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Background: The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality., Methods: Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed., Results: 48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction., Conclusions: Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result., (© 2024. The Author(s).)

Objective: Proximal humeral fracture combined with contralateral midshaft clavicle fracture is an extremely rare injury in children. Few studies focus on the injury mechanism and treatment scheme. The aim of this study is to propose the possible mechanism of this injury and present the treatment results., Methods: This retrospective study included children diagnosed with proximal humeral fractures combined with contralateral midshaft clavicle fractures from August 2016 to March 2019 in the corresponding author's institution. The patients received elastic stable intramedullary nails and external fixation as treatment. The radiological and clinical outcomes of treatments were evaluated using the imaging and the Constant-Murley score (CMS) in follow up., Results: Twelve patients (eight males and four females) with an average age of 7.83 years old (age 5-12) were included in this research. All the patients had suffered a side impact in a road traffic accident or outdoor environment. Hypothesis about the mechanism was the proximal humerus was directly impacted at first and caused the surgical neck fracture, then the contralateral shoulder hits the solid object and the contralateral midshaft clavicle was fractured. During the average 45.2 months (range 36-57) follow-up, all the patient's fractures achieved clinical and radiological union before 14 weeks without complications. Every patient had a satisfactory score (range from 92 to 100) on the CMS criteria for both shoulders., Conclusion: The hypothesis about the mechanism of this combined injury in this study sounds reasonable. It highlights the need for safety-related education about using a safety seat or wearing a seat belt to parents and caregivers, so as to avoid such injury even if the treatment with external fixation (EF) and proximal humeral and elastic stable intramedullary nailing (ESIN) showed good results., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: Restoration of the medial support is especially important for the treatment of proximal humeral fractures. The objective of this study was to investigate the radiographic and clinical outcomes of intramedullary nail fixation with a special focus on the presence of calcar comminution., Methods: In this retrospective study of patients with displaced proximal humeral fractures that were treated by intramedullary nail between January 2018 and July 2021, fracture morphology and the calcar integrity were noted on preoperative radiographs. Patients were divided into two groups according to calcar integrity. During follow-up, radiological assessment and functional outcome, including the deltoid tuberosity index (DTI), neck shaft angle (NSA), visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, active and passive range of motion, were performed. A Student t-test and univariate logistic regression analysis was used., Results: A total of 83 patients (54 female, 29 male) had complete follow-up (average, 12.8 months; range, 10 to 33 months) and functional assessment in our study. The average age was 58.6 years (range, 20 to 89 years). The mean loss of NSA was 4° (range, 0°-12°) and no significant difference was found between two groups (p = 0.27). DTI had an average of 1.50 ± 0.19 (range 1.13-2.04). Patients with intact calcar achieved greater range of forward elevation (129.06 ± 11.91 vs. 121.05 ± 11.97, p = 0.01), and higher SST scores (8.61 ± 1.85 vs. 7.37 ± 2.22, p = 0.02). Two groups showed similar outcomes in VAS, ASES score, and range of abduction. One patient demonstrated a proximal interlocking screw cutting through and osteonecrosis of the humeral head, who underwent a second surgery for screw removal. There were no cases of infection, malunion, nonunion, nerve injury, subacromial impingement, or rotator cuff tear during the study period., Conclusion: Intramedullary nail can favorably be used to manage proximal humeral fractures with good early radiographic and functional outcomes, even for those with comminuted calcar., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Introduction: After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate., Materials and Methods: All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B., Results: The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis., Conclusion: Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant., Evidence Level: IV, retrospective study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The aim of this study is to compare clinically and radiologically the plate osteosynthesis method and the in-tramedullary nail (IMN) method, which is currently used in the surgical treatment of surgical neck proximal humerus fractures (PHFs) in which there is no consensus METHODS: A total of 248 patients who underwent PHF between January 2013 and December 2017 were retrospectively reviewed. Sixty-two patients were included in the study. The results were clinically compared in terms of the amount of blood loss, operative time, and union time. Radiologically, it was compared in terms of intraoperative neck-shaft angle (NSA), final NSA, the American Shoulder and Elbow Surgeons (ASES), and Constant and Visual Analog Scale (VAS) scores., Results: Two groups were formed: plate and IMN. The groups were similar in terms of age, sex, operation side, and follow-up time. There was no difference between the groups in terms of NSA, final NSA, ASES, Constant, and VAS scores. The amount of intraoper-ative blood loss, operative time, and union time was shorter in the IMN group., Conclusion: In surgical neck PHF surgery, plate and IMN are methods that show good clinical outcomes. According to this study, the advantages of the IMN method compared with plate osteosynthesis in Neer type II PHF treatment can be listed as less intraoper-ative blood loss, shorter operative time, and union time.

Background: This study aimed to compare the clinical efficacy of locking plate and intramedullary nail fixations in the treatment of patients with OTA/AO type 11C proximal humerus fractures., Methods: We retrospectively analyzed the data of patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures who underwent surgery at our institution from June 2012 to June 2017. Perioperative indicators, postoperative morphological parameters of the proximal humerus, and Constant-Murley scores were evaluated and compared., Results: Sixty-eight patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures were enrolled in this study. Overall, 35 patients underwent open reduction and plate screw internal fixation, and 33 patients underwent limited open reduction and locking of the proximal humerus with intramedullary nail internal fixation. The total cohort had a mean follow-up duration of 17.8 months. The mean operation time of the locking plate group was significantly longer than that of the intramedullary nail group (P < 0.05), while the mean bleeding volume was significantly higher in the locking plate group than that in the intramedullary nail group (P < 0.05). The initial neck-shaft angles, final neck-shaft angles, forward flexion ranges, or Constant-Murley scores did not show significant differences between the two groups (P > 0.05). Complications, including screw penetrations, acromion impingement syndrome, infection, and aseptic necrosis of the humeral head, occurred in 8 patients (8/35, 22.8%) in the locking plate group and 5 patients in the intramedullary nail group (5/33, 15.1%; including malunion and acromion impingement syndrome), with no significant difference between the groups (P > 0.05)., Conclusions: Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. However, intramedullary nailing has advantages over locking plates for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures in terms of operation time and bleeding volume., (© 2023. The Author(s).)

Objectives: The optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome., Methods: This was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1-4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified., Results: Reduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation., Conclusions: Straight IMN is a reliable treatment for displaced 2-part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients., Competing Interests: Conflicts of Interest and Source of Funding No outside funding or grant was received for the current study. AG receives royalties and consulting fees from DJO global, royalties from Wright/Tornier, royalties from Stryker, and payments from The Journal of Bone & Joint Surgery. ESP receives financial payments for consulting, service on advisory committees, and speakers’ bureau from the commercial entities Miami Device Solutions and Wright/Tornier. For the remaining authors none were declared., (Copyright © 2022. Published by Elsevier Ltd.)

Aim: evaluate the outcome of proximal  humeral nailing over 5 years follow-up, focusing  on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure., Materials and Methods: the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject., Results: mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded "very good" / "good" results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails).  Second surgery was performed in 8.2% (16/194) of cases., Conclusion: intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support.

Introduction: Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients., Methods: A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS., Results: Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively., Conclusion: Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The aim of this study was (1) to compare clinical and radiological outcomes of 3- and 4-part proximal humeral fractures using either IMN or LP (2) and to report complications related to each technique., Methods: A prospective controlled randomized open-label two-arm study was performed. Ninety-nine consecutive adult patients with a 3- and 4-part displaced acute proximal humeral fractures were randomized to be treated with IMN (n = 49) or LP (n = 50). Constant, ASES and SST scores were recorded by the surgeon. Range of motion was evaluated. A visual analog scale (VAS) was used to assess shoulder pain. Complications and revision surgeries were reported., Results: Eighty-five patients were analyzed, nine were lost, and five died during the follow-up period. The mean age was 73.7 years (± 13.3,, and the mean follow-up was 66 months (± 13.5). At last follow-up, VAS was lower in the IMN group (0.9 (± 1.1) vs. 1.9 (± 1.7), p = 0.001). The median Constant score was significantly higher in the IMN group (81.6 (± 10.9) points) vs. in the LP group (75.6 (± 19.5) points) (p = 0.043), and ASES score was also significantly higher in the IMN group (86.3 (± 9.5) vs. 75.2 (± 19.6), p = 0.001). There was no difference in the range of motion or SST scores between the two groups. Complications were seen higher in the LP group (9 (21%) vs. 22 (52%), p = 0.003). Revision surgery was higher in the LP group (37% vs. 21%)., Conclusion: Satisfactory results were accomplished in both groups according to the reported clinical outcomes. Complication and revision rates were higher in LP group., (© 2021. The Author(s) under exclusive licence to SICOT aisbl.)

Summary: For the treatment of proximal humerus fractures, the intramedullary nitinol scaffold is a novel implant that has gained popularity and demonstrated promising 1-year outcomes as an alternative to bone grafting for providing intramedullary structural support to the humeral head. The aim of this video is to demonstrate the insertion of this device safely, while highlighting potential pitfalls, in a 67-year-old patient with a displaced, varus angulated 2-part proximal humerus fracture., Competing Interests: B. Shafiq is a consultant for Depuy Synthes. U. Srikumaran is a paid consultant, presenter, or speaker for Conventus, Fx Shoulder, and Orthofix. He receives other financial support from Arthrex, Depuy, Smith & Nephew, Stryker, and Wright Medical Technology. He received stock or stock options from Quantum OPDS, ROM3, and Tigon Medical. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study was performed to evaluate the clinical effect of MultiLoc® nails (DePuy Synthes, Raynham, MA, USA) on the treatment of four-part proximal humeral fractures (PHFs)., Methods: From January 2014 to January 2018, 32 patients with four-part PHFs were treated with intramedullary MultiLoc® nails in our hospital. The operation time, bleeding volume, postoperative X-ray findings, and fracture healing status were recorded and analyzed. At the end of follow-up, the clinical outcome was evaluated based on the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant-Murley score (CMS), and occurrence of any complications., Results: Among all patients, the average operation time was 124.5 minutes (range, 91-152 minutes), the average amount of bleeding was 90 mL (range, 55-150 mL), and the fracture healing rate was 100%. At the end of follow-up, the mean VAS score was 1.6 ± 0.4, mean ASES score was 84.4 ± 6.3, and mean CMS was 70.3 ± 6.1; no serious complications had occurred; and the patients exhibited good recovery of shoulder function., Conclusions: MultiLoc nails® can be applied to the treatment of four-part PHFs. This surgical fixation method has no obvious complications and helps to restore shoulder function.

Purpose: To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature., Materials and Methods: From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30 months (range 24-42). Moreover, a review of the literature was carried out., Results: The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7 months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65 years, mean follow-up of 22.2 months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws., Conclusions: Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

Introduction: Humerus fractures are frequent, accounting for about 3-4% of all fractures in adults. Treatment for fractures of the diaphyseal and proximal meta-epiphyseal regions remains controversial: there is no unanimity in the scientific community about the superiority of surgical treatment over non-surgical treatment and which is the best between possible surgical treatments. Among the choices for surgical treatment the most commonly used implants are the locking-compression plate and the intramedullary nailing. The purpose of this study was to perform a clinical and radiographic follow-up in patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of anterograde intramedullary nailing with a straight-shaped nail., Patients and Methods: A clinical and radiographic follow-up was performed in 56 patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of antegrade intramedullary nailing using Synthes MultiLoc® system. Clinical data were collected using subjective quality of life assessment forms (SF12-v2), quality of life related to specific disabilities assessment forms (Quick-DASH, ASES score, WORC) and objective functional assessment forms (Constant-Murley score). The radiographic Follow-Up was performed at 30, 90 and 180 days from the date of the surgery., Results: Almost all patients were able to return to a satisfactory quality of life, comparable with the one before the traumatic episode. The functional results were assessed as excellent or good with almost complete recovery of the range of motion and moderate recovery of strength. The residual pain encountered was moderate or zero. The average QuickDASH score was 17.7 ± 4.3 (range 9.1 - 27.3). The average ASES score was 73.8 ± 8.1 (range 58.3 - 88.3). The average WORC score was 543.3 ± 100 [74% ± 4.8%] (range 310 - 740). The mean Constant-Murley score was 69.6 ± 4.6 (range 61 - 84). All patients had a fair or good consolidation of the fracture on radiographic examinations. The calculated RUST score was 4.2 ± 0.4 (range 4-5) 30 days after surgery, 6.1 ± 0.9 (range 4- 8) 90 days after surgery and 9.8 ± 1.5 (range 7-12) to 180 days after surgery. No major complications were found., Conclusions: Treatment of the diaphyseal and proximal meta-epiphyseal humeral fractures with antegrade intramedullary nail provides excellent subjective and objective clinical results and good radiographic results. However, clinical studies with larger number of patients and longer follow-up are necessary., Competing Interests: Declaration of Competing Interests None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the feasibility of locked intramedullary nailing, rather than locking plate fixation combined with fibular allograft augmentation, for initial varus proximal humeral fractures., Methods: This prospective pilot study enrolled patients with initial varus proximal humeral fractures that were treated with a locking intramedullary nail. Radiography was performed to evaluate fracture healing. Data about the visual analogue scale (VAS) pain score, Constant Shoulder Score (CSS), Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score and shoulder range of motion (ROM) were recorded., Results: Twenty patients, including eight with Neer two-part and 12 with three-part fractures, were followed-up, with a mean time of 12.3 months. All patients sustained fractures that healed without re-varus. During the last follow-up, the shoulder function of the patients had recovered well, with a mean VAS pain score of 1.4, a mean CSS of 83.1, a mean DASH score of 80.8, a mean ASES score of 84.0 and a satisfactory ROM. In one patient, the proximal locking screw came out and was removed via a second surgery., Conclusions: The use of a locking intramedullary nail alone for initial varus proximal humeral two-/three-part fractures was feasible. This treatment has advantages, such as preventing re-varus and causing milder surgical trauma, than that seen with a locking plate.

Introduction: The quality of reduction in proximal humerus fractures is valuable with radiographic criteria (Neck-shaft angle [NSA]; medial offset [MO]; distance head tuberosity [DHT] and subacromial space [SS]) that predict functionality. These criteria set for other implants are not described for the intramedullary nail., Material and Methods: Observational cohort study, retrospective, with patients 18 years, with osteosynthesis with intramedullary nail (2014 to 2017), evaluating demographic characteristics, severity of injury (Neer classification), progressive radiographic measurements and complications., Results: 84 cases with an average age of 65 ± 2 years and an average follow-up of 13.9 months were analyzed. By Neer rating 40.4% were grade II, 29.7% grade III and 29.7% grade IV. Consolidation in varus increases to 10.7% at the end of follow-up, with Neer III and IV patients. The 140° deformity is prevalent for Neer II (n = 15/34). 30.9% have a change of neck-shaft angle of 10°. Overall 86.9% has HTD changes 5 mm. Cases Neer III/IV 32% has alteration of SS 5 mm. The most common complication is avascular necrosis (AVN) with 44% of cases., Conclusions: Radiographic measurements have changes in long-term follow-up. Alterations in NSA ( 10o) and SS ( 5 mm) occur in higher proportion of Neer III/IV patients, according to the severity of the fracture, favoring vicious consolidations in varus or valgus and increased presence of AVN.

Background: Intramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail., Design: prospective monocentric cohort study., Setting: single level 1 traumacenter., Materials and Methods: From February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study., Results: After mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity., Conclusions: Intramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result., Level of Evidence: Level 2b - monocentric prospective cohort study., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: To evaluate the effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture (PHF)., Methods: China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wan-fang database, Chinese Biomedicine Database (CBM), PubMed, EMBASE, Web of Science, and Cochrane Library were searched until July 2018. The eligible references all show that the control group uses locking plates to treat PHF, while the experimental group uses intramedullary nails to do that. Two reviewers independently retrieved and extracted the data. Reviewer Manager 5.3 was used for statistical analysis., Results: Thirty-eight retrospective studies were referred in this study which involves 2699 patients. Meta-analysis results show that the intramedullary nails in the treatment of proximal humeral fractures are superior to locking plates in terms of intraoperative blood loss, operative time, fracture healing time, postoperative complications, and postoperative infection. But there is no significance in constant, neck angle, VAS, external rotation, antexion, intorsion pronation, abduction, NEER, osteonecrosis, additional surgery, impingement syndrome, delayed union, screw penetration, and screw back-out., Conclusions: The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. Due to the limitations in this meta-analysis, more large-scale, multicenter, and rigorous designed RCTs should be conducted to confirm our findings., Trial Registration: PROSPERO CRD42019120508.

Background: The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures., Methods: We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months)., Results: Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively., Conclusions: Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment., Materials and Methods: Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score., Results: Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points)., Conclusions: Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people., Material and Methods: Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group., Results: The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05)., Conclusions: The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

Introduction: Straight antegrade humeral nailing (SAHN) has become a standard technique for the surgical fixation of proximal humeral fractures, which predominantly affect elderly females. The nail's proximal anchoring point has been demonstrated to be critical to ensure reliable fixation in osteoporotic bone and to prevent iatrogenic damage to the superior rotator cuff bony insertion. Anatomical variations of the proximal humerus, however, may preclude satisfactory anchoring of the nail's proximal end and may bare the risk of rotator cuff violation, even though the nail is inserted as recommended. The aim of this study was to evaluate the anatomical suitability of proximal humeri of geriatric females aged 75 years and older for SAHN. Specifically, we sought to assess the proportion of humeri not anatomically amenable to SAHN for proximal humeral fracture., Materials and Methods: A total of 303 proximal humeri of 241 females aged 75 years and older (mean age 84.5 ± 5.0 years; range 75-102 years) were analyzed for this study. Multiplanar two-dimensional reformations (true ap, true lateral, and axial) were reconstructed from shoulder computed tomography (CT) data sets. The straight antegrade nail's ideal entry point, "critical point" (CP), and critical distance (CD; distance between ideal entry point and CP) were determined. The rate of proximal humeri not anatomically suitable for SAHN (critical type) was assessed regarding proximal reaming diameters of currently available straight antegrade humeral nails., Results: Overall, 35.6% (108/303) of all proximal humeri were found to be "critical types" (CD <8 mm) as to the recommended minimal proximal reaming diameter of 10 mm of straight antegrade nails currently in use. Moreover, 43.2% (131/303) of the humeri were considered "critical types" with regard to the alternatively used larger proximal reaming diameter of 11.5 mm. Mean CD was 9.0 ± 1.7 mm (range 3.5-13.5 mm) and did not correlate with age (r = -0.04, P = 0.54). No significant differences in CD and rate of "critical types" were found between left and right humeri as well as between females aged between 75 and 84 years (n = 151) and females aged 85 and older (n = 152)., Conclusions: More than a third of proximal humeri of geriatric females are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications, such as rotator cuff violation, fixation failure, and potential malreduction. In view of this finding, we recommend to routinely analyze multiplanar CT reformations of the uninjured contralateral side prior to surgery to improve selection of patients for SAHN and to minimize foreseeable complications. For "critical type" humeri, an alternative surgical procedure should be considered.

Objective: To compare the outcomes of patients who underwent either open reduction internal fixation with a locking plate and screws or closed reduction internal fixation with an antegrade intramedullary nail (IMN) for displaced surgical neck fracture of the humerus., Design: Retrospective comparative study., Setting: Single institute, Level-I academic trauma center., Patients and Intervention: Sixty-nine patients with 2-part surgical neck fracture of the humerus underwent either an IMN (38 patients group A) or a locked plate fixation (31 patients group B)., Outcomes Measurement: Pain on a visual analog scale, University of California Los Angeles (UCLA) Shoulder Score, American Shoulder and Elbow Surgeons (ASES) score, and active range of motion (ROM)., Results: At the 2-year follow-up, there were no significant differences in the visual analog scale pain score (1.3 in group A; 0.9 in group B), ASES score (90.2 in group A; 91.9 in group B), and UCLA Shoulder Score (30.7 in group A; 31.8 in group B) between groups. Active ROM did not differ significantly between groups. There were 3 complications in the IMN group, 1 nonunion requiring autogenous iliac crest bone graft, and 2 cases of screw loosening., Conclusions: For displaced surgical neck fractures of the humerus, both IM nailing and locked plate fixation in patients yielded satisfactory outcomes at the 2-year follow-up with no significant differences in pain or ROM between groups., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The aim of this study was to analyze outcomes of treatment and complications in children treated with flexible intramedullary nailing (FIN) due to humeral fracture., Hypothesis: The FIN for treatment of humeral fractures in children would allow an early functional and cast-free follow-up with a quick pain reduction and low complication rate., Patients and Methods: From May 2002 until May 2016 case records of all children who underwent fixation with titanium intramedullary nails because of humeral fracture were retrospectively reviewed. The study included 118 patients treated with FIN for proximal humeral or humeral shaft fracture. The average age at the time of trauma was 12 years. Mean follow-up was 77 months. Left hand was affected in 51% of patients. The most common mechanism of injury was fall (n=58), followed by sports injuries, road traffic accidents, pathological fractures, motorbike accidents and bicycle riding., Results: There were no residual valgus/varum deformities. All patients achieved complete radiographic healing at a mean of 7.5 weeks. Nine complications were recorded: 1 humeral shaft fracture in patient with osteogenesis imperfecta, 4 entry site skin irritations, 2 skin infections and 2 radial nerve injuries. There were no cases of delayed union, nonunion or mal-union. After removal of the nails, all patients regained full function and all complications resolved., Discussion: The FIN for humeral fractures is a minimally invasive, simple and well reproducible technique with very low complication rate., Conclusion: The FIN for treatment of humeral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction., Level of Evidence: Level IV - retrospective study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Proximal humerus fractures (PHFs) are common injuries seen mostly in elderly patients. Although nonoperative management is acceptable for most patients, surgical fixation is often advocated for younger patients or active, elderly patients with reconstructable fractures. A variety of fixation methods exist: percutaneous pinning, open reduction and internal fixation with locking plates, and intramedullary nailing are viable options. Modern intramedullary nails serve as excellent options for the fixation of many operative PHFs. In this Supplemental Digital Content 1 (see video, http://links.lww.com/JOT/A27), we discuss the care of a 63-year-old active, healthy female with a 2-part PHF. The details of fixation of PHFs using a straight intramedullary nail are included, as well as a relevant literature review and description of our postoperative rehabilitation protocol.

Background: Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus., Methods: Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types., Results: Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found., Conclusion: Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about non-operative treatment of proximal humerus 4-part and severe displaced fractures as those are normally treated operatively. In this study, we present a historical collective of two level I trauma centers, where all humeral head fractures, despite displaced fractures, received non-operative treatment within a 10 years period. Functional and clinical results of 2-, 3- and 4-part fractures were compared to those after fixed angle intramedullary nailing by matched pair analysis., Methods: Between 2000 and 2010, 167 patients with 2-, 3- and 4-part humeral head fractures were treated non-operatively in two level I trauma centers in Rostock. Complete clinical, functional and radiographic follow-up were available for 41 patients in the retrospective analysis. The results were compared by matched-pair analysis to a prospective series of 143 patients treated by antegrade intramedullary nailing using a proximal humeral nail. Of these 143 patients complete radiological and clinical 12 months' follow-up was available for 117 patients. Thus, it was possible to built 41 pairs according to age, gender, and fracture type. Statistical significant differences in constant score (CS), pain, activity of daily living (ADL), range of motion (ROM) and muscle strength were evaluated by Wilcoxon test. Furthermore, x-ray analysis of fracture healing and complications were recorded., Results: Operative treatment was not superior to non operative treatment concerning functional results, even in displaced fractures. The only significant difference was found in 3-part-fractures, where better ROM was reached in the non-operative group (p = 0.05). In contrast, there was a tendency toward better activity of daily living (ADL) in intramedullary nailing, but this did not reach statistical significance. X-ray findings revealed better anatomical reconstruction with less valgus and varus displacements after surgery (15% versus 50%, p < 0.005). The complication rate of 37% was higher in the surgery group with a reoperation rate of 32%., Conclusion: In our study, surgical treatment by fixed angle intramedullary nailing (Targon PH) seems not to be superior to non-operative treatment, regardless of fracture type. In 2-, 3- and 4-part fractures functional and clinical results were similar., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: Humeral head necrosis (HHN) remains a major problem in fracture care. Neither its occurrence, its extend, nor its impact on clinical outcomes is predictable on the long term. This study was designed to evaluate clinical and radiological outcomes in patients depending on the influence of HHN., Patients and Methods: 32 patients with a 3-6 year follow up participated in this study. Their humeral fractures had been stabilized with a standard Targon PH nail (Aesculap, Tuttlingen, Germany) for an acute humeral head fracture. Constant score (CS), DASH score, UCLA shoulder rating scale, and Neer score were assessed. Range of motion (ROM) as well as pain during exercise was documented (VAS). HHN was detected radiologically and graded in stages 0-5., Results: All fractures had healed. HHN was found in 10 cases (31.3%). 4 patients (12.5%) showed interlocking screw perforation as part of the head collapse caused by HHN. Median CS was 73 (range: 24-85). There was no association detectable between number of fracture fragments and CS (p ≥ 0.631). The median DASH score was 16.4 (range: 0-74.1), UCLA score 30 (range: 9-35), Neer score 80 (range: 29-100). Three (37.5%) of the patients with a stage IV or V osteonecrosis reported about pain (twice VAS grade 4, once VAS grade 5). All patients suffering from pain were affected by high grade HHN and screw perforation. CS was nonsignificantly affected by HHN (75.5 vs. 63.5; p = 0.12), however massively diminished if additional implant protrusion was present (63.5 vs. 25; p = 0.02). Findings for normalised CS, relative CS, DASH score, UCLA shoulder rating scale, Neer score, and ROM were analogous., Discussion: Whereas HHN itself seems to contribute only mildly to functional outcome, we identified screw protrusion as major predictor for bad clinical results. The high rate of HHN found in our study (31.3%) may be attributed to the inclusion of mild HHN and our long follow-up period, as it is known that late-onset HHN may occur more than 3 years after trauma., Conclusions: HHN may lead to screw perforation, resulting in poorest outcomes. We recommend regular clinical and radiographic follow-up for at least five years in order to detect impending screw perforation and plan screw removal in time., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other., Material and Methods: This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN)., Results: After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group., Conclusion: If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area., Level of Evidence: IV, retrospective study., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Introduction: Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking., Materials and Methods: Forty-three patients treated with a Long Diphos Nail ® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed., Results: Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment., Conclusions: The results of the study indicate the efficacy of Long Diphos Nail ® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site., Study Design: retrospective, cohort of cases., Level of Evidence: IV., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Antegrade intramedullary nailing has become the gold standard to treat two-, three-, and four-part cephalo-tuberosity fractures. We report a retrospective study of 6 patients who have undergone centro-medullary nailing since January 2012. Mean follow-up was 12 months; the average age was 57 years. Clinical evaluation was based on gross and weighted Constant and Murley score, based on the age and sex, compared to the "normal" body surface area. Radiological assessment allowed us to evaluate bone healing, the occurrence of osteonecrosis of femoral head or of post-traumatic arthrosis. Radiological examination focused even on the state of the tuberosities and on the existence or not of osteolysis of the greater tubercle of the humerus. It was also used to identify the criteria for good reduction, namely cephalic cap angle and diaphyseal axis (αF) in face views. All patients underwent the same surgical procedure. Constant and Murley score for all patients was 64.13 points. Weighted score based on age and sex was 73%. Joint mobility was estimated at an average of 116° for all patients in anterior elevation, 99.9° in lateral elevation, and 42° in external rotation. Average αF angle was 42°. All patients met criteria for good reduction, namely αF. Centro-medullary nailing allows simple and cost-effective bone synthesis with very promising functional results. Comminuted fractures and osteoporosis may limit these indications., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêt.

Background: Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures., Methods: In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates., Results: There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672)., Conclusion: Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck., Hypothesis: The additional calcar screw improves stiffness and failure load., Methods: Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05)., Results: No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases., Discussion: The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: There are multiple surgical treatment methods for proximal humerus fractures (PHF), but rarely do they provide satisfactory results. The objective of this study was to assess radioclinical outcomes and complications in patients treated using a modern intramedullary nailing system the Telegraph I(®)., Materials and Methods: This is an observational multicenter study cohort conducted between March 2008 and December 2009 on 105 patients admitted with a diagnosis of PHF and operated on two trauma I centers. The Neer and Articular Surgical neck Tuberosities classifications were used for the study. The primary outcome measure was the clinical Constant score. Follow-up of the patients was done at 6 weeks, 3 months, 6 months, 1 year, and 3 years after the procedure., Results: A total of 67 patients (51 women and 16 men) were assessed at a mean of 38 months. The weighted Constant score was 88%. The mean rate of complications was 16%. The weighted Constant scores were 84 and 95% for the 2- and 3-part groups, respectively. Articular 4-part fractures had an average score of 86% when they were valgus impacted and 67% for complex disengaged fractures. Notably, the complication rate was 67% for this latter group., Conclusions: Our clinical results support the use of this antegrade nailing for extra-articular and valgus-impacted articular fractures. This procedure does not appear suitable for displaced articular fracture for which arthroplasty may be indicated by elderly.

Proximal humeral fractures are complex lesions with difficult management problems; therefore, they pose a challenge for orthopaedic surgeons. In the literature, numerous treatment techniques have been proposed for these kinds of fractures. In our study we reviewed 30 patients with a mean age of 75 years presenting a proximal humeral fracture (Neer 2-3) and treated at our clinic with a Polarus nail, with a mean follow-up of 7 years. We obtained 73.3% of good and excellent results in line with literature. Complications were recorded in 6 of the patients (20%) recruited in our study. In particular, 3 cases of proximal screw pull-out, 1 case of deep infection and 2 cases of acromio-clavicular joint impingement syndrome. The aim of our study was to review our case histories and compare them with the literature analysing this complex type fracture and treatment options.

PURPOSE. To report the outcomes of Polarus nail fixation for displaced proximal humeral fractures. METHODS. Medical records of 19 men and 27 women aged 26 to 84 (mean, 63) years who underwent fixation using a standard Polarus nail (n=34) or Polarus plus nail with shaft extension (n=12) for proximal humeral fractures of 2 and 3 parts (n=34) and 2-part with extension to the shaft (n=12) were reviewed. Fracture union, neck shaft angle, and hardware complications were evaluated using radiographs. Outcomes were assessed using the Constant score, the visual analogue scale for pain, and subjective satisfaction. The range of motion, grip strength, and ability to return to work were also recorded. RESULTS. The mean follow-up was 20 (range, 15-28) months. The mean humeral neck shaft angle was 137.2º. 44 (96%) patients achieved fracture union after a mean of 14 (range, 11-16) weeks. Two patients with 3-part fractures did not unite; one of them underwent hemiarthroplasty and the other consented for nail removal only. Complications included temporary radial nerve palsy (n=2), impingement symptoms caused by the prominent metal work (n=10), and missing of the proximal screws in the nail (n=4). Respectively in patients aged <60 (n=15) and ≥ 60 years (n=31), the mean Constant scores were 79 and 67 (p=0.04). The mean pain score improved from 93 to 15.5 at 12 months. 16 patients were very satisfied, 22 were satisfied, and 8 were not satisfied with the outcome. Of the latter, 3 were aged <60 years and 5 were aged ≥ 60 years. CONCLUSION. Polarus nail fixation for displaced proximal humeral fractures achieved good fracture union and satisfactory functional outcome, particularly in younger patients and those in active employment, but elderly dependent patients tended to have poor functional results. The rates of minor hardware problems and non-union in 3-part fractures were relatively high.

The optimal surgical treatment for displaced proximal humeral fractures continues to be controversial. One of the new treatment options is the minimally invasive intramedullary nail. The purpose of this study was to evaluate the functional outcome of using the TRIGEN proximal humeral nail (PHN) for the treatment of displaced proximal humeral fractures in elderly patients. From January 2004 to December 2008, 64 elderly patients (age > 60 years old) with displaced proximal humeral fractures were treated using TRIGEN PHN. A complete 12-month postoperative follow-up was available for 54 patients. The study cohort included two-part (29 shoulders), three-part (22 shoulders), and four-part (3 shoulders) Neer classification fracture types. The Constant-Murley score was used to assess functional outcome. Radiological outcomes were evaluated, and all complications were recorded. All fractures were united. The Constant-Murley score data indicated that the patients experienced improvement from 6 to 12 months postoperatively. The mean absolute Constant-Murley score on the injured side increased from 71.2 ± 11.2 points at 6 months to 82.4 ± 16.4 points at 12 months (P = 0.01). The mean neck-shaft angle 1 year after surgery was 125° ± 8.1° (95°-140°). Secondary complications were minimal and observed in only 6 of 54 patients. In conclusion, the TRIGEN intramedullary humeral nail is effective for the treatment of proximal humeral fractures.

This study aims to assess the functional outcome of children treated with elastic stable intramedullary nailing (ESIN) for displaced proximal humerus fractures using the short version of the disabilities of the arm, shoulder, and hand outcome questionnaire (Quick DASH). Fifty-eight consecutive children with displaced proximal humerus fractures were treated with ESIN. Fifty-two children (89.7%) were available for follow-up and responded to the questionnaire after hardware removal. Average age at time of injury was 11.1 ± 2.8 years (range, 4-15.9). Among the 52 patients available for evaluation, 37 had a Quick DASH score of 0 (71.1%), seven a score of 2.3 (13.5%), four a score of 4.5 (7.7%), and four a score of 6.5 (7.7%). Shoulder and elbow ranges of motion were comparable with the noninjured side. No skin irritation or local infections were observed. There was no radiographic evidence of delayed union, refracture, hardware migration, or secondary displacement. Mean follow-up was 18.3 ± 8.3 months (range, 6-39.5). Our study reports good functional outcomes in children with closed isolated fractures, both physeal and metaphyseal, of the proximal humerus treated with ESIN. The use of a standardized rating scale is recommended to homogeneously compare functional outcome and may facilitate the comparison of clinical outcome in different patient populations.

Objective: To evaluate the effectiveness of titanium elastic nails for severe displaced proximal humeral fractures in older children., Methods: Between April 2009 and July 2012, 31 cases of severe displaced proximal humeral fractures were treated with closed or open reduction and fixation with 2 titanium elastic nails, and the clinical data were retrospectively analyzed. There were 23 boys and 8 girls, aged from 10 to 15 years (mean, 12.8 years). The causes of injury were sports injury (16 cases), traffic accident (11 cases), and falling from height (4 cases). The interval from injury to operation was 6 hours to 7 days (mean, 72 hours). According to Neer-Horwitz classification, 17 cases were rated as type III fracture and 14 cases as type IV fracture. There were 21 cases of metaphyseal fractures and 10 cases of epiphyseal fractures., Results: Satisfactory reduction of fracture and stable fixation were obtained in all patients (closed reduction in 23 cases and open reduction in 8 cases). Primary healing was achieved in all incisions; no infection and neurovascular injury occurred. All patients were followed up 12-36 months with an average of 20 months. X-ray films showed that all fractures healed at 7-10 weeks (mean, 8 weeks). During follow-up, no disturbance of development or angulation deformity caused by premature physeal closure or bone bridge formation was observed. At last follow-up, the average Neer score of the shoulder was 95.7 (range, 83-100). The appearance and motion of the shoulder were normal. There was no significant difference in the upper extremity length between affected side and contralateral side [(67.68 +/- 2.56) cm vs. (67.61 +/- 2.54) cm; t = 1.867, P = 0.072]., Conclusion: Titanium elastic nails for severe displaced humeral fractures in older children is a safe and effective method with a low complication incidence.

Introduction: The retrospective study was made to evaluate the fracture patterns at the proximal humeral shaft for which the long version of a standard proximal humeral nail (PHNLV) has been used. The indication has been decided by the individual surgeons., Patients and Methods: Over a five year period 72 consecutive PHNLV cases of an acute fracture were identified and were included in the study. Mean patient age was 68.9 years. Gender ratio was m/f=22/50. 86.1% of the patients fractured their humerus by a fall, the rest by a high velocity accident. We analysed patient comorbidity, ASA score, osteoporosis, social status before accident, additional injuries affecting local soft tissues or other anatomic regions. We analysed the expansion of the fractures, dividing the humerus into five zones. Fracture morphology was categorized according to the standard AO/ASIF classification (if applicable)., Results: Comorbidities were found in 76.4% of the patients. Almost all patients (93.1%) had been living independently at home before the accident. 47.2% of patients had osteoporosis in their medical history. Five patients (6.9%) had a primary palsy of the radial nerve. Six fractures chosen for PHNLV fixation were clearly restricted to the humeral head. The remaining 66 fractures were located in the humeral shaft (AO region 12). There were 5 segmental fractures. Of the remaining 67 fractures affecting the proximal third of the humeral shaft 49.3 percent extended into the humeral head. 98 percent of these fractures displayed spiral morphology., Discussion: Proximal humeral shaft fractures are amazingly similar to subtrochanteric and distal tibial shaft fractures: Spiral fracture types with different grades of comminution are absolutely dominant; a great proportion of the fractures extend into the humeral head with growing tendency of displacement if located closer to the humeral head. Diverging traction of deltoid and pectoralis muscle causes typical displacement if the fracture line runs in between their attachments substantiating the term 'intermuscular fracture'. A distinct classification system for proximal humeral shaft fractures seems meaningful and is proposed., Conclusions: There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third. They explain the specific problems of reduction and fixation. If disrespected they will lead to higher rates of therapeutic failure., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Completely displaced metaphyseal fractures of the proximal humerus in older children may need reduction and stabilization. The authors describe a technique for closed reduction and intramedullary stabilization of these fractures using a centromedullary pin inserted from the distal humerus through a small distal incision. This technique was used successfully in 2 adolescents. Retrograde elastic nails avoid scars in front of the shoulder, impingement problems from prominent extramedullary metal work, and further surgery of a similar magnitude to remove the metalwork. Based on the authors' experience, they recommend this method for reduction and stabilization of displaced irreducible metaphyseal fractures of the proximal humerus in older children and adolescents., (Copyright 2012, SLACK Incorporated.)

Objective: Anatomical reduction of two- to four-part fractures of the proximal humerus using indirect reduction techniques. Intramedullary fixation with a short humerus nail. Restoration of a stable bone-implant construct that enables early functional after-treatment., Indications: Displaced and unstable two- to four-part fractures of the proximal humerus. Fractures of the proximal humerus extending in the humeral diaphysis (use a long nail). Ipsilateral combined lesions of the proximal humerus and the humeral diaphysis (use a long nail)., Contraindications: Poor physical and/or mental status. Critical soft tissue conditions in the area near the surgical site. Local soft tissue infection. Pre-existing severe osteoarthritis of the shoulder joint; severe shoulder stiffness. Head-split fractures of the humerus head that cannot be reduced., Surgical Technique: Exposure of the fracture using an anterior acromial approach and determination of the correct nail entrance point. Anatomic fracture reduction using indirect reduction techniques. Stable fixation using an intramedullary MultiLoc® nail. Determination of the proximal locking configuration depending on the fracture morphology. Distal locking with angle-stable option. POST-OPERATIVE TREATMENT: Post-operative radiographs for documentation of the surgical result and implant position. Use of an arm sling for 7-10 days. Active and passive exercises of the shoulder joint starting on day 1. Shoulder abduction limited to 60° for 2 weeks. Subsequent abduction to 90° until the 4th week. Subsequent active mobilisation without restrictions. Weight bearing and sporting activities after 3 months. Radiological evaluation after 2, 6 and 12 weeks., Results: During a 6-month period, 160 patients were documented in a prospective clinical multicentre study. According to the AO classification, there were 36% A-type fractures, 41% B- and 23% C-type injuries. A 6-month follow-up was available for 17 patients. The mean age of these patients was 67 years. One patient had an A-type fracture. There were ten B- and six C-type fractures. At the time of follow-up, the mean Constant score was 66 points. Radiographically, all fractures had healed. Intra-articular screw penetration and loss of reduction were both observed once.

Introduction: Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus., Methods: We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently., Results: Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%., Conclusions: Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: The ideal fixation technique for the treatment of proximal humeral fractures remains unclear. In the present study, we evaluated the experience of three surgeons with the treatment of two-part surgical neck fractures with angular-stable intramedullary fixation., Methods: Forty-eight patients with forty-eight Neer two-part surgical neck proximal humeral fractures were managed with locked angular-stable intramedullary nail fixation by three surgeons. Shoulder pain and outcomes were quantified with Constant scores and standard radiographs., Results: Thirty-eight patients (including twenty-eight female patients and ten male patients) with a mean age of sixty-five years were followed for at least twelve months (mean, twenty months; range, twelve to thirty-six months). All fractures healed primarily. The mean follow-up Constant score (and standard deviation) was 71 ± 12 points (range, 37 to 88 points), with a mean age-adjusted Constant score of 97% (range, 58% to 119%). The mean Constant pain score was 13 ± 2.2 (possible range, 0 to 15 points, with 15 points representing no pain). The mean forward flexion was 132° ± 22°. All fractures but one healed with a neck-shaft angle of ≥125°., Conclusions: Patients who were managed with locked angular-stable intramedullary nailing of two-part surgical neck proximal humeral fractures via an articular entry point had reliable fracture-healing, favorable clinical outcomes, and little residual shoulder pain.

Objective: To evaluate the preliminary results of minimally invasive treatment for severely displaced proximal humeral fractures in children using titanium elastic nails (TENs)., Methods: Twenty-five cases of TEN treatment of severely displaced proximal humerus fractures in children were evaluated clinically and radiographically. Complications were assessed. The 14 males and 11 females were between 6 and 15 years of age at the time of surgery. Of the 10 left and 15 right humeri treated, 3 were open fractures and 2 were associated with polytrauma. Two laterally inserted retrograde TENs were used in 22 cases. In the remaining 3 cases, 1 medial and 1 lateral TEN were inserted retrograde., Results: Follow-up ranged from 7 to 40 months. All fractures showed both clinical and radiographic evidence of healing within 2 months. There were no major complications related to the treatment. There were 3 cases of skin irritation adjacent to prominent distal ends of the nails, of which the 2 nails in 1 child were removed prematurely at 3 weeks without sequelae. The nails in the other 2 cases were removed at the planned 6-month postoperative time with complete resolution of symptoms. Function of the fractured arm returned to normal quickly in all cases., Conclusions: TEN for the treatment of severely displaced humerus fractures in children is an effective method with a low complication rate.

Background: The Polaris nail is an intramedullary device for treating displaced proximal humerus fractures with few published studies to support its use. Results of a consecutive series of patients treated with the Polaris nail are presented., Methods: Eighteen patients with a mean age of 71 years (range, 37-84) were treated for twelve 2- and six 3-part fractures. Radiographic results for all patients were evaluated. Thirteen patients with an average follow-up of 42 months (range, 24-84) were available for functional evaluation., Results: Seventeen of 18 patients healed. Postoperatively, the neck/shaft angle collapsed an average 11° (range, 5-30°) into varus. Nine of 18 patients had final neck/shaft angles <120° and were considered radiographic malunions. The mean Constant and American Shoulder and Elbow Surgeons (ASES) scores were 61 (range, 20-100) and 67 (range, 10-100), respectively. Forward elevation averaged 118°. Patients had an average 5/8 positive rotator cuff signs. Seven patients underwent reoperation for loss of fixation or prominent hardware, and 1 required revision to a hemiarthroplasty., Conclusion: This study shows a higher than reported percentage of unsatisfactory results using the Polaris nail. The device violates the rotator cuff and is unable to resist the deforming forces that can lead to loss of fixation and varus collapse., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Fractures of the humeral shaft are less frequent than those of the proximal humerus. The formerly recommended treatment of humeral shaft fractures was conservative according to Böhler. This still remains an adequate concept of treatment but according to a change in the technical possibilities and the demands of patients and physicians on fast restoration of function and low pain, there is a trend towards surgical stabilization of humeral shaft fractures. The implant of choice is discussed controversially and consists of various types of nails versus plating. The technique of nailing is antegrade or retrograde and depends on the localization of the fracture. In our opinion good indications for plating are combined fractures of the proximal humerus and the shaft as well as very distal humeral shaft fractures. A primary lesion of the radial nerve is no imperative indication for exploration and different studies have shown the same results for exploration after 2 or 3 months if there is no spontaneous remission.

Background: The "palm tree-like wiring" introduced by Kapandji and its modifications for proximal humeral fractures should be given the generic name "retrograde intramedullary multiple pinning through the deltoid 'V'" (IMPV). IMPV is still preferable for treating valgus-impacted four-part fractures in which K-wires have the advantage of working as an internal fixation material as well as a tool in fracture reduction., Methods: Three 2.4-mm K-wires formed into the desired shape are used as the intramedullary pins and a 3.0- to 3.2-mm upwardly angled hole for each wire is opened in the deltoid "V." After the tips of two wires are introduced into the lateral aspect of the head, the valgus deformity of the head is gradually corrected by alternately tapping the two wires under fluoroscopy. When the head and metaphysis are strongly compressed together, open reduction is attempted. If required, the tuberosity fragments are surgically reduced and stabilized. We performed IMPV on one C2.1 fracture and nine C2.2 fractures with 1 year or more follow-up., Results: No nonunion was observed, but avascular head necrosis with collapse was observed in two C2.2 fractures, of which constant score ratios to the normal side were 55% and 64%, respectively. The constant score ratios of the other eight patients were 92% ± 8% (70-96%)., Conclusions: IMPV is considered to be a preferable reducing and stabilizing method for valgus-impacted four-part fractures regardless of patient age. Additionally beneficial is being able to use the intramedullary pins as a tool for bone fragment reduction.