft tissues - heterotopic ossification, stiffness, neurovascular injury
Stem not fully seated - changes height, proud stem prevents tuberosity reduction
Placing head before tuberosity fixation - very difficult to work around head, poor fixation
Mallet strike on assembled components - cement fracture, loss of fixation

Step 9: Bone Graft Tuberosity-Shaft Junction

Bone Graft Tuberosity-Shaft Junction: CRITICAL FOR HEALING: Use preserved humeral head as autograft source. Morselized head into small cancellous bone chips using rongeur, bone mill, or rasp. Pack bone graft generously at tuberosity-shaft junction circumferentially. Place graft between tuberosities (GT and LT). Fill metaphyseal void. Creates biological environment for union - studies show bone graft improves tuberosity healing from 60% without graft to 80-85% with graft. The metaphyseal void is often large (2-4cm) in comminuted 4-part fractures - fill completely. Some surgeons place graft under tuberosities as well for additional contact. Place graft before reducing and fixing tuberosities.

Exam Pearl

Technical Tip: EXAM KEY: 'I use the native humeral head as autograft bone, morselizing it into cancellous chips using a rongeur or bone mill. I pack this generously at the tuberosity-shaft junction circumferentially and between the tuberosities. This is critical for healing - evidence shows bone graft significantly improves tuberosity union rates from 60% without graft to 80-85% with graft. The metaphyseal void in comminuted 4-part fractures can be quite large, and the autograft provides both mechanical scaffold and biological stimulus for healing. I use all available head bone - typically 20-30cc of graft. I place the graft before reducing the tuberosities so it is compressed when I fix the tuberosities down onto the shaft.'

Dangers at this step

Not using bone graft - 40% lower tuberosity healing rates, poor outcomes
Discarding head fragment early - no autograft source available
Inadequate graft packing - insufficient biological scaffold
Using allograft when autograft available - inferior healing

Step 10: Reduce & Fix Greater Tuberosity

Reduce & Fix Greater Tuberosity: MOST IMPORTANT fragment for function. Reduce greater tuberosity (with supraspinatus, infraspinatus, teres minor attached) to ANATOMIC position: posterior-superior humeral head/prosthesis, sitting ~8-10mm below top of prosthetic head. Hold with previously placed tagged sutures. Fix to SHAFT with heavy non-absorbable sutures (#2 or #5 Ethibond) using multiple techniques: (1) Vertical mattress sutures through drill holes in shaft (2-3 sutures). (2) Horizontal cerclage sutures around shaft and through tuberosity tendon (2 sutures). (3) Side-to-side sutures to lesser tuberosity closing rotator interval (2 sutures). (4) Sutures through prosthesis holes if available (1-2 sutures). Minimum 6-8 sutures total for GT. Ensure bone-to-bone contact of GT to shaft compressing autograft. Test fixation - should be STABLE without gapping with gentle traction. No sharp edges of bone that could cut sutures.

Exam Pearl

Technical Tip: EXAM KEY: 'The greater tuberosity is the most important fragment to fix because it contains the posterior-superior rotator cuff which is essential for abduction and external rotation - if it doesn't heal, the patient has a very poor outcome with pseudoparalysis. I reduce it anatomically to sit 8-10mm below the prosthetic head top and fix it with multiple heavy non-absorbable sutures in a comprehensive construct. I use at least three different fixation points: First, I pass 2-3 vertical mattress sutures through drill holes in the shaft from lateral to medial. Second, I place 2 horizontal cerclage sutures around the shaft capturing the GT tendon. Third, I place 2 side-to-side sutures to the lesser tuberosity which closes the rotator interval. If the prosthesis has suture holes, I use those as a fourth point. I typically use 6-8 sutures total for the GT. The fixation must be stable enough to allow early passive motion at 1-2 weeks. I ensure there is direct bone-to-bone contact of the GT to the shaft which compresses the autograft we placed. I test the fixation with gentle traction - there should be no gapping.'

Dangers at this step

Inadequate fixation - tuberosity migration, nonunion (occurs in 30-40% historically, devastating)
Anatomic malposition - persistent dysfunction even if healed
Too superior position - subacromial impingement, pain, limited elevation
Too inferior position - loss of lever arm, poor mechanics
Weak sutures (#0 or smaller) or too few sutures (<4) - fixation failure
Sharp bone edges - suture cutting, late failure
No bone-to-bone contact - relying on suture fixation alone, nonunion

Step 11: Reduce & Fix Lesser Tuberosity

Reduce & Fix Lesser Tuberosity: Reduce lesser tuberosity (with subscapularis attached) to ANTERIOR position on prosthesis. Anatomic position: medial to bicipital groove, on anterior metaphysis. Hold with previously placed tagged sutures. Fix to SHAFT with heavy non-absorbable sutures using multiple techniques: (1) Vertical mattress sutures through drill holes in shaft (2 sutures). (2) Side-to-side sutures to greater tuberosity - CRITICAL to close rotator interval completely with no gap (2-3 sutures). (3) Horizontal cerclage if needed for additional stability (1 suture). (4) To prosthesis holes if available (1 suture). Minimum 4-6 sutures total for LT. Ensure NO GAP between GT and LT - closes rotator interval, improves stability, prevents superior migration. Ensure bone-to-bone contact LT to shaft. Test fixation stability with gentle traction - no gapping.

Exam Pearl

Technical Tip: EXAM KEY: 'I reduce the lesser tuberosity with subscapularis attached to the anterior prosthesis, medial to the bicipital groove in its anatomic position. I fix it with a similar heavy suture technique using 4-6 sutures total. I use vertical mattress sutures through bone tunnels in the shaft, and most importantly I place 2-3 side-to-side sutures to the greater tuberosity. This is critical because closing the gap between GT and LT - closing the rotator interval - provides additional stability and prevents superior migration of the prosthesis. The lesser tuberosity provides internal rotation function and anterior stability. I ensure there is bone-to-bone contact of the LT to the shaft. If the LT fragment is small or comminuted, I may incorporate it into the subscapularis repair and advance the subscapularis directly to the prosthesis and shaft. I test the fixation with gentle traction - there should be no gapping with shoulder in neutral or external rotation.'

Dangers at this step

Gap between tuberosities - rotator interval defect, superior migration, instability, poor outcomes
Malposition of LT - loss of internal rotation, anterior instability
Inadequate fixation - LT nonunion, subscapularis failure
Excessive tension on subscapularis - tendon failure, stiffness
Not incorporating comminuted LT - fragment lost, subscapularis dysfunction

Step 12: Place Final Prosthetic Head

Place Final Prosthetic Head: After tuberosity fixation complete and stable with all sutures tied, place final prosthetic head. Choose head size based on native head measurement from Step 4 (typically 43-49mm diameter, most common 45-47mm). Choose head HEIGHT/offset to restore anatomy while maintaining tuberosity reduction - typically standard height/offset. Snap or screw head onto humeral stem taper (mechanism depends on system). Verify secure seating with gentle traction test. Do NOT strike head with mallet (can damage taper morse lock or cause cement fracture). Check that tuberosities remain well-positioned with head in place. May need to adjust tuberosity sutures around head for optimal position. Rotate head to best position for tuberosity coverage.

Exam Pearl

Technical Tip: EXAM KEY: 'After I have completed all the tuberosity fixation and tied all sutures, I place the final prosthetic head. I choose the size based on the native head measurement I made earlier, typically 43-49mm in diameter with 45-47mm being most common. I select the standard head height in most cases to restore anatomy while maintaining the tuberosity position we achieved. I seat the head onto the taper with firm hand pressure - I never strike it with a mallet as this can damage the taper morse lock or cause cement fracture which would be catastrophic requiring stem removal. I verify the head is fully seated by attempting to lift it off the taper - it should be locked. I verify the tuberosities remain well-positioned with the head in place and rotate the head to the position that provides best tuberosity coverage and stability. In some systems the head can be rotated on the taper to optimize position.'

Dangers at this step

Wrong head size - overstuffing (stiffness, glenoid erosion) or understuffing (instability, eccentric wear)
Mallet strike on assembled head - taper damage, morse lock failure, cement fracture
Displacing tuberosities while placing head - requires re-fixing
Head not fully seated on taper - dissociation risk, instability
Wrong head height/offset - changes construct stability and tuberosity tension

Step 13: Final Stability Assessment & ROM

Final Stability Assessment & ROM: Reduce shoulder and assess stability systematically in all directions: (1) ANTERIOR stability: Extend arm and externally rotate - assesses subscapularis/LT repair, should be stable. (2) INFERIOR stability: Axial traction - should be minimal translation, tests tuberosity fixation and prosthetic height. (3) POSTERIOR stability: Forward flex to 90° and internally rotate - should be stable. (4) SUPERIOR: Assess for superior subluxation. Check PASSIVE ROM (do not force): Forward elevation to 90-120° (limited intentionally to protect tuberosity healing). External rotation to 20-40°. Internal rotation limited. Assess tuberosity fixation throughout ROM - should remain stable without gapping or crepitus. If gapping occurs, fixation inadequate - requires revision. Document maximum passive ROM achieved for postoperative protocol planning.

Exam Pearl

Technical Tip: EXAM KEY: 'I perform systematic stability testing in all directions. I test anterior stability by extending the arm and externally rotating to assess the lesser tuberosity and subscapularis repair - it should be stable. I test inferior stability with axial traction - there should be minimal translation. I test posterior stability with forward flexion and internal rotation. Then I check passive range of motion carefully - I should achieve 90-120 degrees of forward elevation but I do not force it beyond what feels safe for the tuberosity fixation. External rotation to 20-40 degrees is typical. Throughout the range of motion, I continuously assess the tuberosity fixation - I should feel smooth motion without any gapping or crepitus. If I feel the tuberosities gapping or hear crepitus, the fixation is inadequate and I need to revise it with additional sutures. This intraoperative ROM assessment guides my postoperative rehabilitation protocol - if the fixation feels very strong, I can be more aggressive with passive motion. If it feels tenuous, I protect longer.'

Dangers at this step

Forcing ROM beyond safe limits - tuberosity fixation failure intraoperatively
Not testing stability systematically - miss instability pattern until postoperatively
Not documenting maximum safe ROM - medicolegal issues, inability to guide rehabilitation
Accepting unstable tuberosity fixation - guaranteed failure, requires revision
Not assessing throughout arc - may be stable at 0° but gap at 90° flexion

Step 14: Closure & Immobilization

Closure & Immobilization: Copious irrigation (minimum 9L pulsatile lavage, 3L per 3L bag). Meticulous hemostasis with electrocautery - fracture surgery has more bleeding. Place deep suction drain (10mm flat drain) deep to deltoid. Close rotator interval between supraspinatus and subscapularis if any defect remains (usually partially closed by tuberosity repair). May place additional reinforcing sutures in cuff if tissue quality poor. Close deltopectoral interval loosely with 2-3 absorbable sutures (2-0 Vicryl) - do not restrict deltoid excursion. Subcutaneous layer with 2-0 Vicryl. Skin closure with subcuticular 3-0 Monocryl or staples. Sterile dressing. IMMOBILIZE in shoulder sling with ABDUCTION PILLOW at 30° abduction - this is critical to offload tuberosities and protect repair. Some surgeons use neutral rotation vs slight external rotation. Document postoperative neurovascular exam especially axillary nerve (deltoid contraction, sensation over lateral shoulder).

Exam Pearl

Technical Tip: EXAM KEY: 'I achieve meticulous hemostasis and irrigate copiously with at least 9 liters of pulsatile lavage. I place a deep suction drain which I will remove at 24-48 hours when drainage decreases below 30cc per 8 hours. I close the deltopectoral interval loosely with just 2-3 sutures to avoid restricting the deltoid muscle. I immobilize in a sling with an abduction pillow at 30 degrees of abduction - this is critical because it offloads tension on the tuberosities and protects the repair during the critical 6-week healing period. The abduction pillow is not optional - it is a key component of success. I document a careful postoperative neurovascular examination especially the axillary nerve which I documented preoperatively. I test deltoid contraction and sensation over the lateral shoulder. I obtain immediate postoperative X-rays to confirm component position and tuberosity reduction before the patient leaves the operating room.'

Dangers at this step

Inadequate hemostasis - hematoma formation increases stiffness and infection risk
Overtight deltopectoral closure - restricts deltoid excursion, contributes to stiffness
No abduction pillow - excessive tension on tuberosities during healing, high nonunion rate
Not documenting postoperative neuro exam - medicolegal issues if deficit develops
Drain too superficial - inadequate drainage, hematoma
Sling in adduction - tension on GT repair, higher failure rate

Step 15: Postoperative X-rays & Planning

Postoperative X-rays & Planning: Obtain immediate postoperative X-rays before leaving OR: AP in scapular plane, scapular Y, axillary lateral (or Velpeau axillary if cannot position arm). Assess systematically: (1) Prosthetic head size and height - should restore anatomy, GT sitting 8-10mm below head. (2) Tuberosity position - GT posterior-superior, LT anterior, no gap between them, anatomic contact with shaft. (3) Stem alignment - neutral, not varus (varus predicts superior migration). (4) Version - difficult to assess on X-ray but stem should appear centered. (5) No fracture extension to shaft. (6) Cement mantle quality if visible. Document X-ray findings in operative note. Plan individualized rehabilitation protocol based on: Tuberosity fixation quality (strong vs tenuous), bone quality (normal vs osteoporotic), patient factors (compliance, age). If fixation strong and bone good, standard protocol (passive 0-6 weeks). If fixation tenuous or bone osteoporotic, extended protection (passive 0-8 weeks, delayed active 8-12 weeks). Communicate directly with physiotherapist regarding ROM restrictions.

Exam Pearl

Technical Tip: EXAM KEY: 'I obtain three postoperative X-ray views immediately in the operating room: AP in scapular plane, scapular Y, and axillary lateral if possible or Velpeau axillary view if the arm cannot be positioned. I systematically assess the X-rays: The prosthetic height and head size should restore anatomy, with the greater tuberosity sitting 8-10mm below the prosthetic head top. The tuberosity positions should be anatomic - GT posterior-superior, LT anterior, with no gap between them visible on axillary view. The stem alignment should be neutral on AP view - varus alignment predicts superior migration and poor outcomes. I confirm there is no intraoperative fracture extension into the shaft. These X-rays serve as the critical baseline for all follow-up comparisons. I plan the rehabilitation protocol based on the quality of tuberosity fixation I achieved - if the fixation is strong and bone quality is good, I use the standard protocol with passive motion 0-6 weeks then active 6-12 weeks. If fixation is tenuous or bone is severely osteoporotic, I extend the protection period to 8-12 weeks before allowing active motion. I communicate directly with the physiotherapist about ROM restrictions and my assessment of fixation quality.'

Dangers at this step

Not obtaining immediate postop X-rays - miss malposition or fracture until too late
Not assessing X-rays systematically - miss subtle varus alignment or tuberosity malposition
Wrong rehabilitation protocol - tuberosity failure (too aggressive) or stiffness (too conservative)
Starting aggressive active therapy too early - tuberosity nonunion (30-40% if too early)
Not communicating with therapist - protocol not followed, complications
No baseline X-rays - cannot assess tuberosity healing or migration at follow-up

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 72-year-old female presents with a 4-part proximal humerus fracture. What are your treatment options and how would you decide between hemiarthroplasty versus reverse shoulder arthroplasty versus ORIF?"

EXCEPTIONAL ANSWER

This is an evolving area with changing practice patterns. Let me discuss the three main options and decision-making. For ORIF: I would consider this in younger patients under 65-70 with good bone quality and a reconstructable fracture pattern. However, in a 72-year-old with a 4-part fracture, ORIF is generally not ideal because 4-part fractures have 75-90% AVN risk, high rates of tuberosity malunion (30-40%), and poor functional outcomes in elderly osteoporotic bone. The hardware often fails and may require conversion to arthroplasty. For hemiarthroplasty: This was historically the standard for 4-part fractures in elderly patients. The rationale was to replace the devascularized head while preserving the glenoid and reconstructing the tuberosities. However, outcomes are highly dependent on tuberosity healing - if tuberosities heal (60-80% with bone graft and good fixation), patients achieve reasonable function with 100-130 degrees elevation. But if tuberosities fail to heal (20-40%), patients have poor function with pseudoparalysis and elevation less than 90 degrees. Overall satisfaction is around 70-75%. For RSA (reverse shoulder arthroplasty): This is increasingly becoming the preferred option for elderly patients with complex proximal humerus fractures. The major advantage is that RSA function does NOT depend on tuberosity healing - the deltoid provides elevation through the medialized center of rotation. Studies show RSA achieves better forward elevation (120-140 degrees vs 100-110 for hemi), better pain relief, higher patient satisfaction (85-90% vs 70-75%), and lower revision rates (5-10% vs 15-20%). The main disadvantage is slightly worse external rotation and concerns about glenoid fixation in fracture cases, though modern techniques have addressed this. My approach for this 72-year-old with a 4-part fracture: I would strongly consider RSA as first-line treatment given the superior outcomes in recent literature. I would counsel the patient about both options. If she has very good bone quality, minimal comminution of tuberosities, and I'm confident in achieving excellent tuberosity fixation, hemiarthroplasty remains reasonable. But if there is significant tuberosity comminution, poor bone quality, or any doubt about healing, RSA is preferred. The key is setting appropriate expectations - RSA is more predictable and less dependent on the difficult technical challenge of tuberosity fixation.

VIVA SCENARIOStandard

EXAMINER

"If you proceed with hemiarthroplasty, how do you determine prosthetic height and why is this critical? What happens if you get it wrong?"

EXCEPTIONAL ANSWER

Prosthetic height is one of the most critical technical decisions in fracture hemiarthroplasty and directly determines whether the tuberosities will heal. Let me explain my approach and the consequences of error. The goal is to restore normal anatomy so tuberosities reduce to their anatomic position WITHOUT tension. If there is tension on the tuberosity reduction, they will not heal and the patient will have a poor outcome. I use multiple anatomic references to determine height. My primary landmark is the superior edge of the pectoralis major insertion, which is 5.5-6cm distal to the top of the humeral head - this is the gold standard reference. Second, the greater tuberosity should sit 8-10mm below the top of the prosthetic head in its anatomic position. Third, I measure the native humeral head before discarding it. Fourth, I reference the contralateral normal shoulder on preoperative X-rays for comparison. But the most important step is trialing. Before I cement the final stem, I MUST trial the prosthetic height with tuberosity reduction. I insert the trial stem and trial head, then I reduce the tuberosities using the tagged sutures and assess three things: First, do the tuberosities reduce to their anatomic position without tension - they should reduce easily and sit stably. Second, is there good bone-to-bone contact between tuberosity and shaft. Third, can I achieve 90-100 degrees of passive forward elevation without excessive resistance. If the tuberosities do not reduce easily or there is tension, the prosthesis is too high and I must revise the height before cementing. This trial step is critical because once the stem is cemented, I cannot adjust the height. What happens if I get the height wrong? If the prosthesis is too HIGH - which is the most common error occurring in 30-40% of cases - there is excessive tension on the tuberosity reduction. This leads to tuberosity nonunion in 40-60% of cases, the tuberosities gap away from the shaft, they resorb, and the patient develops pseudoparalysis with elevation less than 90 degrees. The prosthesis also migrates superiorly causing glenoid erosion. This is a catastrophic outcome often requiring revision to reverse shoulder arthroplasty. If the prosthesis is too LOW - which is less common - the shoulder is unstable because the tuberosities are not under appropriate tension. The prosthesis can migrate superiorly and the rotator cuff mechanics are poor leading to weakness. In general, it is better to err slightly low than high. The key message is that proper prosthetic height allows tensionless tuberosity reduction which is essential for healing. Tuberosity healing determines the functional outcome - no healing equals poor outcome. Therefore, getting the height right is critical.

VIVA SCENARIOStandard

EXAMINER

"Describe your technique for tuberosity fixation. What are the key principles and why do tuberosities fail to heal in 20-40% of cases?"

EXCEPTIONAL ANSWER

Tuberosity fixation is the most critical technical aspect of fracture hemiarthroplasty because if the tuberosities do not heal, the patient will have a poor functional outcome with pseudoparalysis. Let me describe my comprehensive fixation technique and address why failure occurs. The key principles are: adequate fixation strength, bone-to-bone contact, biological environment with bone graft, and appropriate postoperative protection. My fixation technique has multiple components. First, I preserve the native humeral head and morselized it into cancellous bone chips for autograft. I pack this bone graft generously at the tuberosity-shaft junction circumferentially and between the tuberosities. Evidence shows this improves healing from 60% without graft to 80-85% with graft by providing biological scaffold and osteoinductive signals. Second, I use heavy non-absorbable sutures - I use #2 or #5 Ethibond, never smaller than #2. I place multiple sutures with different fixation points to create a stable construct. For the greater tuberosity which is most critical, I use 6-8 sutures total: (1) Two to three vertical mattress sutures passed through drill holes in the shaft from lateral to medial capturing the rotator cuff tendons. (2) Two horizontal cerclage sutures around the shaft and through the GT tendon. (3) Two to three side-to-side sutures to the lesser tuberosity which closes the rotator interval - this is critical. (4) If the prosthesis has suture holes, I use one to two additional sutures through the prosthesis. For the lesser tuberosity, I use 4-6 sutures with similar technique. Third, I ensure there is NO GAP between the greater and lesser tuberosities. Closing the rotator interval provides additional stability and prevents superior migration. I ensure direct bone-to-bone contact of the tuberosities to the shaft, compressing the autograft we placed. Fourth, intraoperatively I test the fixation with gentle traction - there should be no gapping. I check passive range of motion - if I feel gapping or crepitus during motion, the fixation is inadequate and I revise it. Why do tuberosities fail to heal in 20-40% of cases despite our best efforts? The main risk factors are: (1) Prosthetic height too high creating tension on the tuberosity reduction - this is the most common technical error. (2) Inadequate fixation with too few sutures (less than 4) or weak sutures (#0 or absorbable). (3) No bone graft at the tuberosity-shaft junction. (4) Severe osteoporosis where sutures cut through bone. (5) Severe comminution of tuberosity fragments with poor bone quality. (6) Too aggressive early active motion during the critical 0-6 week healing period. (7) Patient non-compliance with sling and abduction pillow. (8) Poor vascularity of fragments. The consequences of tuberosity nonunion are severe - the patient develops pseudoparalysis with elevation less than 90 degrees, the prosthesis migrates superiorly causing glenoid erosion, and revision to reverse shoulder arthroplasty is usually required. This is why modern practice is shifting toward primary RSA for complex fractures because RSA outcomes are not dependent on tuberosity healing.