Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: “fixed” and “bio”, avoidance of reaming for the antegrade technique and utilization of “semi-reaming” for the retrograde technique, guidelines for reducing complications, setting the best “timing” for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.     

肱骨干骨折顺行与逆行髓内针固定的病例 对照研究

目的：比较肱骨干骨折顺行与逆行髓内针固定的疗效。方法：入选1999年3月至2006年10月间有完整随访资料的肱骨干骨折105例,分为顺行髓内针组（A组）82例,逆行髓内针组（B组）23例。对两组的手术时间、术中出血量、并发症发生率、骨折愈合时间、骨折愈合率、Constant—Murley肩关节功能评分和Mayo肘关节功能评分等指标进行比较。结果：随访时间平均（31．2±20．9）个月。两组的手术时间、骨折愈合时间、愈合率及并发症发生率比较差异无统计学意义（P〉0．05）。B组术中出血量大于A组（P=0．002）。A组有4例（4．9％）不愈合,8例（9．8％）发生肩痛伴肩关节活动度减小,B组3例（13．0％）术中发生医源性骨折。A组肩关节功能评分低于B组（P=0．04）,肘关节功能评分两组比较差异无统计学意义（P〉0．05）。结论：顺行与逆行髓内针固定均是治疗肱骨干骨折的有效方法,但逆行髓内针固定医源性骨折发生率较高,应正确选择和制备髓内针入点。顺行髓内针固定有较高的肩痛和肩关节活动度减小的并发症发生率,注意将髓内针尾埋于肩袖下方,细致保护和修复肩袖,术后进行合理的康复练习,有利于减少肩痛和改善肩关节功能。     

Orange city tapping nail: An innovative implant for humeral diaphyseal fractures

BackgroundWe have conducted this study to evaluate the effectiveness of Orange City tapping nail in humeral diaphyseal fractures in terms of radiological union, shoulder function and complications. It’s a pilot study with the new implant “Orange City tapping nail” developed at our institute.Materials and methodsThirty patients with humeral diaphyseal fractures were treated with Orange City tapping nail through antegrade nailing procedure. The cases were followed up prospectively for a period of minimum six months. Outcome of the procedure were assessed according to American Shoulder and Elbow Surgeons (ASES) score, radiological union, complications and secondary procedures required.ResultsTwenty eight (93.33%) fractures united with an average consolidation time of 15.75 weeks. Two patients had nonunion. Functional outcome was excellent to good in 24 (80%) patients. One (3.33%) case had infection with Orange City tapping nail.ConclusionResults of Orange City tapping nail were excellent to good for humeral diaphyseal fractures in terms of union, shoulder function and complications. It is a safe, easy and reliable method for the treatment of humeral diaphyseal fractures. Postoperative shoulder stiffness and impingement depends on operative technique and postoperative rehabilitation. We need a larger comparative study with conventional antegrade nail to evaluate the effectiveness of the implant.     

Arthroscopical Findings after Antegrade Nailing of a Proximal Humeral Fracture

Abstract Proximal humeral fractures represent up to five percent of all fractures in adults, commonly found in elderly patients. The final functional results after different operative procedures are among other factors dependent on whether or not a rotator cuff lesion is pre-existent, prior to the fracture, and how its surgical therapy is carried out. However, to what extent prior rotator cuff tears in this special patient group contribute to the functional outcome remains widely unclear. In our institution antegrade intramedullary nailing is the treatment of choice for proximal humeral fractures. One critical point of this technique is the unavoidable split of the rotator cuff on the approach to the proximal humerus and the insertion of the nail through the incised cuff. We report on a case of an impingement after antegrade intramedullary nailing of a proximal humeral fracture. Diagnostic glenohumeral arthroscopy revealed neither a residual lesion of the former rotator cuff incision nor a chondral lesion at the former insertion site of the nail. In the same session subacromial decompression and a nettoyage of adhesions were performed. We assume that splitting the rotator cuff for the insertion of an antegrade nail in a proximal humeral fracture is less relevant than previously assumed and described.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

A new modular nail for the diaphyseal fractures of the humerus

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape - with concave sides - and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the ‘Garnavos’ nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.     

Der „AO/ASIF-Flexnail“

BACKGROUND: The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation. METHOD: Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score. RESULTS: Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome. CONCLUSION: We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.     

Modified extra rotator-cuff entry point in antegrade humeral nailing

Introduction We describe an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing, which preserves the articular surface and rotator cuff integrity.Material and methods Thirty-two patients with humeral shaft fractures underwent antegrade intramedullary nailing using a modified insertion point located 1 cm below the crest of the greater tuberosity, in a region outside the articular surface and rotator cuff area.Results In all cases, nailing was done successfully, without any perforation of the humeral inner cortex by the nail. Extension of the fracture line to the distal metaphysis happened intraoperatively in one case of a distal diaphysis fracture. In the remainder of the patients, postoperative reduction of the fracture was successful, with no sign of an iatrogenic incident of fracture comminution. Excellent active shoulder function and full early functional recovery of the shoulder joint (to 16th week postoperatively) were established in 98% of the patients. All fractures were united in a mean period of 14 weeks.Conclusion We suggest an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing as a possible and safe technique with beneficial results for the shoulders postoperative function.     

Locking flexible nails for diaphyseal humeral fractures in the multiply injured patient: a preliminary study

Multiply injured patients are sometimes treated with standard intramedullary nails for diaphyseal humeral fractures. We evaluated the use of the Synthes titanium locked flexible nail in 43 multiply injured patients (average injury severity score, 35.2) assessing time to union, nonunion rate, shoulder and elbow pain, and range of motion. Twenty-seven patients underwent antegrade insertion, and 16 underwent retrograde insertion. An increase in union rate was noted with antegrade (93%) versus retrograde (69%) insertion, without statistically significant difference in shoulder and elbow pain or range of motion. We recommend the locking flexible humeral nail with antegrade insertion for multiply injured patients with large soft-tissue damage or severe comminution that renders plate fixation difficult.     

Stabilisation von Humeruskopffrakturen mittels antegrader winkelstabiler Verriegelungsmarknagelung (Targon PH)

An antegrade straight intramedullary nailing system with angular and sliding stable interlocking screws was employed for the treatment of dislocated 2-, 3- and 4-part proximal humeral fractures (standard nail) and of combined humeral head and shaft fractures (long nail version) even in the presence of manifest osteoporosis according to the principles of minimum invasive surgery. Isolated fractures of the tubercles and multiply fragmented humeral head fragments represented contraindications for the application of an intramedullary nail. The procedure allows active shoulder motion immediately postoperatively. Mid-term results of a prospective follow-up study of 50 patients with complete examinations after 3, 6 and 12 months postoperatively showed good functional results with 78.8 Constant score points after 1 year, corresponding to 92% of the Constant score of the contralateral intact side. However, numerous complications were observed, mainly related to the backing out of the fixation screws. The number of the severe complications which are mentioned in the literature, such as humeral head necrosis, pseudarthrosis, infection or redislocation, was limited. Correspondingly, patients with manifest complications had a less favourable functional result (65.8 Constant score points corresponding to 73% of the contralateral intact side). Present modifications of the surgical technique for stabilization of the tubercles (additional suture cerclage fixation of fragmented tubercles) and a novel technical modification preventing the backing out mechanism of the fixation screws are expected to decrease the complication rate.     

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion.

OBJECTIVE: A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing. STUDY DESIGN: Prospective multicenter nonrandomized clinical study. PATIENTS: Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters. RESULTS: The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group. CONCLUSION: Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.     

带锁髓内钉与锁定加压钢板内固定治疗肱骨干骨折的随机对比研究

目的前瞻性对比研究带锁髓内钉和带锁加压钢板(LCP)治疗肱骨干骨折的临床效果。方法随机将49例分成两组(髓内钉28例;LCP组21例)。患者全部为新鲜肱骨干骨折,骨折部位距肱骨外科颈至少3cm,距尺骨鹰嘴大于5cm。临床疗效评价包括手术时间、出血量、骨折愈合情况、桡神经恢复、感染和肘关节、肩关节不适症状,影像学评价包括骨折力线、愈合时间、延长愈合和不愈合的发生率。结果平均随访1.5年。LCP组19例(90.5)骨折在16周后愈合,髓内钉组24例(85.7)在16周后愈合(P=0.70)。肩关节疼痛和肩关节活动受限在髓内钉组发生明显(P<0.05),而LCP组未发现这种情况。LCP组肘关节的活动范围明显减少(P<0.05),尤其是肱骨干远端1/3骨折患者。两组总并发症发生率比较无明显差异。结论对于需要手术治疗的肱骨干骨折,髓内钉和LCP都能使骨折稳定以达到最终愈合。     

Antegrade locked nailing for humeral shaft fractures

Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.     

Humeral nailing revisited

Unreamed interlocked humeral nailing for stabilisation of acute humeral fractures was introduced a decade ago. Antegrade and retrograde nail insertion are equally popular. The role of nailing as opposed to plating of humeral fractures is the subject of continuous debate. Between 1997 and 2005, 99 acute fractures of the humeral shaft were treated operatively with the unreamed humeral nail (UHN, Synthes) in our Level I Trauma Centre. The mean age of the patients was 63 years. Only eight patients (8.1%) were polytraumatised, nine patients had an open fracture (9.1%), five had a primary radial nerve palsy (5.1%). There were 54 antegrade and 45 retrograde nailings. The procedures were performed by 19 different surgeons, who carefully followed a detailed operation protocol. There were 6 adverse events: 3 secondary radial nerve palsies (3%), 2 fissures at the insertion point (2%) and one false placement of a locking screw (1%). Three patients developed pseudarthrosis (3%). Eight further operation were necessary (8.1%): 3 exploration of the radial nerve, 3 for treatment of pseudarthrosis, one replacement of a locking screw and one wound revision for superficial wound infection. Ninety patients (92 fractures) were evaluated after bone healing. Shoulder function was assessed using the Constant Score, elbow function with the Mayo Elbow Score. 91.3% and 5.4% of patients had an excellent or good shoulder function, 81.5% and 14.1% had an excellent or good elbow function. All patients with a functional deficit of the shoulder joint had antegrade, all patients with a deficit at the elbow joint retrograde nailing. Motor function recovered in all radial nerve palsies. 93.5% of patients had an excellent or good functional end result.Unreamed humeral nailing is a valid therapeutic option for stabilisation of acute humeral shaft fractures. Antegrade and retrograde nailing are associated with specific but different complications. By strictly adhering to the operation technique, the number and severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional outcome is the rule.     

Treatment of humeral shaft fractures with antegrade intramedullary locking nail

Antegrade interlocked humeral nailing for stabilization of humeral fractures was introduced many years ago, and studies on this method in the orthopedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of an antegrade intramedullary nail (T2, Stryker) for the humeral fractures. Between 2005 and 2008, 52 fractures of the humeral shaft were treated operatively with this intramedullary nail in our department. Eight patients were polytraumatized, and four patients had an open fracture. The mean age of patients was 51.7 years. Forty-eight patients had an adequate duration of clinical follow-up (a mean of 18 months) for analysis. Complications were recorded, and the time to union was measured. Shoulder and elbow functions were assessed using the Constant Score and the Morrey Score, respectively. Forty-six fractures healed, with a mean time to clinical union of 10.3 weeks. Two patients developed pseudarthroses. There were four adverse events: two proximal screws backed out, one superficial infection at the insertion point, and one fracture at the distal end of the nail. Ninety-one percentage of patients had an excellent or good shoulder function. Five further operations were necessary: two for treatment of pseudarthroses, two for removal the backed out proximal screws, and one wound debridement for superficial infection. Antegrade humeral nailing is a valid therapeutic option for stabilization of humeral shaft fractures. By strictly adhering to the operation technique, the number and the severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional results is the rule.     

Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates

OBJECTIVES: To compare the clinical and radiographic results for locked intramedullary (IM) nails and plates used in the treatment of humeral diaphyseal fractures. DESIGN: Prospective randomization by sealed-envelope technique of eighty-four patients into two study groups: those treated by intramedullary nailing (IMN group; n = 38) and those treated by compression plating (PLT group; n = 46). SETTING: Patients admitted consecutively to a university-affiliated Level I trauma center. PATIENT/PARTICIPANTS: All skeletally mature patients admitted to Harborview Medical Center with acute humeral shaft fractures requiring surgical stabilization. Fractures of the diaphysis were defined as being at least three centimeters distal to the surgical neck and at least five centimeters proximal to the olecranon fossa. INTERVENTION: Treatment with locking antegrade intramedullary humeral nails (Russell-Taylor design [Smith and Nephew Richards]) or with 4.5-millimeter dynamic compression and limited contact dynamic compression plates (AO design [Synthes]). MAIN OUTCOME MEASUREMENTS: Clinical outcome measurements included fracture healing, radial nerve recovery, infection, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. RESULTS: Follow-up averaged thirteen months. Forty-two fractures (93 percent) in the PLT group were healed by sixteen weeks versus thirty-three fractures (87 percent) in the IMN group (p = 0.70). Shoulder pain and a decrement in shoulder range of motion (ROM) were significant associations with IMN (p = 0.007 for both variables) but not with PLT. A decrement in elbow ROM was significantly associated with PLT (p = 0.03), especially for fractures of the distal third of the diaphysis, whereas elbow pain was not (p = 0.123). The sum of other complications demonstrated nearly equal prevalence for both treatment groups. CONCLUSIONS: For patients requiring surgical treatment of a humeral shaft fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing.     

Treatment of humeral shaft delayed unions and nonunions with humeral locked nails

OBJECTIVE: To report experience with use of humeral locked nails in treating humeral delayed unions and nonunions. The following techniques yielded encouragingly good results: static locking, short-to-long segment nailing, bone grafting, fracture compression, and minimal surgical trauma. DESIGN AND METHODS: A total of 41 consecutive patients with 13 delayed unions and 28 nonunions were treated with humeral locked nails. Delay from trauma to surgery averaged 4.2 months for delayed union and 15.5 months for nonunion. The average age of patients was 50.2 years; average follow-up time was 23.2 months. There were 7 proximal-third fractures, 21 middle-third fractures, and 13 distal-third fractures. The antegrade approach was used for 13 fractures and retrograde for 28. Open nailing was performed in 39 fractures and closed nailing in 2. If the fracture motion was still present after nail insertion, axial compression of the fracture site was specially applied. Bone grafting was performed in the fractures with open nailing. Thirty-four fractures were nailed with 8-mm nails, and 7 fractures were nailed with 7-mm nails. RESULTS: With a single operation, all but two patients achieved osseous union in, on average, 5.6 months. One of these two patients eventually gained union after another surgery with fracture compression along the original nail and concurrent bone grafting. The second patient, undergoing hemodialysis for chronic renal failure, had persistent nonunion. At follow-up, for patients with antegrade nailing, all but four patients had less than 20 degrees limitation of shoulder abduction. For patients with retrograde nailing, all but two had less than 10 degrees limitation of elbow motion. Only the patient with persistent nonunion had continual pain and significant impairment of arm function. CONCLUSIONS: Humeral locked nailing seems to be effective for humeral delayed unions or nonunions. It may be an acceptable alternative for fractures unsuited for plate fixation, such as those with comminution, osteoporosis, or a severely adhered radial nerve.     

Interlocking nailing with the Seidel nail in fractures of the humeral diaphysis in Paget's disease: a report on two cases

Three diaphyseal humeral fractures in two patients with polyostotic Paget's disease are presented. Two fractures were treated with closed intramedullary interlocking nailing using the Seidel nail, with good results.     

Six-year experience with antegrade intramedullary nail for the treatment of proximal and diaphyseal humeral fractures

Background

Proximal and shaft humeral fractures are very common worldwide; surgical treatment can be a viable option to reduce limb immobilization and to allow the patient an earlier return to daily activities. The aim of our study was to evaluate the outcomes of patients treated with intramedullary nail in our Institute from January 2010 to December 2016.

Materials and methods

This is an observational cohort study. Inclusion criteria were: traumatic proximal and diaphyseal humeral fractures treated with antegrade nail; a minimum follow-up of 6 months. We evaluated the fracture healing time, the functional recovery (using the Constant score) and postoperative complications (need of blood transfusion, infections and need of re-intervention). The t test was used for statistical analysis.

Results

Ninety-five patients were included (20 proximal and 75 diaphyseal fractures). Bone callus formation was evident a mean of 57 days after surgery. In all patients, there was an improvement in the functional recovery over time, but those younger than 65 years had better outcomes. The type of fracture and patients’ gender did not affect these results at one and 6 months of follow-up. In 18 cases, blood transfusions were needed; infections never occurred; finally, revision surgery was performed in 10 cases (two reverse total shoulder arthroplasties, one open reduction and internal fixation with plate and screws and seven nail removals for intolerance).

Conclusion

In our study, intramedullary nail proved to be a minimally invasive technique with a rapid improvement in range of motion, an earlier rehabilitation and acceptable pain.