Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review

Background

While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.

Materials and methods

Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.

Results

Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.

Conclusions

Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.

Level of evidence

Level IV, Systematic review.

Modern perspectives of open reduction and plate fixation of proximal humerus fractures

Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.

Locked antegrade intramedullary nailing of humeral shaft fractures

This paper reports the results of treating 35 humeral shaft fractures with antegrade nailing in patients between the ages of 25 and 92 (mean 64.5): 14 patients were aged between 25 and 59, and 21 between 66 and 92. The nail was set in place proximally with a spiral blade and distally with 1 or 2 screws. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN). The latter technique uses a guide wire which, in cases of an error in the length of the nail, is useful in that it allows another nail to be set in place. Main outcome parameters were fracture healing, shoulder discomfort, and radial nerve recovery. The DASH functional scoring system, modified according to Beaton et al. for subjective assessment was used, and range of motion was checked with the constant score. X-rays were used to assess fracture healing time and cases of malunion. Two patients developed non-union, one caused by a UHN which was too short, and the other by a nail blocked distally by a single screw. In 7 patients, consolidation was achieved, but with varus between 3 and 8 degrees (mean 5 degrees), without aesthetic or functional damage. In 33 out of 35 patients, shoulder functionality had mean DASH score results of 21.9, whereas shoulder range of motion reached a mean constant score (CS) of 26.5 (78.8%) with respect to the opposite shoulder. In 5 cases of stiffness, the UHN turned out to be insufficiently buried. Results improved with the CHN. Much better results were seen in the group of patients aged between 25 and 59 (mean age 43), but worse in older ones (66-92 years, mean age 78). Radial nerve palsy after surgery occurred in 2 cases, and the nerve was immediately examined. It did not appear to be trapped in the fracture in either case, and recovery was complete 6 months later. CHN appears to be a valid solution, both in younger patients, thanks to excellent results, and in older ones, who have fewer functional requirements.

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.