Complications of locked nailing in humeral shaft fractures

BACKGROUND: The purpose of this study was to investigate the complications of humeral locked nailing. METHODS: Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture. RESULTS: In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy. CONCLUSION: Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.     

Open exchange locked nailing in humeral nonunions after intramedullary nailing

Humeral nonunions after cannulated intramedullary nailing have been difficult to reconstruct. In the current study, 23 consecutive patients were treated by open exchange locked nailing with bone grafting. There were 16 men and seven women with a mean age of 46.2 years. The nonunions followed humeral locked nailing in eight patients, Seidel nailing in 13, and Küntscher nailing in two. The average nonunion time was 14.7 months. The nonunions, located at the proximal (1/3) in four humeri, middle (1/3) in 15, and distal (1/3) in four, were antegrade nailed in 10 and retrograde nailed in 13. Nineteen had 8-mm nails and four had 7-mm nails. Supplementary wiring was used in 19 patients. The average followup was 21.4 months. With one surgery, all but one patient (96%) achieved osseous union in, on average, 16.3 weeks. One patient with chronic renal dialysis had persistent nonunion and an osteolytic supracondylar fracture. Other complications included one postoperative radial nerve palsy, one brachial artery injury, and one wire infection. At followup, all patients with solid union had excellent or satisfactory recovery of shoulder function. The average postoperative Neer score (90.7) was significantly better than the average preoperative score (68.5). Two patients had losses of elbow motion of 10 degrees and 20 degrees, respectively. This study shows that humeral nonunion after cannulated intramedullary nailing can be treated effectively by open exchange locked nailing with bone grafting. Supplementary wiring can compress the nonunion and facilitate bone healing.     

Locked nailing with interfragmentary wiring for humeral nonunions

OBJECTIVE: Locked nailing for humeral nonunions is threatened by residual fracture gap and fracture motion. This article describes the clinical experience of using interfragmentary wiring to solve these problems. METHODS: Interfragmentary wiring was used in 21 consecutive humeral nonunions treated with humeral locked nails. The average age of patients was 49.5 years, with an average nonunion duration of 14.4 months. Eighteen patients had previous operations. Nonunions were located at the proximal third in 4, the middle third in 10, and the distal third in 7. Antegrade nailing was used in 11 and retrograde nailing in 10. Sixteen nonunions were nailed with 8-mm nails and five with 7-mm nails. Interfragmentary wiring was applied to either the posterior or the lateral cortex of humeri in a figure-of-eight configuration. Bone grafting was performed in all and average follow-up time was 22 months. RESULTS: With a single operation, all patients achieved osseous union in, on average, 18.3 weeks. One patient with segmental nonunion suffered acute renal failure 4 months after operation, but fracture healing was not affected. Wire infection occurred in one patient with preoperative infection at the nail entry site and was treated by implant removal. Other complications including two transient radial nerve palsies and one brachial artery injury did not affect the final outcome. At follow-up, all but four patients had complete recovery of shoulder flexion and abduction. The average postoperative Neer score (91.1 points) was significantly better than the average preoperative score (65.5 points). All but three patients had complete recovery of elbow motion. CONCLUSION: Interfragmentary wiring, a safe procedure if properly performed, could effectively decrease the residual fracture gap and fracture motion in locked nailing of humeral nonunions. Further biomechanical studies and prospective, randomized, controlled studies are warranted.     

Treatment of nonunions of humeral fractures with inter-locking intramedullary nailing

Objective： To introduce the experience of treating nonunions of humeral fractures with interlocking intramedullary nailing.
Methods： Twelve patients with humeral nonunions were treated with interlocking intramedullary nailing. The time interval between trauma and surgery was 10.5 months on average. Open reduction with anterograde approach was performed. Axial compression was specially applied to the fracture site with humeral nail holder after insertion of distal locked screws. Iliac bone grafting was added.
Results： The average follow-up period was 21 months （ranging 9-51 months）. All patients achieved osseous union 5.8 months after treatment on average. Eleven patients hadgood functions of the shoulder joints and the upper extremities. No patient experienced any permanent neurological deficit. Refracture of the original ununited region occurred in one patient after removal of the internal fixator one year later, but union was achieved after closed re-intramedullary nailing fixation.
Conclusion： Humeral interlocking intramedullary nailing is an effective alternative treatment for humeral nonunion.     

Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures

OBJECTIVE: To determine the effectiveness of exchange reamed nails for treatment of aseptic femoral delayed unions and nonunions. DESIGN: Retrospective chart review. PATIENTS: Nineteen patients admitted to the Carolinas Medical Center Level I trauma center from 1990 to 1996 for repair of femoral shaft fracture nonunion following contemporary locked nailing performed at least six months previously. These patients showed no radiographic evidence of progression of fracture healing for three months and had clinical symptoms of nonunion. INTERVENTION: Exchange reamed nails to treat ununited femoral shaft fracture. MAIN OUTCOME MEASUREMENTS: Radiographic and clinical evidence of union of the fracture or of the necessity for additional procedures. RESULTS: In 53 percent of the patients the secondary procedure resulted in fracture union, whereas in 47 percent, one or more additional procedures were required. Eight of the nine fractures that did not unite with exchange nailing united after a subsequent procedure (bone grafting, compression plating, or nail dynamization). Neither the type of nonunion, the location of the shaft fracture, the use of static versus dynamic cross-locking, nor the use of tobacco products was statistically predictive of the need for additional procedures. CONCLUSIONS: Reevaluation of routine exchange nailing as the recommended treatment for aseptic femoral delayed union or nonunion may be required. A significant number of patients who undergo reamed exchange nailing will require additional procedures to achieve fracture healing.     

肱骨交锁髓内钉治疗肱骨骨折术后骨不连

目的介绍应用肱骨交锁髓内钉治疗肱骨骨折术后骨不连的经验。方法1997年10月～2001年7月,应用肱骨交锁髓内钉治疗12例肱骨骨折术后骨不连患者,其中肥大型5例,萎缩型2例,假关节形成5例。受伤至骨不连手术的时间平均为10．5个月(5～33个月)。手术采用开放复位顺行置入髓内钉,锁入远端交锁钉后向近端打拔以使断端加压,自体髂骨及RBX植骨。结果所有患者获平均21个月(9～51个月)随访。12例患者骨不连均获得愈合,平均愈合时间为5．8个月(3．5～8．0个月)。其中1例去除髓内钉后1年于原骨不连部位发生再骨折,重新植骨内固定而获得愈合。11例肩关节及上肢功能恢复良好。所有患者未遗留神经损伤症状。结论肱骨交锁髓内钉为治疗肱骨骨折术后骨不连的有效方法。     

Locked-nail treatment of humeral surgical neck nonunions

OBJECTIVE: The authors' purpose was to report their experience with the use of locked nails in treating humeral surgical neck nonunions. Locked nailing has the advantages of minimal soft tissue trauma, automatic fracture reduction, and stable fracture fixation. METHODS: Excluding 3 patients with severe medical illness, a total of 15 consecutive patients with 15 nonunions were treated by humeral locked nailing and bone grafting. Delay from trauma to surgery averaged 13.8 months, and 10 patients had previous operations. The average age of patients was 55.1 years; average follow-up time was 22.4 months. There were two hypertrophic and 13 atrophic nonunions. The average preoperative Neer score for shoulder joints was 53.5. All but three cases had varus deformity, with an average angle of 32.3 degrees. RESULTS: Seven nonunions were nailed with 8-mm nails and eight with 7-mm nails. With a single operation, all but one patient achieved osseous union in an average of 5.4 months. This one patient, who had a Neer score of 72, refused further surgery. At follow-up, 13 of the 15 patients had excellent or good functional recovery of shoulder joints, with an average Neer score of 86.7. Four patients had residual varus angulation averaging 15.5 degrees. For patients with solid union, the average range of shoulder motion was 152.3 degrees in flexion and 146.4 degrees in abduction. No patients had significant limitation of elbow motion. Three patients had occasional shoulder pain and no patients had evident shoulder impingement. CONCLUSION: For humeral surgical neck nonunions in which the head fragment still preserves the greater tuberosity, locked nailing with transfixing screws appeared to be a useful alternative, especially in fractures with osteoporosis, severe varus deformity, or severe soft tissue scarring.     

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.     

Closed interlocking nailing of humeral shaft fractures with the Russell-Taylor nail

OBJECTIVE: To assess the role of the Russell-Taylor humeral nail in the treatment of humeral shaft fractures. STUDY DESIGN: Retrospective with a mean radiologic and clinical follow-up at thirty-two months. SETTING: University teaching hospital. PATIENTS: Total of thirty-seven patients treated with the Russell-Taylor humeral nail. INTERVENTION: All patients were treated with the Russell-Taylor humeral nail inserted in an antegrade fashion. OUTCOME MEASURES: Radiologic union and shoulder function in terms of pain, power, range of movement, and activities of daily living. RESULTS: There were four established nonunions and four cases of delayed union (time to union > four months). Age of patient was the only predictor of nonunion. There was one infection and one intraoperative fracture. Two prominent proximal screws required removal, and one nail was removed after union because of impingement. Three patients required manipulation under anesthesia to improve shoulder movement. At review, six patients had residual poor shoulder function as per Constant score, four attributable to shoulder stiffness and two to residual pain. CONCLUSION: The authors' findings indicate a significant rate of delayed or nonunion in the elderly patient. When the high rate of union with conservative treatment is considered, the indications and rationale for intramedullary humeral nailing should be clearly defined.     

Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.

Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.     

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.     

Locked nailing of spiral humeral fractures with or without radial nerve entrapment

The experience of locked nailing of spiral humeral fractures and the perioperative conditions of the radial nerve are reported. The nerve is at risk of entrapment after such a fracture, and severe injury may occur during closed nailing. Among 162 humeral fractures treated by locked nailing, there were 21 spiral fractures: 18 acute fractures, and three delayed unions. The distribution of the fractures was two at the middle and 19 at the distal (1/3). Twelve patients had preoperative radial nerve palsy. All fractures excluding one middle fracture were retrograde nailed, and all patients had radial nerve exploration. Thirteen fractures were locked statically, seven were locked distally and had cerclage wiring, and one was locked distally only. Fisher's exact tests showed that the risk of radial nerve entrapment significantly increased in fractures with varus angulation or resulting from high-energy trauma. All the patients achieved fracture union and regained satisfactory joint functions. The author suggests that in external rotational spiral humeral fractures, radial nerve exploration should be done if nerve entrapment is highly suspected, irrespective of the fracture location or nerve palsy. Locked nailing with transfixing screws or cerclage wire could be a reliable treatment method for these fractures.     

Antegrade interlocking nailing of humeral shaft fractures

The results of 39 humeral shaft fractures (37 patients) treated with antegrade locked nailing using a Russell–Taylor nail were reviewed. There were 30 acute fractures, 6 fractures malaligned in a hanging cast or brace, and 3 pathological fractures. Patient age ranged from 26 to 80 years (average, 59.7 years) and average follow-up was 25.7 months (range, 6–48 months). Fracture union was achieved in 92.3% of our cases, while shoulder function was excellent or good in 87.2% of cases. Antegrade locked nailing offers a dependable solution for the treatment of humeral shaft fractures, especially in polytrauma patients and cases of segmental or pathological fractures. Far less satisfactory results were obtained in comminuted fractures of the proximal third in the humerus, especially in osteoporotic patients, and we therefore advocate caution with the use of intramedullary nailing in this type of fracture. Certain technical aspects such as avoiding nailing the fracture in distraction, properly countersinking the tip of the nail, and achieving adequate fixation stability have been found to be of paramount importance to reduce the incidence of delayed union/non-union rate and to obtain better functional results from the shoulder joint.     

Treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow

OBJECTIVE: To investigate the effect of treatment of humeral shaft nonunion with interlocking nail and percutaneous injection of bone marrow after operation. METHODS: Twenty-five adult patients with humeral shaft nonunion, initially treated with plates, intramedullary nails, or external fixators changed to use RussellTaylor reamed antegrade intramedullary nails with autologous bone grafting and percutaneously bone marrow injection into the fracture sites ten days after the operation to promote union. RESULTS: All patients achieved a solid union with good function. The union period was a median of 4.5 months. CONCLUSION: We believe that the procedure may provide firm internal fixation and improve activity of osteoblasts in fracture sites for accelerating fracture healing.     

Effectiveness of completely round nails with both-ends-threaded locking screws for tibial shaft fractures

BACKGROUND: Completely round nails, in contrast to conventional locked nails with surface grooves, for postoperative endosteal revascularization may increase the nail rigidity and decrease the manufacture cost. Both-ends-threaded screws with higher fatigue strength require smaller nail holes and can further increase the mechanical strength of the nails. METHODS: In this study, both-ends-threaded locking screws were used to treat 68 tibial fractures, including 56 acute fractures in 54 patients and 12 nonunions in 12 patients. There were 41 men and 25 women with a mean age of 39.6 years, and the average follow-up was 24 months. For acute fractures, there were 11 type I, 9 type II, 5 type IIIA, and 3 type IIIB open fractures. Acute fractures were treated with closed nailing. Five hypertrophic nonunions were treated with closed exchanged nailing, and seven oligotrophic nonunions were treated with open nailing and iliac bone grafting. RESULTS: With a single nailing procedure, 53 acute fractures and all nonunions achieved union with mean times of 17.4 weeks and 18.4 weeks, respectively. Three patients underwent exchange nailing and bone grafting and had eventual fracture union. Three fractures with compartment syndrome were treated with fasciotomy. Deep infection occurred in two open fractures but was successfully treated. Nail breakage occurred in one distal fracture and screw backout occurred in another, but fracture union was not affected. Recovery of joint motion was essentially normal in patients without knee or ankle injury. CONCLUSIONS: This study showed that completely round nails with both-ends-threaded locking screws could effectively treat tibial fractures. Completely round nails have the advantages of high mechanical strength and low manufacturing cost.     

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.     

带锁髓内钉内固定加经皮注射红骨髓治疗肱骨骨不连

目的 探讨采用Ｒｕｓｓｅｌｌ－Ｔａｙｌｏｒ扩髓型带锁髓内钉顺得内固定与植骨、术后注射红骨髓治疗肱骨骨不连。方法 肱骨骨不连患者２５例,以往平均手术次数２次,骨折后时间１０个月～４年,平均１年１０个月。用带锁髓内钉顺行静力型固定骨折端,取自体髂骨植骨缺损。术后１０ｄ于骨折区注射自体红骨髓。术后早期功能锻炼。平均随访时间１６个月。结果 所有病例均达到骨性愈合,平均愈合时间４．５个月,关节功能恢复很好。     

Retrograde versus antegrade nailing of femoral shaft fractures

OBJECTIVES: To compare union rates and complications of retrograde intramedullary nailing of femoral shaft fractures with those of antegrade intramedullary nailing. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Two hundred eighty-three consecutive adult patients with 293 fractures of the femoral shaft who underwent stabilization with antegrade or retrograde inserted femoral nails were studied. There were 140 retrograde nails and 153 antegrade nails. Twelve fractures in twelve patients were excluded (three in patients who died early in the postoperative period, three in patients because of early amputation, four in patients who were paraplegic, and two in patients who fractured through abnormal bone owing to metastatic carcinoma), leaving 134 fractures treated with retrograde nails and 147 treated with antegrade nails. One hundred four femurs treated with retrograde nails (Group R) and ninety-four femurs treated with antegrade nails (Group A) had sufficient follow-up and served as the two study groups. The average clinical follow-up was twenty-three months (range 6 to 66 months) for Group R and twenty-three months (range 5 to 64 months) for Group A. Both groups were comparable with regard to age, gender, number of open fractures, degree of comminution, mode of interlocking (i.e., static or dynamic), and nail diameter (p > 0.05). INTERVENTION: Retrograde intramedullary nails were inserted through the intercondylar notch of the knee, and antegrade nails were inserted through the pirformis fossa using standard techniques. MAIN OUTCOME MEASURES: Union, delayed union, nonunion, malunion, and complication rates. RESULTS: After the index procedure there were no significant differences in healing or incidence of malunion between Group R and Group A (p > 0.05). Healing after the index procedure occurred in ninety-one (88 percent) of the femurs in Group R and in eighty-four (89 percent) of the femurs in Group A. In Group R, there were seven delayed unions (7 percent) and six nonunions (6 percent). In Group A, there were four delayed unions (4 percent) and six nonunions (6 percent). Healing ultimately occurred in 100 (96 percent) femurs from Group R and in ninety-three (99 percent) femurs from Group A. In Group R, there were eleven malunions (11 percent), and in Group A, there were twelve malunions (13 percent). When patients with ipsilateral knee injuries were excluded, the incidence of knee pain was significantly greater for Group R patients (36 percent) than for Group A patients (9 percent) (p < 0.001). When patients with ipsilateral hip injuries were excluded, the incidence of hip pain was significantly greater for Group A patients (10 percent) than for Group R patients (4 percent) (p < 0.05). CONCLUSIONS: Retrograde and antegrade nailing techniques provided similar results in union and malunion rates. There were more complications related to the knee after retrograde nailing and more complications related to the hip after antegrade nailing.     

Treatment for nonunion of the shaft of the humerus: comparison of plates and Seidel interlocking nails.

From July 1986 to November 1989, fractures of the humeral shaft in 35 adults who had nonunion of the fracture were managed by plate fixation (19 patients) or antegrade nailing of the fracture fragments with the Seidel interlocking nail (16 patients) together with cancellous bone grafting. The follow-up period ranged from 12 to 52 months. Of the patients who had plate fixation, 89.5% had fracture union within 4.5 +/- 1.7 months; of the patients whose fracture was managed with the Seidel interlocking nail, 87.5% had fracture union within 4.4 +/- 1.8 months. The range of shoulder motion was improved with both techniques. Patients who had plate fixation had more complications than those whose fracture was managed by interlocking nailing (21% v. 12%). The authors prefer interlocking nailing because it is a relatively simpler technique, resulting in fewer complications. It may replace plating in the treatment of nonunion of humeral shaft fractures. However, rotatory instability with interlocking nailing cannot be disregarded, and if this is evident plate fixation should be done.     

Intramedullary nailing of humeral shaft fractures. A retrospective study of 126 cases.

Antegrade intramedullary nailing with four different implants was used in 126 humeral shaft fractures. There were 74 acute fractures, 17 pathologic fractures, 16 fractures malaligned in a hanging cast or brace, 15 fractures with delayed union and 4 fractures that were nailed after failed open reduction and internal fixation. The nonunion rate was 21/95 after primary operation, and after reoperations 14/95. Distraction of the fracture was a significant cause of nonunion, but not type of fracture, localization, implant, and delay between injury and surgery. Shoulder joint function was significantly impaired in 25/67 patients. The patients regarded the result as good or satisfactory in 41/67 of the cases who were followed mean 3 (0.5-10) years. We conclude that antegrade intramedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. It can be recommended as primary treatment only when nonoperative treatment is likely to fail.