Proximal Humeral Nail in the Treatment of 3 and 4-part Fractures of the Proximal Humerus- a Long Term Cohort Study

Introduction: Proximal humerus fractur es are common fractures amongst the elderly population suffering from osteoporosis. The optimal treatment of Neer 3 and 4-part fractures has been debated extensively, and remains controversial. The treatment options are either conservative treatment, shoulder arthroplasty or fracture fixation using either a plate or intramedullary nailing.

Intramedullary nailing using a Proximal Humeral Nail (PHN) has been advocated as an effective and less invasive surgical technique. The purpose of this study is to describe the demographics, radiographic follow up, patient reported outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.

Patients and Methods: 63 consecutive patients with Neer 3 and 4-part fractures were included in this study. The fractures were classified based on the AO classification (AO 11) and the Modified Neer classification. All patients had the fractures stabilized with a standard Targon PH nail (Aesculap, Tuttlingen, Germany). All patients had at least 6 months of follow up. Patient follow up radiographs were scrutinized for evidence of non-union, humeral head avascular necrosis (AVN), hardware penetration and post-traumatic osteoarthritis.

During post-operative follow up, STT score, ASES score, VAS score and patient ROM were assessed.

Results: 60 patients with 63 fractures were included in this study. 25 fractures were classified as Neer 4 fractures and 38 fractures as Neer 3 fractures. The average follow-up was 900 days after surgery (range 250-2386). All fractures achieved union, with 4 cases of AVN. These 2 cases were asymptomatic. 5 fractures required a subsequent operation for refixation or hardware retrieval. At last follow up, the average VAS was 1.3 (+/- 2.19), STT 8.4 (+/- 3.33) and ASES 80.33 (+/- 20.8).

Conclusion: Although PHN is a routinely used in fixation of Neer 2-part fractures, we present a series of 3 and 4-part fractures which were successfully treated with PHN achieving acceptable rate of fracture union and long-term functional outcome with a minimal rate of AVN. PHN can be considered as an effective treatment in these patients.