A structured three-step reduction strategy for locked posterior fracture-dislocation of the proximal humerus through a standard deltopectoral approach: A retrospective case series.
TL;DR
A structured, reproducible anterior-only reduction strategy for selected acute locked posterior fracture-dislocations of the proximal humerus is supported and the principal contribution is the standardization of the reduction sequence and the description of how the humeral head can be disengaged and translated without a posterior approach.
Abstract
Background
Locked posterior fracture-dislocation of the proximal humerus is a rare and technically demanding injury in which the humeral head remains impacted posterior to the glenoid. Although several reduction techniques have been described, the practical details of anterior-only reduction remain incompletely standardized. We evaluated a structured three-step anterior reduction strategy performed through a standard deltopectoral approach.
Methods
We retrospectively reviewed 16 consecutive patients with acute locked posterior fracture-dislocation of the proximal humerus treated between January 2016 and January 2022. All patients underwent reduction through a single deltopectoral approach followed by locking-plate fixation supplemented with suture fixation. The reduction strategy consisted of (1) establishing an anterior reduction corridor by opening the anterior joint through an L-shaped subscapularis incision or a lesser-tuberosity fracture interval, (2) guiding the humeral head with a periosteal elevator introduced between the humeral head and glenoid, and (3) unlocking and translating the head anteriorly using gentle elevator assistance, controlled arm rotation, and, when head-shaft control was limited, direct digital manipulation. Outcomes included fracture union, avascular necrosis (AVN), recurrent dislocation, implant-related complications, range of motion, Constant-Murley score, and subscapularis function.
Results
The mean age was 41.1 ± 8.4 years. The mean interval from injury to surgery was 3.4 ± 1.0 days. All 16 reductions were completed through the initial deltopectoral approach without an additional posterior incision, conversion to arthroplasty, or intraoperative complication. Mean operative time was 85.9 ± 10.5 min and mean estimated blood loss was 152.5 ± 27.7 mL. All fractures achieved radiographic union during available follow-up. At a mean follow-up of 21.2 ± 9.4 months (range, 12-48 months), the mean Constant-Murley score was 85.4 ± 8.6 (range, 70-96). Mean forward flexion, abduction, extension, and external rotation were 151.6 ± 22.7°, 135.0 ± 29.9°, 29.4 ± 10.0°, and 38.1 ± 4.8°, respectively. Internal rotation ranged from T7 to L4. Using the descriptive thresholds applied in the original study (excellent, ≥90; good, 80-89; fair, 70-79), 5 patients were excellent, 8 good, and 3 fair. No AVN, recurrent dislocation, implant-related complication, deep infection, or reoperation was observed during the available follow-up. Lift-off and bear-hug tests were negative in all patients at 12 months.
Conclusions
This series supports a structured, reproducible anterior-only reduction strategy for selected acute locked posterior fracture-dislocations of the proximal humerus. The principal contribution is the standardization of the reduction sequence and the description of how the humeral head can be disengaged and translated without a posterior approach. The technique should not be interpreted as a wholly novel reduction maneuver, and the absence of AVN should be interpreted within the available follow-up period. LEVEL OF EVIDENCE Level IV; Therapeutic study.