Displaced two-part surgical-neck fractures: surgical classification and results of third-generation percutaneous intramedullary nailing
Background: Locking plate and screw constructs are the primary fixation method for displaced two-part surgical neck fractures of the proximal humerus, yet they are associated with various clinical complications. While antegrade intramedullary (IM) nailing offers a potential alternative, early-generation nail designs frequently resulted in high rates of reoperation and morbidity, including rotator cuff irritation and hardware migration.
Objective: This study aims to evaluate the clinical and radiological outcomes of a third-generation, straight, locked IM nail using a percutaneous insertion technique and to establish a classification-based strategy for optimizing nail entry points.
Key Points: A retrospective analysis was conducted on 41 patients (mean age 57 years) with displaced two-part surgical neck fractures (AO/OTA Type 11A3). The third-generation nail design features a straight profile to minimize supraspinatus tendon injury, polyethylene bushings for angular-stable proximal fixation, and tuberosity-oriented screws to prevent glenoid erosion. Surgical neck fractures were classified into three types—valgus, translated, and varus—to guide the specific percutaneous entry portal. At a mean follow-up of 26 months, all fractures achieved union with a mean neck-shaft angle of 132°. The mean Constant-Murley score was 71, and the subjective shoulder value was 80%. Complications included one case of asymptomatic partial avascular necrosis and two reoperations (5%) for hardware-related irritation.
Conclusion: Percutaneous fixation using a third-generation IM nail is a viable alternative to locking plates for two-part surgical neck fractures. The technique provides stable biomechanical fixation and high union rates while minimizing soft-tissue dissection and hardware-related complications.
Introduction
The most commonly used fixation option for two-part surgical neck fractures requiring surgical treatment is a locking plate and screw construct, though many complications have been reported throughout the literature related to this option. [6], Calvo E, de Miguel I, la Cruz de JJ, López-Martín N. Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results. J Shoulder Elbow Surg. 2007;16(6):774–781. doi:10.1016/j.jse.2007.03.019[11], Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br. 2001;83(6):799–804. [12], Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001 Aug;72(4):365–371. doi:10.1080/000164701753542023[13], Cuny C, Pfeffer F, Irrazi M, Chammas M, Empereur F, Berrichi A, et al. [A new locking nail for proximal humerus fractures: the Telegraph nail, technique and preliminary results]. Revue de Chirurgie Orthopédique et Réparatrice de l'Appareil Moteur. 2002 Feb;88(1):62–67. [21], Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017;99-B(3):383–392. doi:10.1302/0301-620X.99B3.BJJ-2016-1028[22], Harrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, et al. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012;94(13):1223–1228. doi:10.2106/JBJS.J.01371[23], Hatzidakis AM, Shevlin MJ, Fenton DL, Curran-Everett D, Nowinski RJ, Fehringer EV. Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus. A multicenter retrospective observational study. J Bone Joint Surg Am. 2011;93(23):2172–2179. doi:10.2106/JBJS.J.00754[25], Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures of the humerus. J Bone Joint Surg Am. 1992;74(4):508–515. [28], Keener JD, Parsons BO, Flatow EL, Rogers K, Williams GR, Galatz LM. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16(3):330–338. doi:10.1016/j.jse.2006.09.006[30], Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg. 2008;17(1):42–54. doi:10.1016/ j.jse.2007.03.016[31], Lin J, Hou SM, Hang YS. Locked nailing for displaced surgical neck fractures of the humerus. The Journal of Trauma: Injury, Infection, and Critical Care. 1998;45(6):1051–1057. [32], Linhart W, Ueblacker P, Grossterlinden L, Kschowak P, Briem D, Janssen A, et al. Antegrade nailing of humeral head fractures with captured interlocking screws. 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Meta-analysis of locking plate versus intramedullary nail for treatment of proximal humeral fractures. J Orthop Surg Res. 2015;10:122. doi:10.1186/s13018-015-0242-4[56], Young AA, Hughes JS. Locked intramedullary nailing for treatment of displaced proximal humerus fractures. Orthop Clin North Am. 2008 Oct;39(4):417–28– v–vi. doi:10.1016/j.ocl.2008.05.001[57] Zhu Y, Lu Y, Shen J, Zhang J, Jiang C. Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of follow-up. J Bone Joint Surg Am. 2011;93(2):159–168. Antegrade intramedullary nailing for surgical neck fractures of the proximal humerus could be an alternative treatment option to locking plates. However, the high rate of complications and reoperations observed with the early designs of first- (unlocked) and second-generation (bent design) intramedullary humeral nails has discouraged their use by most surgeons. [1], Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg. 2004;13(2):191–195. doi:10.1016/S1058274603003100[39], Nolan BM, Kippe MA, Wiater JM, Nowinski GP. Surgical treatment of displaced proximal humerus fractures with a short intramedullary nail. J Shoulder Elbow Surg. 2011;20(8):1241–1247. doi:10.1016/j.jse.2010.12.010[44], Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elbow Surg. 2001 Jan;10(1):7–10. doi:10.1067/mse.2001.109556[48], Robinson CM, Christie J. The two-part proximal humeral fracture: a review of operative treatment using two techniques. Injury. 1993 Feb;24(2):123–125. [50] Sosef N, Stobbe I, Hogervorst M, Mommers L, Verbruggen J, van der Elst M, et al. The Polarus intramedullary nail for proximal humeral fractures: outcome in 28 patients followed for 1 year. Acta Orthop. 2007;78(3):436–441. doi:10.1080/17453670710014040
In an effort to overcome these problems, we developed a third-generation humeral IM nail (Aequalis IM Humeral nail, Wright-Tornier, Bloomington, USA). This new generation of humeral IM nail is cannulated, has a low-profile and straight design, and the proximal screws are tuberosity-oriented and locked by polyethylene bushing inside the proximal part of the nail.[3], Boileau P, d’Ollonne T, Clavert P, Hatzidakis AM, Fehringer EV, Wirth MA, et al. Intramedullary nail for proximal humerus fractures : An old concept revisited. In: Boileau P, editor. Shoulder Concepts 2010. Montpellier: Sauramps médical; 2010. p. 201–224.[4] Boileau P, d’Ollonne T, Hatzidakis AM, Morrey ME. Intramedullary Locking Nail Fixation of Proximal Humerus Fractures: Rationale and Technique. In: Crosby LA, Neviaser RJ, editors. Proximal Humerus Fractures. Springer International Publishing; 2015. p. 73–98. In the present study, we report our clinical experience with percutaneous intramedullary nailing, using this third-generation nail.
The aims of the present study are [1] Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg. 2004;13(2):191–195. doi:10.1016/S1058274603003100 to classify displaced surgical neck fractures to determine the optimal entry points for percutaneous IM nailing, and [2] Boesmueller S, Wech M, Gregori M, Domaszewski F, Bukaty A, Fialka C, et al. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury. 2016;47(2):350–355. doi:10.1016/j.injury.2015.10.001 to report the functional and radiological results of this third-generation nail for the treatment of displaced two-part surgical neck fractures, using a percutaneous technique for nail insertion.
Third generation im humeral nail design rationale
The Aequalis IM humeral nail (Tornier-Wright, Bloomington, MN, USA) is a third-generation IMN (Figure 1), This cannulated nail is short, has a small diameter (9-mm), a straight design (to enter the muscular portion of the supraspinatus), and uses locking screw technology with orientation of the screws for tuberosity fixation. [3], Boileau P, d’Ollonne T, Clavert P, Hatzidakis AM, Fehringer EV, Wirth MA, et al. Intramedullary nail for proximal humerus fractures : An old concept revisited. In: Boileau P, editor. Shoulder Concepts 2010. Montpellier: Sauramps médical; 2010. p. 201–224.[9] Clavert P, Hatzidakis A, Boileau P. Anatomical and biomechanical evaluation of an intramedullary nail for fractures of proximal humerus fractures based on tuberosity fixation. Clinical biomechanics (Bristol, Avon). 2016;32:108–112. doi:10.1016/j.clinbiomech.2015.12.005 The straight nail respects the 3D-geometry of the proximal humerus acting as a mechanical strut to support humeral head under compressive forces [3], Boileau P, d’Ollonne T, Clavert P, Hatzidakis AM, Fehringer EV, Wirth MA, et al. Intramedullary nail for proximal humerus fractures : An old concept revisited. In: Boileau P, editor. Shoulder Concepts 2010. Montpellier: Sauramps médical; 2010. p. 201–224.[4], Boileau P, d’Ollonne T, Hatzidakis AM, Morrey ME. Intramedullary Locking Nail Fixation of Proximal Humerus Fractures: Rationale and Technique. In: Crosby LA, Neviaser RJ, editors. Proximal Humerus Fractures. Springer International Publishing; 2015. p. 73–98.[5], Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997 Sep;79-B(5):857–865. [7], Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct ± intramedullary fibular allograft. J Shoulder Elbow Surg. 2012 Jul;21(7):894–901. doi:10.1016/j.jse.2011.04.015[54] Weeks CA, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Locking plate fixation of proximal humeral fractures with impaction of the fracture site to restore medial column support: a biomechanical study. J Shoulder Elbow Surg. 2013;22(11):1552–1557. doi:10.1016/j.jse.2013.02.003 The proximal locking-screws are captured by a polyethylene bushing, which provides an angular-stable construct preventing screw back-out and migration. [9] Clavert P, Hatzidakis A, Boileau P. Anatomical and biomechanical evaluation of an intramedullary nail for fractures of proximal humerus fractures based on tuberosity fixation. Clinical biomechanics (Bristol, Avon). 2016;32:108–112. doi:10.1016/j.clinbiomech.2015.12.005 The proximal screws are tuberosity oriented (i.e., not humeral-head oriented), in order to avoid glenoid erosion in case of humeral head avascular necrosis and collapse. Finally, the two distal screws are 20° divergent to center the nail inside the medullary canal increasing constructs stability. [3], Boileau P, d’Ollonne T, Clavert P, Hatzidakis AM, Fehringer EV, Wirth MA, et al. Intramedullary nail for proximal humerus fractures : An old concept revisited. In: Boileau P, editor. Shoulder Concepts 2010. Montpellier: Sauramps médical; 2010. p. 201–224.[5], Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997 Sep;79-B(5):857–865. [9] Clavert P, Hatzidakis A, Boileau P. Anatomical and biomechanical evaluation of an intramedullary nail for fractures of proximal humerus fractures based on tuberosity fixation. Clinical biomechanics (Bristol, Avon). 2016;32:108–112. doi:10.1016/j.clinbiomech.2015.12.005
Percutaneous im
Nailing of two-part surgical neck fractures
Patients are placed in the sitting position and the C-arm image intensifier control, approaching from the contralateral side of the table to visualize the proximal humerus, is placed orthogonal to the shoulder (Figure 2). The goal of the minimally invasive percutaneous technique is to enter the cartilage of the humeral head (entering the supraspinatus muscle fibers, not the tendon) before entering the medullary canal of the diaphysis to align the head fragment and the shaft, and then to derotate the diaphysis (Figure 3).
Under C-arm guidance, optimizing the starting point of the nail in the humeral head was essential to obtain anatomical reduction.[46] Riemer BL, D'Ambrosia R, Kellam JF, Butterfield SL, Burke CJ. The anterior acromial approach for antegrade intramedullary nailing of the humeral diaphysis. Orthopedics. 1993;16(11):1219–1223. The entry point of a straight nail must be located approximately 10mm posterior and medial to the bicipital groove.[14], Dilisio MF, Nowinski RJ, Hatzidakis AM, Fehringer EV. Intramedullary nailing of the proximal humerus: evolution, technique, and results. J Shoulder Elbow Surg. 2016;25(5):e130–8. doi:10.1016/j.jse.2015.11.016[26], Jeong J, Jung H-W. Optimizing intramedullary entry location on the proximal humerus based on variations of neck-shaft angle. J Shoulder Elbow Surg. 2015;24(9):1386–1390. doi:10.1016/j.jse.2015.01.016[29], Knierim AE, Bollinger AJ, Wirth MA, Fehringer EV. Short, locked humeral nailing via Neviaser portal: an anatomic study. J Orthop Trauma. 2013 Feb;27(2):63–67. doi:10.1097/BOT.0b013e31825194ad[38], Noda M, Saegusa Y, Maeda T. Does the location of the entry point affect the reduction of proximal humeral fractures? A cadaveric study. Injury. 2011;42 Suppl 4:S35–8. doi:10.1016/S0020-1383(11)70010-9[42] Park J-Y, Pandher DS, Chun J-Y, Md STL. Antegrade humeral nailing through the rotator cuff interval: a new entry portal. J Orthop Trauma. 2008 Jul;22(6):419–425. doi:10.1097/BOT.0b013e318173f751 Once proper entry portal is defined, a cannulated bone awl is used for entry and joystick the humeral head under fluoroscopic guidance. A guide-wire is placed through the bone awl into the humeral head. After manipulation of the arm to obtain the best alignment between the epiphysis and the diaphysis, the guide-wire is then advanced inside the humeral shaft.
Once adequate guide pin placement is achieved, a 9-mm hole is created in the humeral head using a cannulated reamer. The cannulated nail is placed over the guide wire, inserted at the apex of the humeral head, and then inside the diaphysis, providing appropriate fracture alignment. The arm is placed in neutral rotation to achieve adequate derotation of the humeral diaphysis, whereas adequate rotation of the nail is achieved with the assistance of an external jig aligned with the forearm (Figure 4).
After assessment of the reduction and the nail’s depth under fluoroscopy, the guide wire is retrieved and the two distal screws were first placed in the diaphysis. Once distal fixation is obtained, gentle retrograde impaction of the distal to the proximal segment via a sliding slap-hammer is then performed (“backslap” hammering) to allow intraoperative immediate compression of the fracture site (Figure 5). Finally, proximal fixation is obtained by percutaneous insertion of a minimum of two proximal locking-screws via the attached jig. Postoperatively, the shoulder is placed in a sling for 1 week postoperatively. Passive elbow and shoulder mobilization with pendulum exercises (5 times a day and 5 minutes per session) is performed immediately. Patients are encouraged to remove the brace at day one, and to use their hand for ADLs.
Clinical study
We performed a retrospective and were able to follow and review 41 patients who underwent placement of the AequalisTM IMN to treat a displaced two-part surgical-neck fracture (AO/OTA Type 11A3). All surgical-neck fracture were displaced with displacement of the shaft of > 25% of its width and/or > 45° of angulation. Mean age at surgery was 57 years old (range: 17-84). There were 25 females and 16 males. Mechanism of injury was due to a low energy trauma (fall) in 78% of cases (32 patients). The dominant side was involved in 55% of the cases. The mean operative time was 42 minutes (range: 20-110 minutes). Patients were reviewed and radiographed with minimum one year follow up; the mean follow up was 26 months (range: 12-53).
Classification of displaced two-part surgical neck fractures
Using preoperative radiographs and CT-scans, surgical-neck fractures were classified in 3 types, according to the displacement of the humeral head fragment (Figure 6):
- Valgus Surgical-Neck Fractures (Type A- 8 cases): the medial translation of the diaphysis is partial and combined with some abduction which leads to valgus deformity of the humeral head.
- Translated Surgical-Neck Fractures (Type B- 19 cases): when the shaft is entirely translated medially and anteriorly by the pectoralis major and internally rotated by the latissimus dorsi and teres major, there is no more contact between the head fragment and the diaphysis, and therefore, no humeral head deformity.
- Varus Surgical-Neck Fractures (Type C- 14 cases): the shaft is translated laterally with some adduction, leading to varus head deformity.
With increasing surgical experience, we have used this classification to choose the optimal percutaneous entry point for the IM nail (Figure 7).
Complications
And reoperations
At the final follow up, one patient had partial avascular necrosis of the humeral head, which remained asymptomatic at the last review, three years postoperatively. Two patients (5%) were reoperated. One patient had removal of a too proud causing rotator cuff irritation, and impingement. A second patient with shoulder stiffness and pain underwent arthroscopic scar release and removal of anterior proximal screw which wasnot tighten enough.
Results
At last review, mean active forward elevation was 145° (range: 90°-180°), and external rotation 50° (range: 20°-80°). Mean Constant-Murley Score and subjective shoulder value (SSV) were 71 (range: 43-95) and 80% (range: 50-100%), respectively. At the last follow up, the mean SSV was 80% ± 12 (Figure 8).
At final follow-up, all fractures went onto union, and the mean humeral neck-shaft angle was 132° ± 5° (Figure 9). No cases underwent screw migration or intra-articular penetration. The mean correction of the angulation was 16.5°±8.3° (Table 1).
We observed one partial humeral head avascular necrosis ,as already mentioned, and two malunions, early in our experience: one patient had incomplete reduction of humeral translation whereas the other one developed a varus malunion of the surgical neck. Both fractures were noted to be mal-reduced at the time of surgery because of intraoperative technical error: the entry point of the nail was incorrect (i.e., too lateral). With increasing surgical experience, we developed a strategy to enter the nail at the correct spot, based on the type of displacement of the humeral head fragment (Figures 5, 6).
Discussion
Our study shows that antegrade insertion of third-generation IMN through a percutaneous approach provides high rate of fracture healing, excellent clinical outcome scores with low rates of complications. Such IM nail has a low-profile and straight design, and the proximal screws are tuberosity-oriented and locked by polyethylene bushing inside the proximal part of the nail. We found several advantages for using this new generation of humeral IMN through a percutaneous approach for the treatment of displaced two-part surgical neck fractures, including minimal soft-tissue damage with minimal risk of humeral head osteonecrosis (only one case in our series), short operative time (42 minutes in average, including our learning curve) and improved cosmesis (Figure 9 and 10).
The results of our study suggest that the use of this new generation of IMN minimizes complications reported with existing current IM nails, and is a reliable and safe alternative to locking plate fixation for the treatment of displaced two-part surgical neck fractures. The straight design and small dimensions (for diameter and length) of the AequalisTM IMN avoid iatrogenic cuff and cartilage problems seen in the past with first- (unlocked) and second-generation (bended) of humeral nails. Except the one patient with a proud nail, no patient complained about cuff tendinitis or pain. Our results also confirm the benefits of locking screw technology applied to IM humeralnails (no cases of screw migration), and tuberosity-based fixation for proximal screws (no screw penetration and glenoid erosion in case of humeral head necrosis).
From a technical standpoint, optimal entry point for the nail is of paramount importance and must be based on the displacement of the humeral head fragment: the nail should enter more lateral in case of valgus tilt and more medial in case of varus tilt. The use of intraoperative fracture site impaction (“backslap” technique) reinforces the construct and allows immediate activity and rehabilitation.
Conclusion
Percutaneous IM nailing, using a third-generation of humeral nail, is a reliable and safe alternative to locking plate fixation for the treatment of displaced 2-part surgical neck fractures. It provides high rate of fracture healing and excellent clinical outcome scores. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. Our results encourage us to pursue our experience. In our opinion, percutaneous IM nailing of displaced surgical-neck fractures using a third-generation IM nail provides the combined advantages of pining (biological fixation with minimal dissection of the fracture site) and plating (biomechanical strong construct), without the drawbacks of both techniques.
References
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