OTA 2006 Posters

Scientific Poster #109 Geriatrics

Percutaneous Locked Intramedullary Nailing of 2-, 3-, and 4-Part Proximal Humerus Fractures
Steve Nguyen, MD (n);
J. Dean Cole, MD (c,e-DePuy, a Johnson and Johnson Company);
Donna L. Lamb, MBA, BSN (n); Alicia Torres, CST (n);
Fracture Care Center at Florida Hospital, Orlando, Florida, USA

Background: Acceptable treatments of proximal humerus fractures in the literature include hemiarthroplasty, open reduction and internal fixation (ORIF) with plates, and intramedullary nailing. The purpose of this study is to investigate whether second-generation nails with locking capability allows for adequate fixation of 2-, 3-, and 4-part proximal humerus fractures.

Methods: 44 patients (46 fractures) with 2-, 3-, and 4-part proximal humerus fractures were treated with the ACE locking proximal humeral nail. Three patients required hemiarthroplasty. Patients were placed on a captain's chair in a beach chair position. Manipulation of the humeral head fragment was performed with percutaneous K-wires to correct varus or valgus malalignment. Percutaneous incision was made over the proximal humeral head sharply splitting the deltoid and the rotator cuff in line with its fibers. Orthogonal views of the entry site were confirmed under fluoroscopy using axillary, internal, and external rotation of the proximal humerus. Starting reamer was then inserted over a K-wire. The nail was then inserted over a guide wire and locked proximally with 4.8-mm screws and distally with 3.5-mm screws. If the greater tuberosity required fixation, one of two methods were chosen: (1) Suture anchors were secured through one of the proximal locking holes in the nail and secured to the greater tuberosity through a small incision, or (2) The greater tuberosity was secured with suture to the subscapularis tendon. The proximal locking screws were then locked to the nail through a set screw. Intraoperative range of motion was tested following fixation. Postoperatively, patients were allowed to perform pendulum exercises and passive and active-assisted forward flexion and abduction for the first 6 weeks if there was a greater tuberosity repair. Active and passive range of motion was allowed if the greater tuberosity was stable and did not require repair. Minimal weight bearing on the shoulder was allowed until healing was noted.

Results: Average age of fixation was 67 years with 31 females and 13 males. There were twelve 2-part, twenty-four 3-part, and nine 4-part fractures. Of the three patients who underwent hemiarthroplasty, one was a 3-part head-splitting fracture dislocation and two were 4-part proximal humerus fractures. All other fracture configurations were amenable to fixation. 44% of fractures were left, 52% right and 4% bilateral. 21 patients required second incisions to repair the greater tuberosity. Nine patients were lost to follow-up. Average time to union was 5.2 months. There was one nonunion requiring ORIF that subsequently healed. There were no infections. The average range of motion in degrees was:

   Flexion  Abduction  Internal Rotation  External Rotation
 6 weeks  88  81  94  23
 12 weeks  117  88  101  34
 6 months  128  125  95  38


Conclusion: Percutaneous locked intramedullary nailing of proximal humerus fractures demonstrated high union rates, excellent early range of motion, and minimal morbidity. This method of repair appears to be a viable alternative to hemiarthroplasty or formal ORIF with plates. Head splitting injuries and some 4-part fractures in this series still required hemiarthroplasty. The use of a straight humeral locking nail (ACE-DePuy) allows for the use of the articular surface of the humeral head as a fixation point by allowing for a more medial starting point. This enhances the stability of the fixation construct.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
· The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an "off label" use). · · FDA information not available at time of printing.