Management of Proximal Humeral Fractures with Intramedullary Flexible Nails

Abstract

Background: Treatment of unstable, displaced fractures of the proximal end of the humerus has remained controversial in the literature. Conservative treatment often results in stiffness of the shoulder and malunion. Open reduction and internal fixation may result in avascular necrosis of the fragments of the humerus. Fixation of 2- or 3-part proximal humeral fractures with retrograde intramedullary, flexible nails seems to provide appropriate stabilization without further damage to the vascularity of the bony fragments. The purpose of this retrospective study is to evaluate the results of closed reduction and retrograde intramedullary flexible nail fixation of proximal humeral fractures.
Patients and Methods: From 1990 to 1998, closed reduction and retrograde intramedullary, flexible nail fixation was performed on a total of 46 patients with 2- or 3-part fractures of the proximal humerus. 10 patients were lost to follow-up. All of the fractures were classified according to the Neer classification. 26 female and 10 male patients with a mean age of 51 years (range: 30-78) were reviewed clinically and radiologically with a mean follow-up of 82 months (range: 42 -44). The shoulder function was evaluated with the Constant scoring system and compared with the opposite shoulder. Radiographic evaluation was done in the anteroposterior, lateral and axillary views of the shoulder after surgery and at final follow-up. Angulation and displacement of the fracture, occurrence of non-union, partial or total avascular necrosis of the head and hardware failure were noted.
Results: The mean Constant score was 78 in 3-part fractures and 84 in 2-part fractures at the final follow- up. 91.6 % of the patients were still satisfied with the clinical outcome of the treatment. 3 patients with partial humeral head necrosis were noted. Neither non-union nor total avascular necrosis of the humeral head was noted in any patient. Nail perforation of the humeral head was seen in 14 cases, especially in the elderly.
Conclusions: From the results of our study, we suggest that 2-part fractures and minimally displaced 3-part fractures of the proximal humerus can be treated with retrograde, flexible intramedullary nails successfully.

Proximal humerus fracture - intramedullary nailing

References

• 1 Aktuglu K, Oncag H. Humerus cerrahi boyun kırıklarında intramedüller çivileme.  Acta Orthop Trauma Turc. 1992;  26 159-162 (In Turkish)
• 2 Cameron B D, Williams G R. Operative fixation of three-part proximal humeral fractures.  Tech Shoulder Elbow Surg. 2002;  2 111-123
• 3 Constant C R, Murley A HG. A clinical method of functional assessment of the shoulder.  Clin Orthop. 1987;  214 160-164
• 4 Hawkins R J, Bell R H, Gurr K. The three-part fracture of the proximal part of the humerus.  J Bone Joint Surg [Am]. 1986;  68 1410-1414
• 5 Hintermann B, Trouillier H H, Schafer D. Rigid internal fixation of fractures of the proximal humerus in older patients.  J Bone Joint Surg [Br]. 2000;  82 1107-1112
• 6 Ilchmann T, Ochsner P E, Wingstrand H. et al . Non-operative treatment versus tension-band osteosynthesis in three and four-part proximal humeral fractures.  Int Orthop. 1998;  22 316-320
• 7 Jaberg H, Warner J JP, Jakob R P. Percutaneous stabilization of unstable fractures of the humerus.  J Bone Joint Surg [Am]. 1992;  74 508-515
• 8 Khodadadyan-Klostermann C, Raschke M, Steenlage E. et al . Intramedullary wiring of proximal humerus fractures: results of a minimally invasive treatment concept.  Eur J Trauma. 2002;  4 234-241
• 9 Kocialkowski A, Wallace W A. Closed percutaneous K-wire stabilization for displaced fractures of the surgical neck of the humerus.  Injury. 1990;  21 209-212
• 10 Koval K J, Gallagher M, Marsicano J G. et al . Functional outcome after minimally displaced fractures of the proximal part of the humerus.  J Bone Joint Surg [Am]. 1997;  79 203-207
• 11 Neer C S . Displaced proximal humeral fractures: Part II. Treatment of three and four-part displacement.  J Bone Joint Surg [Am]. 1970;  52 1090-1103
• 12 Neer C S . Displaced proximal humeral fractures: Part I. Classification and evaluation.  J Bone Joint Surg [Am]. 1970;  52 1077-1089
• 13 Palvanen M, Kannus P, Parkkari J. et al . The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls.  Osteoporosis Int. 2000;  11 822-831
• 14 Putz P, Pauwells P. Hackethal's method of bundle nailing for proximal or diaphyseal fractures of the humerus.  Acta Orthop Belg. 1995;  61 (Suppl 1) 162-165
• 15 Rajasekhar C, Ray P, Bharma M. Fixation of proximal humerus fractures with the Polaris nail.  J Shoulder Elbow Surg. 2001;  10 7-10
• 16 Resch H, Povacz P, Frohlich R. et al . Percutaneous fixation of three and four-part fractures of the proximal humerus.  J Bone Joint Surg [Br]. 1997;  79 295-300
• 17 Schlegel T F, Hawkins J R. Displaced proximal humeral fractures: evaluation and treatment.  J Am Acad Orthop Surg. 1994;  1 54-66
• 18 Sturzenegger M, Fornaro E, Jakob R P. Results of surgical treatment of multifragmented fractures of the humeral head.  Arch Orthop Trauma Surg. 1982;  100 249-259
• 19 Vrancken Peeters M J, Kastelen G W, Breslau P J. Proximal humerus fractures. A prospective study of the functional outcome after conservative treatment.  Europ J Trauma. 2001;  3 133-136
• 20 Zifko B, Poigenfürst J, Pezzei C. Intramedullare Markdrahtung unstabiler proximaler Humerusfrakturen.  Orthopäde. 1992;  21 115-120