Surgical Discussion

Patient positioning:  The patient was positioned in a semi-beach chair position on a radiolucent operating table, with the left arm placed at the table's edge and the forearm secured in a spider pneumatic positioner.

Anatomical surgical approach:  A longitudinal incision was made along the anterolateral aspect of the arm, starting at the level of the acromion. The deltopectoral interval was identified, and the deltoid insertion, biceps brachii and brachialis muscles were identified. Limited soft tissue dissection was performed to preserve vascularity. Sequential clamping and individual lag screw fixation of each intermediate fragment were performed. A long PHILOS plate was contoured to match the anatomy: it sat on the posterolateral aspect of the humeral head, curved posteriorly around the deltoid insertion, preserving the majority of its insertion on one of the intermediate fragments, before curving anteriorly to sit on the anterior aspect of the distal mid-shaft between heads of brachialis muscle. Multiplanar fluoroscopy confirmed adequate plate positioning before final fixation using four distal bicortical locking screws and one bicortical plus three monocortical proximal locking screws.

The multifragmentary nature of the fracture, consisting of four intermediate fracture fragments between the humeral head and distal shaft, complicated reduction and fixation. Confirmation of axis alignment was achieved through radiographic identification of both the anteroposterior axis of the humeral head and the axis of the forearm. Sustained longitudinal traction was provided by the spider positioner. Care was taken to maintain the integrity of the deltoid muscle insertion on one intermediate fragment. The bridge plate construct provided relative stability, with intermediate fragments fixed using individual lag screws for provisional positioning rather than absolute stability.

Postoperative protocol:   Not specified

Orthopaedic implants used:   Contoured long PHILOS plate