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Current Reviews in Musculoskeletal Medicine logoLink to Current Reviews in Musculoskeletal Medicine
. 2023 Jan 10;16(2):85–94. doi: 10.1007/s12178-022-09816-w

The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not

Natalia Martinez-Catalan 1,✉, Pascal Boileau 2
PMCID: PMC9889584  PMID: 36626085

Abstract

Purpose of Review

The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing.

Recent Findings

According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement.

Summary

Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.

Keywords: Intramedullary nailing, Proximal humerus fracture, Treatment, Greater tuberosity, Complications, Reduction

Introduction

The role of intramedullary nailing for proximal humerus fractures (PHFs) has recently regained some interest due to improvements in nail designs, which have dramatically decreased the rate of complications and reoperations reported with 1st and 2nd generation of intramedullary nails (IMNs). However, to avoid complications, it is not enough to improve nails’ features. Equally important are a correct treatment indication, adequate implant selection, and satisfactory surgical technique. The aim of this review article is to provide some clarity regarding what works and what does not in PHFs treated with intramedullary nailing.

When Should Proximal Humerus Fractures Be Considered for Surgery?

In general, surgery should be considered (1) for PHFs in which the head is severely compromised due to fracture-dislocation, severe impaction, or a division (split) of the head itself (Fig. 1a), (2) for non-impacted fractures with gross instability between the humeral shaft and humeral head (Fig. 1b), and/or (3) in those in which tuberosities are severely displaced, especially the greater tuberosity (GT) (Fig. 1c) [1, 2].

Fig. 1.

Fig. 1

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3D reconstruction of fracture-dislocation (a), displaced varus posteromedial (VPM)–impacted fracture (b), displaced VPM fracture with associated greater tuberosity fracture displaced medially and posteriorly (c–d)

In the treatment of PHFs, it is important to avoid underestimation of GT displacement for 3 reasons: (1) the GT serves as a guide to achieve a correct reduction of the humeral head and (2) contributes to revascularization of the head and (3) site of attachment of the posterosuperior rotator cuff [2, 3].

Additionally, patient age, anticipated demands, and comorbidities should be taken into consideration when evaluating proximal humerus fractures. Low-demanding patients may accommodate some functional restrictions while patients who live at home and are independent in their activities of daily living might well become socially dependent after a fracture by functional restrictions or chronic pain [4].

For Surgical Fractures, Internal Fixation or Arthroplasty?

Inappropriate estimation of the risk of avascular necrosis (AVN) after a PHF may lead to an inadequate selection of the surgical treatment modality [5]. If all 4-part PHFs are believed to develop osteonecrosis, surgeons may erroneously recommend shoulder hemiarthroplasty for displaced fractures in young patients. On the contrary, if surgeons try to fix complex fracture-dislocations when there is little probability of head fragment survival, there will be an increased risk of complications due to humeral head necrosis. In general, internal fixation should be avoided in cases of head-splitting and comminuted displaced humeral head fragment devoid of soft tissue attachments [2].

When Internal Fixation Is Considered, Which Device for Which Fracture?

Although no stabilization device for PHF fixation has demonstrated superiority yet, most experts agree that the goal of any internal fixation device should be to achieve stable fixation with minimum soft tissue disruption. Compared to plate fixation, the use of intramedullary nails provides adequate stability requiring minimum soft tissue dissection and even more, in some simple fractures, the surgery can be performed percutaneously [3].

Several nail designs have been used over time to treat PHFs. First-generation nailing included straight nails, with large diameter and without self-locking screws. The absence of locking mechanism led to loss of reduction and malunion. Second-generation humeral nails included proximal locking screws; however, due to their curved design, they penetrated the supraspinatus insertion on the greater tuberosity leading to iatrogenic supraspinatus tears. Nolan et al. [6] using the Polarus nail reported a 94% healing rate, but a 50% malunion rate due to loss of fixation during the healing process. They concluded that this nail damages the rotator cuff and it is not resistant enough to avoid loss of reduction and varus collapse, because due to it being curved, it is forced to enter more lateral in the humerus where the subchondral bone is not as dense as in a more medial position.

Most modern implants, the so-called third-generation nails (Stryker T2 Proximal Humeral Nail (Stryker, Kalamazoo, MI, USA), Synthes MultiLock Proximal Humeral Nail (MultiLoc PHN; Synthes GmbH, Solothurn, Switzerland), Trigen Humeral Nail (Smith and Nephew, Memphis, USA), Aequalis Proximal Humeral Nail (Tornier, Bloomington, MN, USA), were designed to avoid complications reported with previous generations of nails and they are the most widely nail implants used nowadays. They are short and straight with a small diameter which facilitates entry through the muscular part of the supraspinatus into the humeral head. Moreover, they provide technological advantages allowing for proximal angular stable constructs: nylon or polyethylene bushings or threaded holes to secure interlocking screws, locking spiral blades to increase the bone-implant interface, screw-in-screw technologies, blunt screw tips to avoid intra-articular penetration, more divergent screws for tuberosity fixation, holes for suture fixation, or countersunk screwheads to reduce acromial contact.

Most existing nail designs focus on humeral head fixation, whereas, in our opinion, the challenge is reducing and fixing both tuberosities, most importantly the GT. Malreduction of GT in 3-part and 4-part fractures has been associated with an increased risk of complications, including avascular necrosis [7, 8•, 9]. Humeral head-oriented proximal screws may cause glenoid cartilage damage in cases of humeral head necrosis, as has been reported with the use of locking plates (Fig. 2a, b) [10–12]. The use of tuberosities-oriented proximal screws (Aequalis Proximal Humeral Nail) provides strong stabilization for the tuberosities and decreases the risk of glenoid erosion in case of head necrosis (Fig. 2c).

Fig. 2.

Fig. 2

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Anteroposterior radiograph of humeral head necrosis and screw penetration after IMN fixation (a) and plate fixation (b). Axial view of CT scan showing tuberosities-oriented proximal screws (c)

How Can Outcomes Be Optimized when Performing Intramedullary Nail Fixation of Proximal Humerus Fractures?

To maximize outcomes with IMN fixation in PHFs, it is important (1) to understand the fracture pattern and fragment displacement, (2) to vary the surgical technique according to the type of fracture to reach anatomic reduction and stable fixation, and (3) to avoid postoperative immobilization in internal rotation.

Understanding of Fracture Pattern and Fragment Displacement

All PHFs should be evaluated using standard radiographs consisting of an anteroposterior (AP) view and a lateral Y view. Three-dimensional CT scan images are useful to understand fracture displacement and to plan surgery.

Each pattern of fracture has its own pathophysiology and complications. However, despite the variety of fracture patterns, the muscle deforming forces cause a predictable displacement of the 4 major fragments (“the 4-segment concept”) [13]. Furthermore, not all fracture fragments are equal: while some degree of diaphysis translation is acceptable, GT displacement (superiorly or posteriorly) must be corrected.

Fragment Displacement in Fractures with Intact Tuberosities [1, 14•]

  • Surgical neck (SN) fractures. The head is oriented to the glenoid, due to the balance between internal and external rotator muscles. When displaced, the shaft is translated medially (due to pectoralis major, latissimus dorsi, and teres major) (Fig. 3a, b).

  • Valgus-impacted fractures. The head is facing superiorly to some extent due to comminution of the lateral side of the humerus. When displaced, the humeral shaft displaces medially (Fig. 3c).

  • Varus posteromedial fractures. The humeral head faces posteriorly and inferiorly and the diaphysis translates laterally (Fig. 3d).

Fig. 3.

Fig. 3

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3D reconstruction of surgical neck fracture with associated anteriorly displaced humeral shaft (a, b), valgus-impacted fracture with associated GT fracture (c), and varus-impacted fracture with associated GT fracture (d)

Fragments’ Displacement in Fractures with Involvement of One or Both Tuberosities

In fractures presenting displaced GT, the GT is typically translated posterior and medial by the infraspinatus and teres minor (Fig. 4a–b).

Fig. 4.

Fig. 4

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3D reconstruction of varus fracture with associated GT fracture displaced posteriorly and medially (a). axial view of CT scan showing GT fracture displaced posteriorly and medially (b). 3D reconstruction of valgus fracture with associated GT and LT fractures displaced posteriorly and anteriorly, respectively (c). axial view of CT scan showing GT and LT fractures displaced posteriorly and anteriorly, respectively (d)

The main vertical fracture plane typically locates posterior to the bicipital groove and both tuberosities are separated in the transverse plane due to the pull of subscapularis and external rotator muscles attached at the tuberosities. The GT is pulled posteromedially, whereas the LT is pulled anteromedially by the subscapularis (Fig. 4c).

In fractures with tuberosity involvement, humeral head stabilization is achieved when tuberosities are reduced and fixed. The main goal of operative treatment must be to derotate the head fragment and reach anatomic reduction of the tuberosities, especially the GT. Loss of reduction of the GT may lead to retraction and atrophy of external rotator muscles which may result in definitive pseudoparalyzed and stiff shoulder [3].

Variation of the Surgical Technique Accordingly the Fracture Type

Positioning: Confirm Adequate Fluoroscopic Visualization of Fracture and Humeral Shaft

The patient can be positioned either in beach chair or in supine (“lazy lateral”) position. Adequate patient positioning is essential to achieve correct visualization, fracture reduction, and nail entry point. In the “lazy lateral” position, the C-arm enters perpendicular to the patient axis (Fig. 5a), while in the beach chair position, it enters parallel to the body of the patient (Fig. 5b).

Fig. 5.

Fig. 5

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Patient position: “lazy lateral” position (a) and beach chair position (b)

Surgical Approach

Depending on the type of fracture and the surgeon’s preference, three surgical approaches can be used:

  • Percutaneous approach. It is used most frequently for fractures without tuberosity involvement not requiring tuberosity fixation [14•]. We systematically use a percutaneous approach, through the Neviaser portal (Fig. 6a), located posterior to the AC joint as it has many advantages: it is entering the supraspinatus medially through its muscle fibers (avoiding iatrogenic tear) and allows reaching easily the starting point in the articular cartilage (Fig. 6b).

  • Superior transdeltoid or deltoid-splitting approach. It is indicated most often when tuberosities are involved. The split is performed between the anterior and middle deltoid in line with the acromion (Fig. 7a). The extension down of this interval should be limited to 4 cm to avoid iatrogenic damage of the axillary nerve. This approach does not violate any of the fracture fragments’ blood supply, and it facilitates the reduction and fixation of the GT fragment (Fig. 7b). Detachment of the anterior deltoid must be meticulously repaired, as deltoid deficiency, either from detachments or loss of innervation, is a “surgical disaster” with few solutions.

  • Deltopectoral approach. It is especially useful for anteroinferior fracture-dislocations, where access to the dislocated head for removal underneath the conjoined tendon is more safely achieved working through the deltopectoral interval.

Fig. 6.

Fig. 6

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Percutaneous approach through the Neviaser portal posterior to the acromioclavicular joint (a). Anteroposterior radiograph of nail entry point through the Neviaser portal (b)

Fig. 7.

Fig. 7

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Superior transdeltoid or deltoid-splitting approach. Vertical 4-cm incision starting at the anterolateral corner of the acromion (a). The superior transdeltoid approach facilitated the reduction and fixation of the GT fragment (b)

Fracture Reduction

Fracture reduction is the key point in proximal humerus fractures because treatment success depends on accurate reduction; in those cases in which fracture reduction is satisfactory, good outcomes can be expected independent of the fracture pattern [15].

Fractures may be reduced by manipulating the arm and using traction sutures in the rotator cuff, Steinmann pins, Kirschner wires, or an elevator introduced percutaneously if needed.

For surgical neck fractures with no head malalignment, the shaft is aligned with the humeral head using traction and rotation and by applying a posteriorly directed force onto the shaft. When the humeral head is in the varus or valgus, it needs to be aligned properly. This can be done by using the nail as a joystick to facilitate fracture reduction.

For fractures involving both tuberosities, it is necessary to reduce the head and tuberosities before nail insertion. This can be done percutaneously using Steinmann pins or Kirschner wires or by introducing an elevator (Fig. 8). When the open approach is selected, traction sutures are placed around the bone tendon junction to manipulate displaced tuberosities and provide temporary stabilization.

Fig. 8.

Fig. 8

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Percutaneous fracture reduction introducing an elevator

Nail Entry Point

Once the fracture has been reduced, the nail entry point is determined under fluoroscopic visualization. The nail is inserted in the superolateral part of humeral cartilage, through the supraspinatus muscle or the rotator interval (Fig. 9) [16]. This part of the cartilage does not contact with the glenoid, so it will not lead to clinical symptoms [14•]. When the nail is inserted in a more lateral position (at the level of the greater tuberosity), there is a greater risk of cuff tears, iatrogenic GT fractures, varus malalignment, and loss of fixation [6, 17]. This has been reported with the use of second-generation nails due to their curve design.

Fig. 9.

Fig. 9

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Intraoperative radiograph of nail entry point in the lateral articular margin of the humeral head (a). Anteroposterior radiograph of intramedullary nail fixation using a medial nail entry point (b)

Lopiz et al. [17] published a prospective randomized study comparing 26 fractures stabilized with a straight humeral nail inserted through the articular surface (Multilock proximal humeral nail) and 26 fractures stabilized using a curvilinear one inserted at the articular surface-greater tuberosity junction (Polarus humeral nail) for PHFs treatment. Radiographic evidence of varus collapse (shaft angle <120°) was more frequent with curvilinear nails (20% vs 11.5%) as was the case for subacromial impingement (73% vs 35%). The proportion of good to excellent results was also higher with the straight nails (65%) compared with the curvilinear nails (46%). Mouccioli et al. [16] in a cohort of 40 displaced PHFs (23 proximal humeri and 17 humeral shafts) with a mean age of 60 years (20–89 years), using 3rd generation IMNs (34 Aequalis and 6 MultiLoc), reported good outcomes and low rate of supraspinatus tendon lesion (12.5%).

However, the entry point has to be not only medial but also optimized in the proximal fragment according to the type of fracture to avoid malreduction [1]. For valgus fractures, the nail must be inserted more lateral (Fig. 10a). In surgical neck fractures without head deformity, the entry point locates anterior to the acromion (Fig. 10b), whereas in varus-impacted fractures, the optimal entry point is more medial (Fig. 10c, d), typically anterior or posterior to the acromioclavicular joint (Neviaser portal). A lateral entry point in fractures with varus head deformity has been reported to increase the risk of loss of reduction and varus malunion [6, 16, 17].

Fig. 10.

Fig. 10

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Variation in nail entry point according to head deformity. Anteroposterior radiograph of valgus head deformity using a more lateral entry point (a). Fracture without head deformity in which entry point is located just anterior to the acromion (b). Varus head deformity using a more medial entry point (c). Three-dimensional computed tomography image showing different entry portals used to insert straight intramedullary nail (d). Portal A is used in the case of valgus deformity of the humeral head, portal B is used in the absence of head deformity with shaft translation, and portals C and D are used in the case of varus deformity of the humeral head. Portal D (Neviaser portal) is used in the case of combined varus and posterior tilt of the humeral head

Nail Height

Nail height is another aspect to take into consideration because if the nail is too high and protrudes it can lead to acromial impingement (Fig. 11a). Moreover, variations in nail height modify the position of proximal interlocking screws (Fig. 11b). This is particularly important for more deeply placed nails because axillary nerve can be damaged with lateral screws (posterolateral screws have little risk of nerve damage).

Fig. 11.

Fig. 11

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Nail height. Protrusion of the proximal end of the nail (a). Deeply placed nail (b)

Proximal Screw Fixation

Complications related to failure of proximal screws are the most common complications after nail fixation in PHFs. This is due to (1) deficient screw locking mechanism and (2) screw orientation.

The 1st generation of humeral nails lacked a locking mechanism for proximal screws which contributed to screw migration and failure of fracture fixation. With 2nd-generation nails, proximal interlocking screws were incorporated but did not allow angular stable constructs. A high rate of screw back out was reported with these nails, ranging between 4 and 26% [17]. On the contrary, 3rd generation of nails includes improvements in locking mechanisms allowing fixed angular stable constructs.

Poor screw orientation is another feature that may influence implant failure. Some authors suggest that proximal screws directed at those areas of the head with better bone quality (ascending calcar screws) can improve stability and reduce varus deformation, especially in elderly patients [15, 17, 18]. Additionally, proximal screws can be oriented to the humeral head or to the tuberosities. Tuberosity-oriented screws seem to be an advantage because they secure tuberosity fixation and, in case of avascular necrosis, do not penetrate the humeral head. The high rates of revision surgery associated with avascular necrosis are related to secondary intra-articular screw penetration and glenoid erosion, as happened with locked plates. In the absence of screw penetration, AVN is usually well tolerated and painless [19, 20]. Therefore, efforts should be directed toward tuberosity reduction and fixation.

Avoiding postoperative immobilization in internal rotation

Many surgeons typically immobilized the shoulder in internal rotation with the arm resting in the abdomen; however, this position places under tension the greater tuberosity and leads to potential rotational malunion of the humeral shaft. Thus, to optimize management, our preference is to place the shoulder in neutral rotation for 2 to 4 weeks after surgery. Since the first postoperative day, the patient is encouraged to perform active elbow exercises and shoulder pendulum exercises and to remove the sling to perform daily activities (eating, dressing, washing). After 2 weeks, rehabilitation is started based on assisted exercises of elevation and rotation and strengthening begins 6 weeks after surgery.

Results

When analyzing existing literature on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions because studies include different nail designs, different fracture patterns, and heterogenicity in patient age. However, despite high rates of complications reported with 1st and 2nd generation of nail designs, the literature seems to support the use of modern nail designs for the treatment of PHFs [21]. Outcomes seem to be better for more simple fractures, while the rate of complications increases with the complexity of the fracture.

In two-part fractures, rates of fracture healing range from 90 to 99%, with loss of reduction and varus malunion the most common complications. Most cases of loss of reduction in two-part fractures have been associated with malreduction or insufficient reduction at the time of the surgery, especially in varus-impacted fractures. Boileau et al. [14•], in a series of 41 two-part displaced surgical neck fractures, reported good clinical outcomes and low complications rate using third-generation nail (Aequalis, Tornier) and percutaneous approach. At the final follow-up, all fractures healed satisfactorily, with a mean forward elevation of 146°, mean ER of 50°, and mean Constant score (CS) of 71. They observed 1 partial avascular necrosis and 2 (5%) cases of malunion due to malreduction at the time of the surgery and lateral entry point. There were no cases of screw loosening or intra-articular screw penetration. Two patients (5%) underwent revision surgery due to impingement and stiffness. Muccioli et al. [16] in a group of 40 humeral fractures (17 shaft fractures, 17 two-part SN fractures, and 6 three-part fractures) treated with the same design of IMN reported 95% of healing rate with 2 cases of non-united shaft fractures. There was 1 tuberosity malunion and 6 cases showed persistent varus (3 cases because of insufficient fracture reduction and 3 cases presented secondary loss of reduction due to lateral entry point). After ultrasound analysis of rotator cuff integrity, they observed 12.5% of asymptomatic supraspinatus lesion. The rate of revision surgery was 7.5% with no cases of revision due to supraspinatus lesion. Rotman et al. [22] in a study of 25 two-part displaced PHFs treated with third-generation nail (MultiLoc) observed that 24% of patients presented a postoperative decrease in neck-shaft angle (NSA) of over 20°. However, functional outcomes were similar between patients with or without loss of fracture reduction. Recently, Lopiz et al. [24•] in a study of 32 PHFs with a mean age of 82 years (80 years or older) presenting mostly two-part (81%) and few three-part (19%) fractures treated with third-generation nail (MultiLoc) reported 15.6% of patients with less than 125° and 18.8% of revision surgery (five subacromial impingement mostly due to inadequate technique and one loss of reduction). In this elderly cohort of patients, the Constant score was satisfactory or excellent in all patients (mean CS of 70) and good perceived quality of life was reported (mean EQ-VAS of 64) despite limited ROM. They did not report any case of nonunion, AVN, or screw loosening.

On the contrary, in more complex fractures presenting displaced tuberosities fracture (3- and 4-part fractures), fracture malreduction has been associated with poor functional outcomes and high complication rate. Wong et al. [23] compiled available evidence about IM nail fixation in a meta-analysis including two-part, three-part, and four-part fractures. The nail device used most frequently was the Polarus nail in 36% of cases. Their reported results include a 99% healing rate, a mean VAS of 0.8 (with the majority of patients reporting no or mild pain), a mean elevation of 140°, a mean external rotation of 40°, and a frequency-weighted mean CS of 73. Nonetheless, the CS for two-part and three-part fractures was significantly higher compared to two-part fractures. The rate of complications was 42%, including loss of reduction (10%), intra-articular screw penetration (9%), malunion (9%), AVN (4%), and subacromial impingement (4%). However, the rate of complications varied between fracture patterns: for two-part and three-part fractures, the rates of complications were 33.6% and 57.8%, respectively, being fracture displacement/malunion as the most common complication. The rates of revision surgery for two-part, three-part, and four-part fractures were 13.6%, 17.4%, and 63.2%, respectively. Kloub et al. [9], in a prospective study of 35 four-part fractures treated with intramedullary nailing (Multiloc, Depuy), reported 57% complication rate. The most common complication was AVN reported in 26% of cases (17% complete AVN, 9% partial AVN), followed by GT resorption (14%) and loss of reduction (11%). The rate of revision procedure was 30%, with avascular necrosis being the most common cause (42%), followed by resorption of GT (25%) and loss of reduction (17%). Those cases with complete AVN presented worse outcomes and higher rates of revision surgery. Gadea et al. [7] performed a retrospective, comparative, and multicenter study of 107 four-part PHFs (54 cases of IMN and 53 cases of plate fixation). Several different IM nails were used. In the nail group, they reported 17% of avascular necrosis, 11% of intra-articular screw penetration, and 18% of revision surgery. Anatomical reduction of the humeral head was achieved in 57% of cases treated with IMN and in 58% of cases treated with locking plates. The rate of tuberosity healing in anatomical position was 72% in the nail group and 70% in the plate group. No differences were found between nail and plate fixation regarding functional outcomes and rate of complications although a higher revision rate was observed in patients treated with locking plates (30% vs 18%). Poor functional outcomes were observed in both groups in those cases in which the head was reduced in varus, malreduction of the tuberosities, and avascular necrosis.

The main problem with 3-part and 4-part fractures is that reduction is difficult and challenging, especially in patients with osteoporotic bone, in which tuberosities are usually comminuted. Fixation of a PHF with malreduction of the tuberosities increases the risk of loss of fixation, AVN, and secondary intra-articular screw penetration [7, 8]. In fact, the influence of fracture reduction in final results has been widely described in the literature and the majority of studies report worse outcomes in the presence of fracture malreduction or malunion [8, 15], independent of the type of fracture or type of fixation [12, 25]. Kloub et al. [8] analyzed 137 patients with 3-part and 4-part PHFs treated with nail fixation (Targon), and demonstrated satisfactory results if adequate fracture reduction is achieved. The relative Constant score (CSrel) deteriorated from 88% when reduction was excellent to 70% and 52% when fracture reduction was moderate and poor, respectively. Moreover, the rate of avascular necrosis rises up from 2% in those with anatomical reduction to 28% and 60% in those with moderate- and poor-quality fracture reduction, respectively. However, even in four-part fractures, satisfactory results can be expected with IMN if fracture is anatomically reduced. Greenberg et al. [15] in a series of 60 3-part and 4-part fractures treated with IMN (Targon PH nail) reported 88% of healing rate and 12% of complications; three fractures healed in varus malposition or presented displaced GT, one case of implant failure, and 3 fractures developed avascular necrosis. Three patients (5%) required revision surgery.

In addition to the pattern of fracture, another aspect to consider when analyzing complications of nail fixation is the nail design (straight or curved). Stedtfeld et al. [26] observed that the presence of a bone ring around the nail is essential to prevent secondary fracture displacement, especially in varus. This is easier when the nail enters the medial into the cartilage where there is dense subchondral bone. This condition is very difficult to achieve with curved nails that required a lateral entry point.

Conclusions

IM nail fixation for fractures without tuberosity involvement is satisfactory in the vast majority of fractures. In fractures with tuberosity involvement, the ultimate outcome is influenced substantially by the quality of fracture reduction. Tuberosity malreduction leads to poor clinical outcomes, higher rate of complications, and AVN. Humeral head malreduction increases the rate of postoperative loss of fixation, especially in varus posteromedial–impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves cuff tendon, and avoids iatrogenic fractures of the GT. Stable fracture fixation enables early mobilization and decreases the risk of stiffness. To optimize postoperative management, postoperative immobilization in internal rotation should be avoided because it places under tension GT’s fixation and leads to potential rotational malunion of the humeral shaft.

Declarations

Conflict of Interest

Pascal Boileau: designer and consultant for Tornier/Wright; outside the present study, Smith & Nephew, Conmed. The other author declares that she has no competing interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Footnotes

This article is part of the Topical Collection on Surgical Management of Massive Irreparable Cuff Tears

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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