Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head.

Percutaneous reduction and fixation of severe humeral head fractures would be the treatment of choice since it will not increase the risk of necrosis already inherent in these fractures. Nevertheless, the question arises of whether anatomical reduction is possible with the percutaneous technique and whether the reduced fracture can be adequately stabilized. It is important to study the fracture closely before the operation in order to determine the fracture type and identify the relationship of the individual fragments to each other. Radiographs taken in at least two planes are essential and a CT scan with 3D reconstruction would be desirable. Besides extraarticular fractures, surgical neck fractures with avulsion of the greater tuberosity (B1 and B2 fractures) and valgus impacted fractures (C1 and C2 fractures) are good indications for this method due to the fact that in these cases intact connections to rotator cuff tendons or remnants of intact periosteum between fragments still exist. Less good indications are fractures with severe lateral displacement of the articular segment and severely displaced fracture dislocations (C2 and C3 fractures). From 1990 to 1999, a total of 88 patients with 37 B1 and B2 fractures and 41 C1 and C2 fractures were operated on percutaneously. The initial 27 patients with 9 B1 and B2 and 18 C1 and C2 fractures were followed up. All B1 and B2 fractures showed good to very good functional results (Constant Score 91%). The Constant Score of the C1 and C2 fractures was 87%. The necrosis rate of the C1 and C2 fractures was 11%. In conclusion, it can be said that the presence of soft tissue bridging of the various fragments is crucial for the reduction to gain benefit from the ligamentotaxis effect. Thus, fractures such as valgus impacted or three-part fractures are very good indications for this technique. It can also be stated that the necrosis rate is low or at least not increased compared to cases treated by open reduction. Since the fracture is not exposed, adhesion within the surrounding gliding surfaces is reduced and the rehabilitation period is shorter.