Arthroscopic Screw Fixation Technique for Transverse Glenoid Fractures

The patient is placed in the beach-chair position (Fig 2). A standard posterior portal and an anterior portal through the rotator interval are established. Hematoma is removed using a shaver. In the presented case, diagnostic arthroscopy showed a SLAP lesion (Snyder type II) (Fig 3). Thus, tenotomy of the long biceps head with suprapectoral tenodesis was performed. First, the impacted transverse glenoid fracture is mobilized applying an elevatorium. Then, the rotator interval is released thoroughly to expose the conjoint tendon and the coracoid process. Also, the coracoacromial ligament is released from the lateral aspect of the coracoid, enabling placement of a small, serrated reduction clamp (“lobster claw”) through the anterior portal (Fig 4). The coracoid can be grasped firmly with the clamp (Fig 2). The manipulation of the clamp allows easy mobilization and reduction of the coracoglenoidal fragment, just like using an extracorporeal “joystick” (Fig 6). The arthroscope is then switched from the posterior to the high anterolateral portal, where it remains for the rest of the procedure. The reduction clamp remains in the anterior portal, clamped to the coracoid, sustaining fracture reduction. As the rotator interval has been released, the position of the arthroscope in the high anterolateral portal allows to alternate between the glenohumeral and the pre-coracoidal/subacromial view. Using a low anterolateral portal, the lateral aspect of the coracoid base can be released from residual soft tissue. Through the posterior portal, a small Langenbeck retractor can be introduced and used to retract the anterior border of the supraspinatus tendon posteriorly. Thus, the cranial aspect of the glenoid bone at the 12:00- to 12:30-o’clock position is exposed. For the entry point of the cannulated screw, a high anteromedial portal is established lateral to the coracoid base, just anterior to the distal clavicle. Through this portal, the K-wire of a cannulated small-fragment osteosynthesis system (ASNIS 4.0 mm; Stryker) is introduced and drilled into the cranial glenoid fragment at the 12:30-o’clock position (Fig 7). Still, the arthroscope remains in the high anterolateral portal to enable to change repeatedly between the 2 perspectives: first, the glenohumeral view on the glenoid fracture line, and second, viewing cranially toward the lateral base of the coracoid to control the entry point of the K-wire. With the cranial fragment held in the correct reduction, the K-wire is further advanced under power into the caudal fragment. During this step, preliminary retention is controlled arthroscopically, to avoid penetration of the glenoid surface with the K-wire. According to the arthroscopic view, fluoroscopy in the anteroposterior plane shows adequate fracture reduction with the K-wire parallel to the joint line (Fig 8). Next, the entry point of the K-wire is predrilled using a cannulated 2.7-mm drill. Then, a cannulated, self-cutting 4.0-mm screw is inserted via the K-wire. As the screw is advanced tight adaptation of the fracture line can be appreciated (Fig 9). The K-wire and the clamp are removed. Finally, portals are closed, sterile dressing is applied, and the shoulder is immobilized in a sling. Postoperative computed tomography of the right shoulder shows excellent fracture reduction (Fig 10). The shoulder is immobilized with a sling for 6 weeks and passive motion is limited to 90° of flexion and abduction. As radiograph controls show bony healing, active mobilization with free range of motion can be initiated after 6 weeks.

The patient is placed in the beach-chair position (Fig 2). A standard posterior portal and an anterior portal through the rotator interval are established. Hematoma is removed using a shaver. In the presented case, diagnostic arthroscopy showed a SLAP lesion (Snyder type II) (Fig 3). Thus, tenotomy of the long biceps head with suprapectoral tenodesis was performed. First, the impacted transverse glenoid fracture is mobilized applying an elevatorium. Then, the rotator interval is released thoroughly to expose the conjoint tendon and the coracoid process. Also, the coracoacromial ligament is released from the lateral aspect of the coracoid, enabling placement of a small, serrated reduction clamp (“lobster claw”) through the anterior portal (Fig 4). The coracoid can be grasped firmly with the clamp (Fig 2). The manipulation of the clamp allows easy mobilization and reduction of the coracoglenoidal fragment, just like using an extracorporeal “joystick” (Fig 6). The arthroscope is then switched from the posterior to the high anterolateral portal, where it remains for the rest of the procedure. The reduction clamp remains in the anterior portal, clamped to the coracoid, sustaining fracture reduction. As the rotator interval has been released, the position of the arthroscope in the high anterolateral portal allows to alternate between the glenohumeral and the pre-coracoidal/subacromial view. Using a low anterolateral portal, the lateral aspect of the coracoid base can be released from residual soft tissue. Through the posterior portal, a small Langenbeck retractor can be introduced and used to retract the anterior border of the supraspinatus tendon posteriorly. Thus, the cranial aspect of the glenoid bone at the 12:00- to 12:30-o’clock position is exposed. For the entry point of the cannulated screw, a high anteromedial portal is established lateral to the coracoid base, just anterior to the distal clavicle. Through this portal, the K-wire of a cannulated small-fragment osteosynthesis system (ASNIS 4.0 mm; Stryker) is introduced and drilled into the cranial glenoid fragment at the 12:30-o’clock position (Fig 7). Still, the arthroscope remains in the high anterolateral portal to enable to change repeatedly between the 2 perspectives: first, the glenohumeral view on the glenoid fracture line, and second, viewing cranially toward the lateral base of the coracoid to control the entry point of the K-wire. With the cranial fragment held in the correct reduction, the K-wire is further advanced under power into the caudal fragment. During this step, preliminary retention is controlled arthroscopically, to avoid penetration of the glenoid surface with the K-wire. According to the arthroscopic view, fluoroscopy in the anteroposterior plane shows adequate fracture reduction with the K-wire parallel to the joint line (Fig 8). Next, the entry point of the K-wire is predrilled using a cannulated 2.7-mm drill. Then, a cannulated, self-cutting 4.0-mm screw is inserted via the K-wire. As the screw is advanced tight adaptation of the fracture line can be appreciated (Fig 9). The K-wire and the clamp are removed. Finally, portals are closed, sterile dressing is applied, and the shoulder is immobilized in a sling. Postoperative computed tomography of the right shoulder shows excellent fracture reduction (Fig 10). The shoulder is immobilized with a sling for 6 weeks and passive motion is limited to 90° of flexion and abduction. As radiograph controls show bony healing, active mobilization with free range of motion can be initiated after 6 weeks.