Summary

short straight locking-nail, introduced through a percutaneous approach with immediate fracture-site impaction reduces complications and provides good functional outcomes

Abstract

Background

The optimal technique for operative fixation of displaced two-part surgical-neck fractures remains controversial. Complications associated with IM nailing, including loss of reduction, screw cutout, and intra-articular penetration, are frequent.

Purpose

We asked whether the use of a short, straight locking-nail, introduced through a percutaneous approach with immediate fracture-site impaction would reduce complications and improve functional outcomes scores.

Methods

41 consecutive patients (mean age was 56 [17-80]) with a displaced surgical neck fracture were treated with this approach. The fractures were classified in 3 groups, according to displacement : translation (20 cases), varus deformity (14 cases) and valgus deformity (7 cases). The cannulated IM locking-nail nail was introduced through a percutaneous approach in the humeral head. After first distal locking, retrograde hammering (“backslap” technique) for immediate static compression of fracture site was performed, and then proximal screws were locked inside the nail. Patients were prospectively evaluated with serial radiographs, as well as the Constant-Murley and the Subjective Shoulder Value (SSV) scores. The mean follow up was 21 months [12-48].

Results

All fractures healed primarly, whatever the displacement. No patient had intra-articular screw penetration or cut-out. No patient had complete osteonecrosis, but one had partial osteonecrosis. Incomplete reduction was observed in 2 patients : one residual translation and one residual varus. Two patients required further surgery : one to remove a proud nail and one to remove a screw. The mean Constant-Murley Score and the mean SSV were 71 [43-89] and 82% [60-100], respectively. The mean active forward elevation was 145° [90-180], and external rotation 45°[20-90]. Patients with varus deformity were the youngest (44y) and had the best functional results. Patients older than 60 years had lower functional results, whatever the initial fracture displacement.

Conclusion

High rates of fracture healing and excellent clinical outcome scores can be achieved when treating displaced surgical-neck humerus fractures percutaneously with short locking-nail fixation. Intraoperative fracture site impaction reinforces the construct and allows immediate rehabilitation. The percutaneous approach is time saving, and preserves bone vascularity, potentiallly decreasing the risk of osteonecrosis and non-union.
Key words: Two-part fractures, surgical-neck fractures, proximal humeral nail, locking-nail.
Level of evidence: Therapeutic Level IV.