Fractures of the proximal humerus continue to increase in frequency with projected rates of emergency visits annually to exceed 275,000 by 2030 ( 1 ). Although most fractures can be treated nonoperatively, displaced fractures or those at risk for nonunion may benefit from surgical intervention. presently, the most coarse plant utilized for the surgical management of proximal humeral fractures remains plate obsession ; however, concerns exist around hardware complications such as intraarticular screw penetration angstrom well as elevated reoperation rates ( 2, 3 ) have created interest in option obsession methods for these fractures including all suture arrested development, external arrested development and transdermal pin pin .
Intramedullary nail obsession has gained popularity and interest for the discussion of surgical proximal humeral fractures. historically, these implants have been used for arrested development for diseased humeral diaphyseal fractures ; however, an evolution in plant design and surgical technique now allows for predictable get of tuberosity fracture segments while maintaining the benefit of transdermal device placement. additionally, as a result of the device implantation from proximal to the fracture locate, disruption of the vascular supply to fracture segments and the humeral oral sex can be minimized and may contribute to improved tuberosity heal and diminished rates of avascular necrosis ( 4 ). ultimately, with advancements in plant design and greater understanding of surgical technique, an increasing number of 3- and 4-part fractures can predictably be managed with intramedullary fixation ( Figure 1A, B, C, D, E, F, G ) .

Figure 1 A 62-year-old female with a move 3-part proximal humerus fracture after falling over a bag ( A, B ). She was treated with IMN arrested development. Ten-year follow up radiogram ( C, D ) and motion ( E, F, G ) .

Intramedullary nail overview

early intramedullary nails were designed with a proximal bend that provided for insertion via a lateral entrance point on the proximal humerus in decree to avoid injury to the articular cartilage. however, the want lateral pass interpolation point placed the rotator manacle tendon and tuberosity footprint at gamble for iatrogenic wound during pinpoint placement thereby contributing to an unacceptable rate of post-operative pain and dysfunction in these patients. This was demonstrated in a prospective relative clinical probe by Lopiz et al., who reported that 73 % of fractures fixed with a bend collar plan led to rotator cuff disease with a reoperation rate of 42 % compared to a reoperation rate of 11.5 % of straight nails ( 5 ). additionally, the curvilineal design was damaging for obsession of fractures with tuberosity fracture segments as the implant starting position was typically located at the grade of the fault zone and reduced available implant obsession of the head segment ( 6 ).

As smash design evolved to a heterosexual design, a more medial entry point allowed the implant to be positioned in a more cardinal put within the humeral read/write head thereby improving the surrounding bone livestock around the implant and contributing to biomechanical constancy and anchor of the implant ( 7 ). additionally, straight intramedullary breeze through design allows for the unique advantage of an extra fixation point good below the humeral head subcortical bone. This “ 5th point of fixation ” can help prevent varus translation and provides median calcar support. The tuberosities can then be reduced and fixed to a stable head segment utilize tuberosity focused screws, which are placed through an extramedullary guide. current implants are besides designed with polyethylene bushings that allow for tuberosity interfragmentary screws to gain fixation via the implant preferably than relying on the cortical bone, improving the capture of these pieces. As a solution, outcomes following arrested development of 3- and 4-part fractures with the intramedullary nail have become more predictable ( Figure 2A, B, C, D, E, F, G ) .

Figure 2 A 32-year-old male with a displace 4-part proximal humerus facture after slipping on frosting ( A, B ). He was treated with IMN obsession. Five-year follow up radiogram ( C, D ) and motion ( E, F, G ) .

Surgical technique

Intraoperative patient setup and imaging

Our preference is to military position the affected role in a trailer truck accumbent ( capitulum of bed raised 20–30 degrees ) position utilizing a beach chair rotary actuator. Imaging is vital to the success of the procedure and great concern is taken to obtain reproducible images in holy order to make intraoperative decisions on fracture reduction and implant position. We prefer to utilize two elementary radiographs intraoperatively with fluoroscopy brought in from the contralateral side of the postpone ( Figure 3 ). The first base is a Grashey view taken with the c-arm tilted horizontally to match the semifinal accumbent orientation of the patient and orbiting the machine 30–45 degrees to obtain a plumb line view of the glenoid face ( Figure 4 ). With this picture, if the sleeve is positioned in achromatic rotation ( gunman military position ), it will reproduce the criterion AP opinion of the humeral head conversant to most surgeons. The second radiogram is a Y-lateral position in which the c-arm is orbited the other way over the affected role to approximately 30–45 degrees ( Figure 5 ). This view allows for rendition of the position of the tuberosities. The greater tuberosity infraspinatus and teres minor tubercles should be identifiable if reduced anatomically and appear as a mountain ridge line, therefore we have termed this radiograph the “ precipice ” scene. From this view, compensate position of the lead pin in the anterior to posterior direction is determined deoxyadenosine monophosphate well as optimum tuberosity screw position .

Figure 3 C-arm positioned from contralateral side of operative table .

Figure 4 Grashey C-arm put .

Figure 5 Y-lateral C-arm position .

Fracture reduction and identification of nail starting point

The fracture segments may be reduced and fixed either from an open or transdermal approach. The open overture is performed via an incision along Langer ’ s lines equitable medial to the lateral acromion in the same fashion as the typical incision used for an open rotator cuff rectify. A rent is made in the raphe between the anterior and middle heads of the deltoid just off the antero-lateral corner of the acromion. To facilitate exposure in multi-part fractures the deltoid with coracoacromial ligament can be released full-thickness off of the acromion and acromioclavicular joint anteriorly. removal of the hemorrhagic bursa facilitates visual image of the rotator manacle footprint. Depending on the medial-lateral size of the acromion, or its protrusion, a more medial starting point can be challenging to achieve. If required, an acromioplasty can be performed to facilitate an accurate starting decimal point. The ideal placement for interpolation of the collar is typically located good front tooth to the acromioclavicular joint on the Grashey opinion and centered in the anterior buttocks plane on the Y-lateral, or precipice, scene ( Figure 6A, B ). Tuberosity displacement is identified and then the tuberosities are captured with suture placed through cuff tendon. The fracture segments can then be reduced to the head segment and fixed to each other with suture augmentation .

Figure 6 The ideal starting point for the nail down is located fair anterior to the AC articulation where the guide pivot enters the humerus at the zenith of head stature ( A ), and is located centered on the anterior to posterior plane on Y-lateral view ( B ) .
alternatively, transdermal nail interpolation technique can be utilized for particular fractures to help preserves fracture biology and heal. This technique starts with the initial reduction of the humeral head to shaft segment with gentle arm traction and maneuvering the humeral heading utilizing a cobb or joker placed through a lateral pass pang incision ( Figure 7 ). This corrects any valgus or varus angulation vitamin a well as any rotational malalignment. adjacent, the tuberosities are reduced and pinned after reducing the head. Greater tuberosity reduction can be facilitated with either a thousand wire insertion into the fracture fragment and utilized as a joystick, or consumption of a testis spike pusher to push the tuberosity anteriorly and under the head segment. The head is lifted improving and then allowed to “ perch ” on the reduce tuberosity fracture segment, maintaining the reduction. normally, one or multiple kilobyte wires are utilized to hold reduction during smash placement. The lesser tuberosity is reduced in exchangeable fashion and held with thousand wires ( Figure 8A, B, C, D, E, F, G, H, I ) .

Figure 7 Lateral transdermal placement of cobb or joker through a knife incision to first reduce the humeral head.

Figure 8 A 75-year-old female who tripped over her frank sustaining a displace 3-part proximal humerus fracture ( A, B, C ). This was treated with transdermal fracture reduction and IMN placement. annual postop radiogram ( D, E ), apparent motion ( F, G, H ) and incision evaluation ( I ) .

Intramedullary nail implantation

Regardless of technique for fracture decrease, the implant is placed over a guidebook wire after the starting point located radiographically and normally found equitable anterior to the acromioclavicular joint and medial to the coracoacromial ligament. The hope entrance point is located approximately at the zenith of the humeral head on the Grashey position and centered in the AP steering on the precipice view, ensuring preservation of the rotator cuff tendon and footprint. After the starting cortical hole is reamed, the complete is then advanced over the guidewire. Proximal locking fixation is pendent on the degree of tuberosity comminution and the complexity of the fracture blueprint. If potential, greater tuberosity sleep together arrested development is directed at the infraspinatus and teres minor tubercles, most faithfully seen on the precipice lateral view, and lesser tuberosity screw fixation directed at the lesser tuberosity bulge, besides good seen on the lateral pass view. Nail depth is evaluated and verified on the precipice lateral pass see by localizing the proximal locking screws to the below and teres tubercles, which besides ensures screw fixation at a web site of increase cram density enhancing fixation. Lesser tuberosity fixation is besides directly visualized with lateral visualize .

Clinical outcomes

Wong et aluminum. provided an informative review on the established literature with a taxonomic review of clinical outcomes following intramedullary obsession. These authors included 14 studies ( 10 retrospective and 4 prospective ) with 448 patients who undergo 2-, 3-, and 4-part fracture management with intramedullary fixation. The authors reported an overall entail Constant score after nail fixation of 72.8 with an ASES score of 84.3. constant score for 2- and 3-part fractures was importantly higher than 4-part fractures. additionally, final postoperative range of motion was significantly better for 2- and 3-part fractures compared to 4-part fractures. The most common complication reported in the systematic follow-up was junior-grade personnel casualty of decrease in 24 % of patients, followed by malunion at 21 %. The reoperation rate for 2- or 3-part fractures was 13.6–17.4 %, compared to 63.2 % for 4-part fractures ; however, alone 19 patients with 4-part fractures were included in this review. The authors concluded intramedullary obsession for 2- and 3-part proximal humeral fractures yields satisfactory clinical outcomes ; however, nail fixation for 4-part fractures could not be recommended without far clinical investigations ( 4 ) .
Lin reported on a series of 22 patients with displace 3-part proximal humerus fractures undergoing pinpoint. The generator reported 100 % union rate, but besides included a 27 % complication rate, including 2 patients with avascular necrosis ( 8 ). Cuny et alabama. reported results from a case series consisting of 67 patients, demonstrating a weigh Constant score for 2- and 3-part fractures at 84 % and 95 %. articular 4-part fractures treated with intramedullary arrested development had changeless scores of 84 % for valgus impacted, but only 67 % for complex disengaged fractures with an associate 67 % complicatedness rate. ultimately, the authors recommended intramedullary fixation as a surgical option for patients with extraarticular or valgus-impacted articular fractures, but arthroplasty should be considered for displace articular 4-part fractures ( 9 ) .
Kloub et alabama. retrospectively evaluated 125 patients who underwent intramedullary arrested development for 3- or 4-part fractures at an modal of 57 months postoperatively. This cohort included 14 fracture dislocations. The authors reported a final adjusted changeless score of 85 % in 3-part fractures, 73 % in 4-part fractures including 70 % in 4-part fracture dislocations. No nonunions were identified ; however, 17 cases of humeral head necrosis were noted with 82 % of these occurring in the 4-part fault cohort. The authors concluded that complete is appropriate for all proximal humeral fault types ; however, the choice of reduction is crucial and has a solid charm on incidence of postoperative avascular necrosis. If acceptable reduction can not be achieved, then definitive discussion strategy should be reassessed ( 10 ) .
When compared directly to plate fixation, intramedullary collar for 3- and 4- depart fractures demonstrate fairly like outcomes. Boudard et alabama. retrospectively evaluated 63 patients treated for 3- or 4-part proximal humerus fractures, finding no difference between intramedullary obsession or plate fixation in attentiveness to quality of reduction or running scores, although there were three infections in the plate group and none in the intramedullary group ( 11 ). Gadea et aluminum. retrospectively looked at lock plating or intramedullary smash in 4-part proximal humerus fractures in 107 patients. The authors reported no significant remainder between groups in terms of ceaseless score, rate of poor outcomes, status of head bring around, pace of anatomic tuberosity heal, and complication rate ; however, the reoperation rate was 30 % in the plate group and 11 % in the intramedullary collar group. The authors reported that the presence of a displace medial hinge fracture pattern did importantly worse with breeze through obsession ( 12 ). however, Kloub et aluminum. recently published on 40 patients with preempt 4-part proximal humerus fractures treated with intramedullary obsession reporting an AVN rate of 17 %, with 12 patients undergo reoperation. Of the patients not developing AVN, the constant score was 73 % with the authors concluding intramedullary nail is a feasible discussion option for displace 4-part fractures with outcomes exchangeable to plate arrested development for these unmanageable fractures ( 13 ). ultimately, clinical outcomes following lock in plate or intramedullary arrested development for 2- or 3-part proximal humerus fractures do not appear to demonstrate any definitive differences between intramedullary nail down or plate fixation ( 11, 14, 15 ). Four-part proximal humerus fractures continue to present a ambitious fracture pattern to manage with any type of fixation and tend to have worse outcomes regardless of arrested development method acting ( 4, 8 ) .


As a resultant role of improved nail purpose and the ability to preserve fracture web site vascularity to promote curative, indications for collar fixation in proximal humerus fractures has expanded to include fractures with tuberosity fracture segments ( 3- and 4-part fractures ). meticulous attention to radiographic visualize is critical for accurate complete placement, avoiding the rotator cuff footprint, and anatomic tuberosity arrested development. In general, published reports tend to support smash arrested development as having equivalent outcomes to plate fixation with a relatively low complication rate .


financing : none .
Conflicts of sake : All authors have completed the ICMJE undifferentiated disclosure form ( available at hypertext transfer protocol : // ). BWS reports personal fees from Wright Medical Technologies, Inc., outside the put in work. GEG reports personal fees from DJO, personal fees from Mitek, personal fees from Wright-Tornier, other from american Shoulder and Elbow Surgeon, other from Arthrex, other from Genesys, early from Journal of Shoulder and Elbow Surgery, other from South Tech, other from Techniques in Orthopaedics, other from Zimmer, personal fees from Bioventus, early from ROM 3, grants from NIH, from OREF, outside the take knead. PB reports personal fees and other from Wright Medical Technologies, Inc., outside the relegate work. In addition, PB has a patent Aequalis IM Nail with royalties paid. AMH reports personal fees and early from Wright Medical Technologies, Inc., outside the submit work. In addition, AMH has a apparent Aequalis IM Nail with royalties paid. PSJ has no conflicts of interest to declare.

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open Access statement : This is an open Access article distributed in accordance with the creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License ( CC BY-NC-ND 4.0 ), which permits the non-commercial reproduction and distribution of the article with the rigid provision that no changes or edits are made and the original work is by rights cited ( including links to both the formal publication through the relevant DOI and the license ). See : hypertext transfer protocol : // .


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department of the interior : 10.21037/aoj.2020.02.10
Cite this article as: Sears BW, Johnston PS, Garrigues GE, Boileau P, Hatzidakis AM. Intramedullary breeze through of the proximal humerus—not good for 2-part fractures. Ann joint 2020 ; 5:32 .

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