Intramedullary Nailing in Proximal Humerus Fractures: Outcomes Beyond the Simple Two-Part
Abstract
Background: Proximal humerus fractures (PHFs) are common injuries, particularly in the elderly. While intramedullary nailing (IMN) has gained popularity for treating these fractures, its efficacy in complex cases, especially those with comminuted calcar, remains a topic of debate. This study aimed to evaluate the outcomes of IMN in PHFs with and without calcar comminution.
Methods: A prospective observational study was conducted on 40 patients with displaced PHFs treated with IMN. Patients were divided into two groups based on the integrity of the calcar: intact (group A) and comminuted (group B). Radiographic and clinical outcomes were assessed at 3, 6, and 12 months postoperatively.
Results: All fractures achieved union. Minimal loss of reduction was observed in both groups, with no significant difference between them. Functional outcomes, including pain, range of motion (ROM), and patient-reported scores, improved over time in both groups. Patients with intact calcar showed significantly better outcomes in terms of Simple Shoulder Test (SST) score and forward elevation at all follow-up points. The complication rate was low (2.5%), with one case of osteonecrosis in group A.
Conclusion: IMN is a safe and effective treatment for displaced PHFs, even with comminuted calcar. Although calcar comminution may lead to slightly worse outcomes in specific functional parameters, the overall impact is minimal. IMN offers a viable alternative to plate fixation, particularly in complex fractures, with favorable outcomes and a low complication rate.
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10. Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Proximal humerus nailing: a randomized clinical trial
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11. Günther CM, Müller PE, Mutschler W, Sprecher CM, Milz S, Braunstein V. Straight proximal humeral nails are surrounded by more bone stock in comparison to bent nails in an experimental cadaveric study. Patient Saf Surg. 2014;8:18. doi: 10.1186/1754-9493-8-18. [PubMed: 24817909]. [PubMed Central: PMC4016779].
12. Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, et al. Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures. Clin Orthop Relat Res. 2015;473(9):3038-45. doi: 10.1007/s11999-015-4322-x. [PubMed: 25910780]. [PubMed Central: PMC4523505].
13. Lescheid J, Zdero R, Shah S, Kuzyk PR, Schemitsch EH. The biomechanics of locked plating for repairing proximal humerus fractures with or without medial cortical support. J Trauma. 2010;69(5):1235-42. doi: 10.1097/TA.0b013e3181beed96. [PubMed: 20118814].
14. Boileau P, d'Ollonne T, Bessière C, Wilson A, Clavert P, Hatzidakis AM, et al. Displaced humeral surgical neck
fractures: classification and results of third-generation percutaneous intramedullary nailing. J Shoulder Elbow Surg. 2019;28(2):276-87. doi: 10.1016/j.jse.2018.07.010. [PubMed: 30429058].
15. Fu H, Wu J, Wu X. Intramedullary Nail for Treatment of Proximal Humeral Fracture: A Credible Fixation in
Comminuted Calcar. Orthop Surg. 2023;15(8):2007-15. doi: 10.1111/os.13616. [PubMed: 36514186]. [PubMed Central: PMC10432444].
16. Martinez-Catalan N, Boileau P. The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not. Curr Rev Musculoskelet Med. 2023;16(2):85-94. doi: 10.1007/s12178-022-09816-w. [PubMed: 36626085]. [PubMed Central: PMC9889584].
17. Sharma GM, Naik LG, Chaitanya W, Chavan S, Roy K, Pawar P, et al. Treatment of Three-and Four-Part Proximal Humerus Fractures by MultiLoc Nailing Technique-A Prospective Study. J Clin Diagn Res. 2017;11(11):RC09-RC11. doi: 10.7860/JCDR/2017/30973.10875.
18. Spross C, Zeledon R, Zdravkovic V, Jost B. How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(9):1566-72. doi: 0.1016/j.jse.2017.02.026. [PubMed: 28412105].
19. Jia Z, Li C, Lin J, Liu Q, Li G, Hu X. Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures. J Med Res. 2020;48(12):300060520979212. doi: 10.1177/0300060520979212. [PubMed: 33334211]. [PubMed Central: PMC7750834].
20. Osterhoff G, Hoch A, Wanner GA, Simmen HP, Werner CM. Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures. Injury. 2012;43(10):1651-6. doi: 10.1016/j.injury.2012.04.015. [PubMed: 22579397].
21. Sears BW, Johnston PS, Garrigues GE, Boileau P, Hatzidakis AM. Intramedullary nailing of the proximal humerus-not just for 2-part fractures. Ann Joint. 2020;5. Doi :10.21037/aoj.2020.02.10.
22. Greiner S, Kääb MJ, Haas NP, Bail HJ. Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury. 2009;40(2):186-91. doi: 10.1016/j.injury.2008.05.030. [PubMed: 19100544].
2. Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: nationwide emergency
department sample, 2008. Arthritis Care Res (Hoboken). 2012;64(3):407-14. doi: 10.1002/acr.21563. [PubMed: 22162357].
3. Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, et al. Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg Am. 2011;93(2):121-31. doi: 10.2106/jbjs.I.01505. [PubMed: 21248210]. [PubMed Central: PMC3016042].
4. Maier D, Jäger M, Strohm PC, Südkamp NP. Treatment of proximal humeral fractures - a review of current concepts enlightened by basic principles. Acta Chir Orthop Traumatol Cech. 2012;79(4):307-16. [PubMed: 22980928].
5. Konrad G, Audigé L, Lambert S, Hertel R, Südkamp NP. Similar outcomes for nail versus plate fixation of three-part proximal humeral fractures. Clin Orthop Relat Res. 2012;470(2):602-9. doi: 10.1007/s11999-011-2056-y. [PubMed: 21879402]. [PubMed Central: PMC3254759].
6. Helfen T, Siebenbürger G, Mayer M, Böcker W, Ockert B, Haasters F. Operative treatment of 2-part surgical neck fractures of the proximal humerus (AO 11-A3) in the elderly: Cement augmented locking plate Philos™ vs. proximal humerus nail MultiLoc®. BMC Musculoskelet Disord. 2016;17(1):448. doi: 10.1186/s12891-016-1302-6.
27793135]. [PubMed Central: PMC5084335].
7. Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011;42(4):408-13. doi: 10.1016/j.injury.2010.11.058. [PubMed: 21176833].
8. Kloub M, Holub K, Urban J, Látal P, Peml M, Křivohlávek M. Intramedullary nailing of displaced four-part fractures of the proximal humerus. Injury. 2019;50(11):1978-85. doi: 10.1016/j.injury.2019.06.029. [PubMed: 31405519].
9. 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): 1241-7. doi: 10.1016/j.jse.2010.12.010. [PubMed: 21420325].
10. Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Proximal humerus nailing: a randomized clinical trial
between curvilinear and straight nails. J Shoulder Elbow Surg. 2014;23(3):369-76. doi: 10.1016/j.jse.2013.08.023. [PubMed: 24291047].
11. Günther CM, Müller PE, Mutschler W, Sprecher CM, Milz S, Braunstein V. Straight proximal humeral nails are surrounded by more bone stock in comparison to bent nails in an experimental cadaveric study. Patient Saf Surg. 2014;8:18. doi: 10.1186/1754-9493-8-18. [PubMed: 24817909]. [PubMed Central: PMC4016779].
12. Spross C, Kaestle N, Benninger E, Fornaro J, Erhardt J, Zdravkovic V, et al. Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures. Clin Orthop Relat Res. 2015;473(9):3038-45. doi: 10.1007/s11999-015-4322-x. [PubMed: 25910780]. [PubMed Central: PMC4523505].
13. Lescheid J, Zdero R, Shah S, Kuzyk PR, Schemitsch EH. The biomechanics of locked plating for repairing proximal humerus fractures with or without medial cortical support. J Trauma. 2010;69(5):1235-42. doi: 10.1097/TA.0b013e3181beed96. [PubMed: 20118814].
14. Boileau P, d'Ollonne T, Bessière C, Wilson A, Clavert P, Hatzidakis AM, et al. Displaced humeral surgical neck
fractures: classification and results of third-generation percutaneous intramedullary nailing. J Shoulder Elbow Surg. 2019;28(2):276-87. doi: 10.1016/j.jse.2018.07.010. [PubMed: 30429058].
15. Fu H, Wu J, Wu X. Intramedullary Nail for Treatment of Proximal Humeral Fracture: A Credible Fixation in
Comminuted Calcar. Orthop Surg. 2023;15(8):2007-15. doi: 10.1111/os.13616. [PubMed: 36514186]. [PubMed Central: PMC10432444].
16. Martinez-Catalan N, Boileau P. The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not. Curr Rev Musculoskelet Med. 2023;16(2):85-94. doi: 10.1007/s12178-022-09816-w. [PubMed: 36626085]. [PubMed Central: PMC9889584].
17. Sharma GM, Naik LG, Chaitanya W, Chavan S, Roy K, Pawar P, et al. Treatment of Three-and Four-Part Proximal Humerus Fractures by MultiLoc Nailing Technique-A Prospective Study. J Clin Diagn Res. 2017;11(11):RC09-RC11. doi: 10.7860/JCDR/2017/30973.10875.
18. Spross C, Zeledon R, Zdravkovic V, Jost B. How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(9):1566-72. doi: 0.1016/j.jse.2017.02.026. [PubMed: 28412105].
19. Jia Z, Li C, Lin J, Liu Q, Li G, Hu X. Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures. J Med Res. 2020;48(12):300060520979212. doi: 10.1177/0300060520979212. [PubMed: 33334211]. [PubMed Central: PMC7750834].
20. Osterhoff G, Hoch A, Wanner GA, Simmen HP, Werner CM. Calcar comminution as prognostic factor of clinical outcome after locking plate fixation of proximal humeral fractures. Injury. 2012;43(10):1651-6. doi: 10.1016/j.injury.2012.04.015. [PubMed: 22579397].
21. Sears BW, Johnston PS, Garrigues GE, Boileau P, Hatzidakis AM. Intramedullary nailing of the proximal humerus-not just for 2-part fractures. Ann Joint. 2020;5. Doi :10.21037/aoj.2020.02.10.
22. Greiner S, Kääb MJ, Haas NP, Bail HJ. Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury. 2009;40(2):186-91. doi: 10.1016/j.injury.2008.05.030. [PubMed: 19100544].
| Files | ||
| Issue | Vol 11 No 4 (2025) | |
| Section | Research Articles | |
| DOI | https://doi.org/10.18502/jost.v11i4.20291 | |
| Keywords | ||
| Proximal Humeral Fractures Intramedullary Fracture Fixation Treatment Outcome | ||
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How to Cite
1.
Sharma B, Mittal V, Agrawal V, Sharma Y. Intramedullary Nailing in Proximal Humerus Fractures: Outcomes Beyond the Simple Two-Part. J Orthop Spine Trauma. 2025;11(4):187-91.
