Management of Proximal Humeral Fractures with Intramedullary Flexible Nails

Abstract

Background: Treatment of unstable, displaced fractures of the proximal end of the humerus has remained controversial in the literature. Conservative treatment often results in stiffness of the shoulder and malunion. Open reduction and internal fixation may result in avascular necrosis of the fragments of the humerus. Fixation of 2- or 3-part proximal humeral fractures with retrograde intramedullary, flexible nails seems to provide appropriate stabilization without further damage to the vascularity of the bony fragments. The purpose of this retrospective study is to evaluate the results of closed reduction and retrograde intramedullary flexible nail fixation of proximal humeral fractures. Patients and Methods: From 1990 to 1998, closed reduction and retrograde intramedullary, flexible nail fixation was performed on a total of 46 patients with 2- or 3-part fractures of the proximal humerus. 10 patients were lost to follow-up. All of the fractures were classified according to the Neer classification. 26 female and 10 male patients with a mean age of 51 years (range: 30-78) were reviewed clinically and radiologically with a mean follow-up of 82 months (range: 42 -44). The shoulder function was evaluated with the Constant scoring system and compared with the opposite shoulder. Radiographic evaluation was done in the anteroposterior, lateral and axillary views of the shoulder after surgery and at final follow-up. Angulation and displacement of the fracture, occurrence of non-union, partial or total avascular necrosis of the head and hardware failure were noted. Results: The mean Constant score was 78 in 3-part fractures and 84 in 2-part fractures at the final follow- up. 91.6 % of the patients were still satisfied with the clinical outcome of the treatment. 3 patients with partial humeral head necrosis were noted. Neither non-union nor total avascular necrosis of the humeral head was noted in any patient. Nail perforation of the humeral head was seen in 14 cases, especially in the elderly. Conclusions: From the results of our study, we suggest that 2-part fractures and minimally displaced 3-part fractures of the proximal humerus can be treated with retrograde, flexible intramedullary nails successfully.