Percutaneous and Intramedullary Devices for Proximal Humerus Fractures: Past, Present or Future?

Christina Hiscox, M.D., FRCSC
Ryan T. Bicknell, M.D., MSc, FRCSC
Queen's University
Kingston, ON

Optimal treatment of proximal humerus fractures is based on many factors including fracture pattern, age, bone quality and surgeon experience. This necessitates a fracture and patient specific approach to treatment. Historically, the use of percutaneous and intramedullary devices has been criticized for poor results and high complication rates. However, recent improvements in indications, technology and techniques have lead to an increase in popularity, and may show promise for the future.

 

Principles

These techniques have the advantage of less dissection and soft tissue disruption and have potential use in medically unwell patients under regional anaesthesia. However, they require a closed reduction or percutaneous reduction techniques. As a result, these techniques are usually reserved for minimally displaced fractures with minimal comminution, primarily 2- and 3-part fractures, in patients with good bone quality. Therefore, patient selection is a key factor to a successful outcome.

Complications of these techniques include neurovascular injury, pin/screw loosening, fracture displacement, articular cartilage penetration, infection, avascular necrosis and glenohumeral joint arthritis1,4,6,3. The anatomy should be considered to avoid injury to neurovascular structures and good fluoroscopic images must be obtained to rule out cartilage perforation. Rowles et al. found that lateral pins were a mean of 3 mm from the axillary nerve and anterior pins were 2 mm from the long head of biceps, 11 mm from the cephalic vein and 17 mm from the musculocutaneous nerve1. Tuberosity pins were six and 7 mm from the axillary nerve and posterior circumflex artery respectively. Thirty-three percent of pins penetrated the articular cartilage despite using fluoroscopic guidance.

Percutaneous Pinning

The use of threaded pins in 2- and 3-part fractures with minimal comminution is preferable. Herscovici et al. found a 100% failure rate with smooth K-wires, and a 20% failure with terminally threaded pins2. They also found a 100% failure rate in patients with 4-part fractures. Fenichel et al. found 70% of 2 and 3-part fractures treated with threaded pins had good or excellent results and 14% had significant secondary displacement due to failure of fixation, all in 3-part fractures3. Keener et al. found satisfactory results in 3 and 4-part fractures with good bone quality and lack of medial comminution4.

Newer systems that connect the pins may provide more stable constructs. Castoldi et al. found that the diameter of the wires and length of the threads did not affect results5. If the wires converged through the fracture site there was less resistance to torsion and bending. If the ends of the wires were linked together by an external fixator there was increased stiffness and strength. Carbone et al. found that pins locked in a metallic clip placed externally on the skin had better outcomes and fewer complications than traditional percutaneous pinning6. There were 27% complications in the percutaneous group and 11% in the linked group. Three-part fractures did better than 4-part fractures in both groups.

Intramedullary Nails

Traditionally, IM nails were inserted through the rotator cuff footprint and therefore often caused problems with shoulder pain7. Other issues with earlier IM nails have included screw back out8 and nonunion from excessively large nails. However, newer designs are angular stable and use variable mechanisms of locking the proximal fixation to the nail9. Some authors have suggested a more medial articular starting point for the nail, avoiding the greater tuberosity10,11,12. This technique spares the rotator cuff insertion and has little effect on the humeral head articular surface, resulting in a decreased rate and severity of postoperative shoulder pain.

Armodios et al. evaluated outcomes of 2-part fractures treated with angular-stable intramedullary nail fixation13. The nails were inserted through a more medial articular start point. All fractures healed with little residual pain. The mean Constant score was 71 points with an age-adjusted score of 97% and mean forward elevation of 132 degrees. There was no loosening of the proximal fixation, the malunion rate was 3% and there was no evidence of osteonecrosis. Four patients (11%) required re-operation after fracture healing.

Zhu et al. preformed a randomized controlled trial in 2-part fractures comparing locking plates versus locking nails14. At one year, the average ASES, VAS scores, and strength of the supraspinatus were significantly better in the locking plate group. However, at three years, no significant difference was found in any parameters and there were fewer complications in the nail (4%) compared to the plate group (31%).

Conclusions

There are several options for the treatment of proximal humerus fractures, each with its associated advantages and disadvantages. Although percutaneous techniques are currently less popular than other options, they have several benefits - especially with newer implants and procedures. These advantages include a reduction in soft tissue dissection, the ability to perform surgery under regional anaesthesia in medically ill patients, and the decreased complication rates seen in some studies. However, patient selection, fracture type, bone quality and surgeon experience is essential to achieving a successful outcome with these techniques.

References

  1. Rowles D.J., McGrory J.E. Percutaneous Pinning of the Proximal Part of the Humerus: An Anatomic Study. J Bone Joint Surg Am 2001;83-A(11):1695-1699.
  2. Herscovici D., Saunders D.T., Johnson M.P., Sanders R., DiPasquale T. Percutaneous Fixation of Proximal Humeral Fractures. Clin Orthop Relat Res 2000;375:97-104.
  3. Fenichel I., Oran A., Burstein G., Perry M. Percutaneous Pinning Using Threaded Pins as a Treatment Option for Unstable Two- and Three-Part Fractures of the Proximal Humerus: A Retrospective Study. Int Orthop 2006;30(3):153-157.
  4. Keener J.D., Parsons B.O., Flatow E.L. Outcomes After Percutaneous Reduction and Fixation of Proximal Humeral Fractures. J Shoulder Elbow Surg 2007;16(3):330-338.
  5. Castoldi F., Bonasia D.E., Blonna D., Rossi R., Dettoni F., Assom M., Sankey A., Halewood C., Amis A. The Stability of Percutaneous Fixation of Proximal Humeral Fractures. J Bone Joint Surg Am 2010;92(S2):90-97.
  6. Carbone S., Tangari M., Gumina S., Postacchini R., Campi A., Postacchini F. Percutaneous Pinning of Three- or Four-Part Fracturesof the Proximal Humerus in Elderly Patients in Poor General Condition: MIROS® Versus Traditional Pinning. International Orthopaedics (SICOT) 2011.
  7. Boileau P., D'ollonne T., Clavert P., Hatzidakis A., Fehringer E., Wirth M. et al. Intramedullary Nail for Proximal Humerus Fractures: An Old Concept Revisited. Shoulder concepts 2010 Arthroscopy & Arthroplasty 2010:201-224.
  8. Adedapo A., Ikpeme J. The Results of Internal Fixation of Three-and Four-Part Proximal Humerus Fractures with the Polarus Nail. Injury 2001;32:115-121.
  9. Fakler J.K., Hogan C., Heyde C., John T. Current Concepts in the Treatment of Proximal Humeral Fractures. Orthopedics 2008;31:42-51.
  10. Mittlmeier T., Stedtfeld H., Ewert A., Beck M., Frosch B., Gradl G. Stabilization of Proximal Humeral Fractures with an Angular and Sliding Stable Antegrade Locking Nail (Targon PH). J Bone Joint Surg Am 2003;85:136-46.
  11. Cuny C., Pfeffer F., Irrazi M., Chammas M., Empereur F., Berrichi A., Metais P., Beau P. A New Locking Nail for Proximal Humerus Fractures: The Telegraph Nail, Technique and Preliminary Results. Rev Chir Orthop Reparatrice Appar Mot 2002;88:62-7.
  12. Park J.Y., Pandher D.S., Chun J.Y. Antegrade Humeral Nailing Through the Rotator Cuff Interval: A New Entry Portal. J Orthop Trauma 2008;22:419-25.
  13. Hatzidakis A.M., Shevlin M.J., Fenton D.L., Curran-Everett D., Nowinski R.J., Fehringer E.V. Angular-Stable Locked Intramedullary Nailing of Two-Part Surgical Neck Fractures of the Proximal Part of the Humerus:A Multicenter Retrospective Observational Study. J Bone Joint Surg Am 2011;93:2172-9.
  14. Zhu Y., Lu Y., Shen J., Zhang J., Jiang C.  Locking Intramedullary Nails and Locking Plates in the Treatment of Two-Part Proximal Humeral Surgical Neck Fractures. A Prospective Randomized Trial with a Minimum of Three Years of Follow-up. J Bone Joint Surg Am. 2011;93:159-68.

 

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