The forgotten fragment: additional lesser tuberosity fixation of 4-part proximal humeral fractures - a biomechanical investigation

Background: Fractures of the proximal humerus are common. The most frequent surgical treatment option is open reduction and locking plate fixation. Multifragmentary fractures, including 3- and 4-part fractures, are especially challenging to teat because they correlate with an increased risk of fixation failure. In the past, several mechanisms of additional fixation were investigated, but none directly addressed the lesser tuberosity (LT). The goal of this study was to investigate the biomechanical impact of additional anterior fracture fixation in lateral locked plating (LLP) of 4-part proximal humeral fractures (PHFs). Methods: Twenty-seven fresh frozen human shoulder specimens (mean age, 80 years) with intact rotator cuffs (RCs) were randomized into 4 groups: 3-part PELF with LLP and RC cerclage (n = 6); 4-part PHF with LLP and RC cerclage as standard of care (n = 7); 4-part PHF with LLP, RC cerclage, and 2 anterior 3.5-mm cortical screws (n = 7); and 4-part PHF with LLP, RC cerclage, and additional anterior one-third tubular plate (additional anterior plating [AAP], n = 7). Static load of the RC was simulated with weights. A force-controlled cyclic loading test was performed with a servo-hydraulic testing machine, followed by load-to-failure testing. An optical motion capture system recorded humeral head range of motion. Results: LLP of a 4-part PHF showed more humeral head motion than LLP of a 3-part PIT without fracture of the LT (P < .001). Fixing the LT to the humeral head with two 35-mm screws significantly reduced humeral head motion compared with LLP with RC cerclage alone (P < .006). Using AAP significantly increased the construct stiffness compared with the standard of care (P = .03). Conclusion: LLP of a 4-part PHF is biomechanically less stable than LLP of a 3-part PHF without fracture of the LT. Additional screw fixation of the LT in 4-part PHFs improves stability compared with LLP alone. In case of metaphyseal comminution, AAP is favorable from a biomechanical perspective. (C) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.