(iii) Intramedullary ﬁxation
for fractures of the proximal
Fractures of the proximal humerus are extremely common. While there is
as yet no consensus regarding surgical management, this article dis-
cusses the rationale behind nailing and details the authors’ technique.
Keywords fracture; humeral nail; intramedullary; proximal humerus
Proximal humerus fractures are very common, accounting for
5% of all fractures and they are the third most frequent fracture
in the elderly.
The incidence increases exponentially after the
ﬁfth decade of life, and is almost twice as high in females in this
87% are caused by a fall from standing height.
mechanisms include a direct blow to the proximal humerus,
electrical shock, and convulsions.
In the younger patient they
result from high-energy trauma. Proximal humeral fractures have
a signiﬁcant impact on the patient’s quality of life, which is
particularly important in elderly patients who often become
partially or wholly dependant upon others for activities of daily
living. With ever increasing life expectancies in the developed
world, the incidence of proximal humeral fractures is likely to
continue to rise and consequently so will the medical and social
burden of managing them.
The vast majority of proximal humeral fractures are either
undisplaced or minimally displaced and can be managed non-
operatively with satisfactory long-term outcomes. However,
surgical intervention is usually necessary for displaced fractures
if a favourable outcome is to be achieved.
include intramedullary nailing, plate ﬁxation, tension-band
wiring, Kirschner wires and hemi-arthroplasty. All are associated
with a high incidence of complications
and no single
method has been shown to be superior.
The controversy over
implant choice and the high complication rate are both related to
a number of important challenges encountered in the manage-
ment of these difﬁcult fractures.
There are several problems associated with the management of
displaced proximal humerus fractures
!Poor bone stock in elderly patients which makes ﬁxation
!Displacement of the tuberosities by the action of the rota-
!Comminution and consequent technical difﬁculty.
!Secondary avascular necrosis.
!Post-traumatic and post-surgical stiffness.
General surgical principles
Surgical treatment aims to achieve stable anatomical reduction
thus permitting early mobilisation and pain-free function with
sound bony union. Such an outcome is dependant on many sur-
gical and patient factors. Surgical factors include choice of implant,
meticulous technique and the experience of the surgeon. Patient
factors include age, bone quality, fracture conﬁguration, general
health, functional requirements, compliance and motivation.
To achieve a successful outcome requires meticulous surgical
technique, minimal soft-tissue disruption, anatomical reduction
and rigid ﬁxation with the minimum of implants. In some cases
perfect anatomical ﬁxation may have to be sacriﬁced for stability.
The operating surgeon should be aware of the various techniques
available, and choose the one appropriate for the individual pa-
tient and the pattern of the fracture. In this article the authors
have described their rationale and technique for intramedullary
While reports of intramedullary nailing in the literature are
we believe that with good surgical technique, it
is possible to reduce the incidence of the commonly reported
complications which include:
!non- or mal-union
The main advantage intramedullary ﬁxation is a closed
reduction and consequent minimal disruption of the soft-tissue
envelope. The small incision makes for less damage to the blood
supply and a shorter operation time
than other techniques.
Other advantages include rigid angular-stable ﬁxation, and,
compared with plate ﬁxation, the biomechanical advantages of a
shorter lever arm as well as higher stiffness values in bending
and torsional load.
Authors recommended surgical technique
While there are many commercially available intramedullary
nails their concepts for use and surgical techniques are similar.
Merzesh Magra MBBS MRCS SpR Trauma and Orthopaedic Surgery,
Mid-Yorkshire NHS Trust, Pinderﬁelds Hospital, Wakeﬁeld, UK. Conﬂict
of interest: none.
Caroline Witney-Lagen MBBS MRCS SpR Trauma and Orthopaedic
Surgery, Mid-Yorkshire NHS Trust, Pinderﬁelds Hospital, UK. Conﬂict of
Balachandran Venkateswaran MS (Orth) FRCS (Tr&Orth) Consultant
Orthopaedic and Trauma Surgeon, Honorary Senior Lecturer, University
of Leeds, Mid-Yorkshire Hospitals NHS Trust, Pinderﬁelds Hospital, UK.
Conﬂict of interest: none.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 144 !2013 Elsevier Ltd. All rights reserved.
Our personal preference is currently the Stryker"T2 proximal
humeral nail (T2-PHN).
The operation is carried out under general anaesthetic sup-
plemented with an interscalene brachial plexus block, which
makes for lighter anaesthesia and improves post-operative pain
control. Intravenous prophylactic antibiotics are administered.
The patient is positioned in the beach chair position on a
radiolucent operating table with their head turned to face away
from the operative side. This ensures optimal unrestricted access
to the shoulder. Before skin preparation and draping it is
important to correctly position the image intensiﬁer on the
opposite side of the table to the operating surgeon. Then under
ﬂuoroscopic control closed reduction of the fracture is attempted
by adducting the arm, and supinating the forearm while applying
longitudinal traction. This manoeuvre usually reduces the frac-
ture into an acceptable position, even in cases with severely
Using a marker pen the surface anatomy of the anterior and
posterior acromion are delineated. Our preference is for the
anterolateral Mackenzie approach to the proximal humerus
(Figure 1), which utilizes a relatively avascular plane, away from
the anterior and posterior circumﬂex humeral arteries. The
incision is deltoid-splitting and extends from the anterior border
of the acromion, parallel to the anatomic axis of the humerus.
The length of incision varies according to the complexity of the
fracture but should not usually be longer than 5 cm to avoid
damage to the anterior motor branch of the axillary nerve. If it is
necessary to extend the incision, the axillary nerve should be
identiﬁed, dissected free and protected. We do not wash the
fracture site with saline in order to preserve biology and any
fracture haematoma is preserved and if removed is retained and
reapplied at the end of the procedure.
It is important to restore the anatomical neck/shaft angle and
the medial buttress.
Restoring and maintaining the medial
buttress and soft-tissue attachments is essential to preserve the
vascularity in addition to conferring mechanical strength. In
three- and four part fractures it is of paramount importance to
accurately reduce the tuberosities.
Lack of soft-tissue
attachment to the head, especially in a four part fracture, may
preclude ﬁxation and such cases may be better managed by
We recommend the use of grafted bank bone chips to support
the medial buttress and the head fragment before suturing the
tuberosities. The graft is compacted and tightly packed ensuring
anatomical head alignment and support to the medial buttress. In
two part fractures bone graft is usually not necessary unless there
is medial comminution.
The tuberosities with their rotator cuff tendon attachments
[Figures 2 and 3] are reduced by traction on number 5 Ethibond
(Ethicon", Johnson & Johnson Medical Ltd) To minimize the
risk of impingement, care must be taken bring the greater tu-
berosity fragment inferior to the articular surface of the humeral
head. When both tuberosities have been reduced the sutures are
tied to each other. This restores proximal humeral anatomy and
in essence converts three or four part fractures into a two part
fracture before nail insertion (Figure 4).
Figure 1 Anterolateral Mackenzie approach.
Figure 2 Displaced 4 part proximal humerus fracture.
Figure 3 Tuberosities sutured.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 145 !2013 Elsevier Ltd. All rights reserved.
The ideal entry point for guide pin insertion is usually on the
highest point of the articular surface just medial to the sulcus of
the greater tuberosity in line with the humeral anatomical axis
and between 1 and 1.5 cm behind the biceps tendon. The entry
point is exposed using a 1 cm longitudinal incision into supra-
spinatus in the same orientation as its muscle ﬁbres. This mini-
mal approach through well vascularized tissue minimizes rotator
cuff damage. The proximal entry reamer is then introduced over
the guide pin followed by the selected nail which is inserted into
the medullary canal over the guide pin using gentle rotatory force
directed caudally. If initial passage of the nail is tight, hand-held
reamers are used to minimize the risk of iatrogenic fracture. The
nail is inserted to the desired level under ﬂuoroscopic control.
Achieving an anatomic neck-shaft angle is extremely impor-
tant. Varus mal-reduction is associated with a particularly poor
Thus it is particularly important to maintain the
anatomic neck-shaft angle of approximately 135 degrees.
During nail insertion the acromion can sometimes lateralize the
nail along with the head fragment relative to the shaft. To pre-
vent this, the arm is extended with traction to allow un-impeded
passage of the nail. It is extremely important to sink the proximal
end of the nail 3e4 mm below the greater tuberosity to prevent
the common complication of sub-acromial impingement.
Proximal locking is performed using the radiolucent proximal
locking jig (Figure 5). We regard three screws as the minimum
acceptable but prefer to use all four locking screws. It is impor-
tant to conﬁrm the screw length under ﬂuoroscopic control as
overly long screws can result in intra-articular joint penetration.
Burying the screws beyond the lateral outer cortex is not desir-
able, because they can be difﬁcult to retrieve if nail removal is
clinically indicated at a later date. Thus screws should be
measured from the lateral cortex to a point 5 mm from the
articular surface of the humeral head (Figure 6).
The nail is locked distally in dynamic mode using the jig. This
prevents migration of the implant but allows a few millimetres of
collapse. Then the tuberosity fragments, which have already
been reduced and tied to each other, can be reinforced with
further stitches through drill holes or by using the screw heads of
the proximal locking screws. Reinforcement helps minimize the
incidence of tuberosity displacement secondary to the pull of the
rotator cuff muscles. Any previously saved fracture haematoma
is then placed around the fracture site as we believe that any
contained cells cytokines and growth factors etc. may help to
reduce time to union and reduce the risk of non-union. Finally
ﬂuoroscopic screening is performed to assess dynamic fracture
reduction and stability. This also has the advantage of conﬁrming
appropriate screw length and demonstrating that all humeral
head screws are 5 mm away from the articular surface. During
the wound closure the rotator cuff and deltoid are repaired.
Initially the shoulder should be immobilized in internal rotation
using a shoulder immobilizer for one week. However, after the
ﬁrst 24 h the patient is permitted to remove their arm from the
Figure 4 Fracture reduction.
Figure 5 Locking jig.
Figure 6 Final position of nail with reduced fracture.
MINI-SYMPOSIUM: PROXIMAL HUMERAL FRACTURES
ORTHOPAEDICS AND TRAUMA 27:3 146 !2013 Elsevier Ltd. All rights reserved.
immobilizer to perform gentle pendular exercises as tolerated.
After one week passive assisted range-of-motion exercises are
commenced followed after three weeks by active assisted exer-
cises under physiotherapeutic supervision. In our post-operative
regime there is no restriction on the range of movement but
forced stretches are only permitted after six weeks. By six to eight
weeks there is often excellent radiographic and clinical evidence
of fracture healing.
Summary of operative principles
!Small superior deltoid-splitting approach permitting good
access but preserving blood supply
!Bone grafting to the medial buttress and head
!Anatomical reduction of the tuberosities and their rotator
cuff attachments prior to nail insertion
!Recessing the proximal end of the nail to preclude
!Restoration of the anatomical neck/shaft angle avoiding
valgus or varus mal-reduction
!Use of four proximal locking screws 5 m short of the
!Early post-operative mobilisation
Proximal humerus fractures are an orthopaedic conundrum.
They are difﬁcult to evaluate and treat and currently there is no
consensus regarding their management
which has been
largely based on individual opinions and expertise. However,
there is general agreement that in younger patients with good
bone stock and high functional demand, all efforts should be
made to preserve the humeral head and ﬁx the fracture.
There have been a number of papers reporting the results of
proximal humeral nailing in relatively small patient numbers.
These have shown very varied results.
We have previously
reported our results using the Stryker T2-PHN in a series of 61
We achieved a mean Constant Murley score of 64.9
and a mean Oxford Shoulder Score of 21.7. This is broadly in line
with other smaller series using the T2-PHN,
with the results achieved using other nails
and with plate
We found that statistically signiﬁcantly better
results occurred in patients aged under seventy years, in 2- and
3-part fractures, in patients without medial metaphyseal
comminution and in patients with a neutral post-operative neck-
Our re-operation and complication rates were better than most
reported in the literature for both nails and plates. While the
surgeon cannot inﬂuence patient factors such as age and fracture
conﬁguration, good surgical technique can help to avoid com-
In our early cohort of patients our most common complications
were impingement, followed by tuberosity non-union or mal-
union. Simple technique modiﬁcation to ensure that the prox-
imal nail end was buried below the cortex reduced the rate of
impingement, and robust ﬁxation of the tuberosities using number
5 Ethibond reduced tuberosity non-union and mal-union. Careful
attention to screw length and ensuring that they are 5 mm short of
the articular surface reduces the risk of intra-articular screw
penetration whilst ensuring adequate bone-purchase.
We have previously shown that a poorer prognosis is associ-
ated with medial metaphyseal comminution.
support is also known to be important in maintenance of reduction
following plate ﬁxation.
Therefore it is logical that reconstruc-
tion of the medial column using bone-grafting will help to reduce
the risks associated with loss of medial column support. Finally
achievement of a neutral post-operative nail alignment is partic-
ularly important. Varus mal-reduction decreases the lever arm of
the rotator cuff resulting in higher stresses and increased likeli-
hood of failure.
The importance of post-operative alignment was
also evidenced by our personal experience with no complications
in our 21 patients with neutral alignment compared to complica-
tions in 14 of our 18 varus malalignment patients ( p<0.001).
Studies of humeral nailing studies have reported violation of
the rotator cuff during nail entry to be associated with post-
operative shoulder pain.
Using a medial entry point
through the articular surface of the humerus has the potential to
cause less pain.
In our experience patients suffering from continuing post-
operative pain usually respond favourably to removal of the
ﬁxation after union.
Intramedullary nails allow proximal humeral fractures to be
reduced and ﬁxed through small incisions with minimal soft-
tissue disruption, preservation of humeral head periosteal
blood supply, reduced intra-operative blood loss and reduced
Angular-stable locking nails offer a high degree
of stability, even in osteoporotic bone, permitting early mobili-
zation leading to favourable clinical outcomes.
nails have biomechanical advantages over plates including a
shorter lever arm and improved stiffness values under bending
and torsional load.
Thus we believe that intramedullary nailing, in combination
with suturing of the tuberosities, provides stable ﬁxation whilst
achieving minimal disruption of the soft-tissue envelope and
preservation of the periosteal blood supply. This permits early
motion, rehabilitation and return to function. They are not uni-
versally applicable and in elderly patients with head-splitting
injuries, severe comminution or limited functional goals, early
hemi-arthroplasty should be considered. A
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