Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing

• Published in: Journal of shoulder and elbow surgery Vol. 28; no. 2; pp. 276 - 287
• Main Authors: Boileau, Pascal, d’Ollonne, Thomas, Bessière, Charles, Wilson, Adam, Clavert, Philippe, Hatzidakis, Armodios M., Chelli, Mikael
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2019; Elsevier
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Bone Nails; Female; Follow-Up Studies; Fracture Fixation, Intramedullary - adverse effects; Fracture Fixation, Intramedullary - instrumentation; Fracture Fixation, Intramedullary - methods; Fracture Healing; Human health and pathology; Humans; intramedullary (IM) locking nail; Life Sciences; Male; Middle Aged; proximal humeral fracture; proximal humeral nail; Range of Motion, Articular; Retrospective Studies; Shoulder Fractures - classification; Shoulder Fractures - diagnostic imaging; Shoulder Fractures - physiopathology; Shoulder Fractures - surgery; Surgery; surgical neck fractures; third-generation humeral nail; Treatment Outcome; Two-part fractures; Young Adult; Treatment Study; proximal humeral nail; third-generation humeral nail; Level IV; surgical neck fractures; proximal humeral fracture; Case Series; intramedullary (IM) locking nail; Two-part fractures
• ISSN: 1058-2746; 1532-6500
• DOI: 10.1016/j.jse.2018.07.010

The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression (“back-slap” hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.