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 CME 4: October, November, December 2003
Trauma Test 1: Fractures of the Long Bones and Joints
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The Journal of Bone and Joint Surgery (American) 85:2103-2110 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Intramedullary Nailing of Humeral Shaft Fractures with a Locking Flexible Nail

James P. Stannard, MD1, Howard W. Harris, MD1, Gerald McGwin, Jr., PHD1, David A. Volgas, MD1 and Jorge E. Alonso, MD1

1 Division of Orthopaedic Surgery, University of Alabama at Birmingham, 509 Medical Education Building, 1813 6th Avenue South, Birmingham, AL 35294-3295. E-mail address for J.P. Stannard: james.stannard{at}ortho.uab.edu

Investigation performed at the Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Synthes) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A video supplement to this article is available from the Video Jour- nal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

Background: Studies on intramedullary nailing of humeral shaft fractures in the orthopaedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of a new flexible, locking intramedullary nail that can be implanted in the humerus in either a retrograde or an antegrade manner without violating the rotator cuff mechanism or damaging the articular surface of the humeral head.

Methods: Fifty consecutive patients with fifty-one humeral shaft fractures were entered into our prospective clinical outcome study. The fracture was classified on the basis of the anatomic location and pattern. Implant positioning and fracture alignment were assessed postoperatively. Complications were recorded, and the time to union was measured. Shoulder function was evaluated with use of a combination of the Constant shoulder score, Short Form-36 (SF-36) clinical outcome data, range-of-motion measurements, and a subjective pain-rating scale.

Results: Forty-one patients with forty-two fractures had an adequate duration of clinical follow-up (a mean of twenty-two months) for analysis. Thirty-nine fractures healed, with a mean time to clinical union of twelve weeks (range, four to fifty weeks). Thirty-eight of the forty-two shoulders had minimal or no pain. Thirty-six shoulders had a full range of motion. The mean Constant shoulder score was 90 points. Four patients had five complications, which included two nonunions, two hardware failures, and one wound infection. All four patients had been managed with a 7.5-mm nail. A multivariate analysis demonstrated that an age of more than fifty years was associated with a lower Constant score and that the occurrence of a complication was associated with a lower physical component score on the SF-36.

Conclusions: The flexible humeral nail allows both retrograde and antegrade implantation and static locking. Nail insertion can be accomplished without violating the rotator cuff or damaging the articular surface of the humeral head. Although the nail functioned well in most of our patients, the use of a small-diameter (7.5-mm) nail was associated with a higher complication rate. This implant should be used with caution in any patient with a medullary canal diameter of ≤8 mm.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.


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