To the Editor:

I want to share a technical pearl that I do not think is universally known regarding fixation of proximal humerus fractures. While tension band fixation (suture through cuff and plate) is an obvious necessity for displaced tuberosity fractures in the treatment of 3 and 4 part proximal humerus fractures, I also have found it to be a helpful component of the fixation construct for surgical neck fractures and for the unfractured tuberosity in 3-part fractures (that which is still attatched to the humeral head.)

Failure of fixation of surgical neck fractures with locking plate and screw fixation alone tends to occur in varus due to the pull of the rotator cuff. The simple addition of tension band suture fixation is very effective in conjuction with locking plate and screw fixation to prevent this varus displacement. I have used this technique at least 20 times with no fixation failure (2 failed at > 8 months due to avascular necrosis in 4 part fractures).

Technically, after the approach and fracture exposure, I place a #2 fiberwire suture into the subscapularis, supraspinatus, and infraspinatus as a first step. These sutures may be used as a reduction aide as they afford control of the proximal fragment. Once the fracture is reduced (the hard part), the plate is applied and screws inserted. The sutures are then passed through the holes in the plate and tied as the final step in fixation. Alternatively, the sutures can be passed through the holes in the plate just before plate application, but they should be tensioned and tied after completion of metallic fixation. This additional fixation affords a tension band augmentation circumferentially. I recommend this technique for the fixation of virtually all proximal humerus fractures.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.