European Journal of Trauma and Emergency Surgery

Focus on Intramedullary Nailing

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures Jochen Blum1, René Engelmann2, Raphael Küchle2, Matthias Hansen1, Pol M. Rommens2

Abstract There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fractures of the humerus can be nailed with satisfying results. Basic ideas for humeral nailing are less invasive approaches to the humerus, less soft tissue damage, e.g. lower rates of radial nerve palsy, closed reduction and the biomechanical aspects of a central implant with elastic fixation properties. Nailing of diaphyseal humeral shaft fractures is an equivalent alternative to plating; nailing of proximal metaphyseal humeral fractures is still new and needs more reliable scientific data to clear its advantages compared to other fixation techniques. Nailing of distal metaphyseal humeral fractures is no serious option at the moment. Angular stable interlocking systems show better fixation qualities for proximal fractures or fracture components. Although in very osteoporotic bone cutouts are registered. Static interlocking is advisable. High torsional stability of the fracture fixation has to be achieved, since significant torsional load occurs during the usual movement of the upper limbs. As there is an important learning curve, possible complications of intramedullary nailing have to be kept in mind and avoided by a careful operation technique. Key Words Humeral shaft fracture Æ Nailing Æ Angle stable Eur J Trauma Emerg Surg 2007;33:149–158 DOI 10.1007/s00068-007-7035-3

Introduction Still today many surgeons consider the humerus to be a long bone that is most suitable for conservative treatment, at least in the case of diaphyseal or proximal metaphyseal fractures [1]. This differs from the distal metaphyseal humeral fractures, which for almost all authors are subject to open reduction and internal fixation. Nevertheless, there is an increasing tendency toward open reduction also in diaphyseal or proximal metaphyseal fractures, as better techniques and implants allow for better reduction and fixation. Furthermore, patient’s expectations for an early mobilization under stable condition of the humerus are also increasing [2, 3]. For this aim obviously many different methods and implant models are available, which points out that also today there is no golden standard in the operative treatment of diaphyseal or proximal metaphyseal fractures of the humerus [4–7]. Having reserved external fixators for specific fracture situations as wide open humeral fractures or highly contaminated soft tissues on the upper arm, the choice to opt for plating or nailing is difficult to be based purely on scientific data and results, as there are too many influencing factors and too small study populations still today [5–7]. Furthermore, it seems that monomaniac behavior in respect to plates and nails will lead to a smaller spectrum of treatment possibilities and thus might create the wrong choice of implant in specific situations. Nevertheless, plating traditionally finds more support than nailing in the community of orthopedic

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Department of Trauma, Hand, and Reconstructive Surgery, Academic Teaching Hospital of the University Mainz, Worms, Germany, 2 Department of Trauma Surgery, University Hospital of the Johannes Gutenberg University of Mainz, Mainz, Germany. Received: February 27, 2007; revision accepted: February 28, 2007; Published Online: April 4, 2007

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trauma surgeons. Therefore, ther intramedullary nailing humeral shaft fractures is a where should it be preferred

the question arises wheof humeral head and valuable alternative and against plating?

History of Intramedullary Humeral Nailing Gerhard Ku¨ntscher used intramedullary nailing to stabilize humeral shaft fractures in a non-interlocked fashion [8]. Ender nails, Rush pins, and Hackethal nails as bundle nailing had been used in the 1980s and 1990s [9, 10]. They were thin nails rather than rods. Low rotational stability, migration tendency and rotator cuff perforation were known complications. For proximal metaphyseal humeral fractures in the past nailing still did not offer serious alternatives to plating. This is different for children and their humeral fractures, where the use of retrograde elastic titanium nails without interlocking is widespread and accepted [11]. The search for lesser invasive operative procedures also for the humerus with the advantage of elastic fixation led to the development of several new humeral nail generations. Another motivation was also to lower the risk of radial nerve palsy known from humeral plating [3, 12–14]. In a first moment, the effect of the development has been a wider acceptance of humeral shaft nailing and in recent years also the success of nailing proximal humeral fractures. In order to combine the biological advantage of nailing with a high amount of stability, modern humeral nails are interlocked. First prototypes had been introduced by Derduweden [15] and Seidel [10, 16–18]. They opened the path for further development, leading to the modern interlocked humeral nails. In discussing the modern concepts of intramedullary nailing of the humerus, a distinction between diaphyseal and metaphyseal humeral fractures, as well as the combination of both is necessary. Nevertheless, modern humeral nail families include both a diaphyseal nail and a proximal nail [Expert Humeral Nail (EHN-AO) or T2 Humeral nail (Stryker) and others].

Humeral Shaft Fractures and Nailing Approach There is still an ongoing discussion about the approach for humeral nailing [12, 19]. Early humeral nails like the original Seidel nail showed large diameters and needed reaming. This is connected with a nail insertion through a rotator cuff split [7], which led to intense criticism against the antegrade approach

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[17, 18]. Possible damage to the shoulder function has been a strong argument for the retrograde approach, which is still our standard approach [20–25]. Being extra-articular, it is technically more demanding, but less threatening for the joint functions of the upper extremity. Since modern humeral nail systems led to smaller nail diameters and furthermore follow an unreamed technique, the contrast between antegrade and retrograde approaches is less sharp today. For proximal metaphyseal fractures, the antegrade approach is the appropriate one; in pure diaphyseal fractures, we still prefer the retrograde approach, if possible [2, 12, 19, 26]. The modern concept of antegrade humeral nailing uses a small anterior incision, starting from the acromio-clavicular joint [6, 8, 12, 27]. Using a deltoidsplit, this remains more biological than the lateral approach, since it leads through the raphe between anterior and middle 1/3 of deltoid. Furthermore opening the medullary canal should be performed slightly medially from the major tuberculum and not through the insertion of the supraspinatus tendon in order to avoid later rotator cuff dysfunction (Figures 1a to 1c). The modern concept of retrograde humeral nailing chooses the entry portal proximally of the olecranon fossa [8, 21, 24]. The dorsal surface of the distal humerus is exposed after longitudinal splitting of the distal triceps fibers. The bone area beginning at the superior edge of the olecranon fossa and extending approximately 25 mm proximally is exposed. The ideal entry point to the medullary canal is located at the center of an imaginary triangle between the medial and lateral supracondylar ridge and the roof of the olecranon fossa. After predrilling the entry point is enlarged with a conical burr to 10 mm of width and 20 mm of length. In the case of a very narrow canal, hand reamers are used to increase the diameter of the canal. The assembled nail is inserted without force, especially without a hammer. With careful rotatory hand movements, the nail is driven to the fracture gap and beyond after fracture reduction, with good visualization provided by image intensifier [2, 19, 24, 25] (Figures 2a to 2c). The limits of both approaches are diaphyseal fractures, which distally will not allow for insertion of two interlocking bolts, thus being in the distal 4 cm of the shaft. Clinical and biomechanical discussions about using an antegrade rather than a retrograde approach for these very distal shaft fractures are still ongoing and not perfectly answered yet [19, 28].

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Blum J, et al. Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

Figures 1a to 1c. Antegrade humeral nailing: a) Pathological humeral shaft fracture in a female patient with mamma carcinoma, a.p.-view. b) Antegrade insertion of a 7.5 mm UHNÒ, proximal oblique static interlocking, a.p.- and lateral view. c) Situation after 6 months with progressive metastasis – sufficient stability as palliative treatment, a.p.- and lateral view.

Figures 2a to 2c. Retrograde humeral nailing without interfragmentary compression: a) Spiroid fracture of the humerus after rotation of the arm with a hammer in hand. Patient with long-time cortisone therapy, wide intramedullary canal, a.p.- and lateral view. b) Retrograde insertion of a 9.5 mm UHNÒ, static interlocking, postoperatively, a.p.- and lateral view. c) Bony consolidation after 16 weeks, a.p.- and lateral view.

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Interlocking Modern concepts in intramedullary nailing of humeral shaft fractures are based on interlocked nails [2, 8, 19, 23, 28, 29] mostly titanium-nails. The reason for interlocking is the problem of torsional load on the humeral shaft, which is more significant compared to tibial or femoral nailing, where axial load is the leading component. Biomechanical testing with interlocked nails showed almost the same rotational stability than in humeral plate osteosynthesis, increasing even more in static interlocking [4, 20, 30–36]. New nail generations like the ‘‘unreamed humeral nail (UHN)’’, its cannulated version the ‘‘Expert humeral nail (EHN)’’, the ‘‘T2humeral nail’’ or the ‘‘Targon humeral nail’’ [37] and others offer this options. Especially, the feature of possible interfragmentary compression showed to be useful in transverse shaft fractures, where the effect of torsional load is even more evident, since those fracture patterns show only low fragment indentation. The low intrinsic torsional stability contains a higher risk of nonunion and can be targeted through the compression of the fracture gap [38–40] (Figures 3a to 3c). Obviously, the need for interlocking at the nail tip might offer some difficulties, since for most nails it needs free-hand interlocking and is not guided through an aiming device. A new humeral nail type, an expandable nail (FixionÒ) has been designed in order to substitute free hand interlocking. The technology behind the FixionÒ humeral nail is based on an expandable, stainless steel tube with reinforcement bars. The insertion is performed with the folded nail in a reduced diameter. Once positioned, it is expanded within the medullary canal using pressurized saline solution. The expansion should enable the nail to adapt to the shape and diameter of the medullary canal. Own biomechanical data demonstrated [41] that especially under torsional load, the stability achieved with this nail is not sufficient. Proximal Humeral Fractures and Nailing The proximal metaphyseal humeral fracture seemed not to be suitable for nailing for many years. But newly designed short humeral nails with angle-stable interlocking options offer a better fixation quality in the humeral head and are able to treat proximal metaphyseal fractures with good stability [8, 26, 37]. For the epiphyseal fractures, they might show also a serious alternative for plating, but here additional hardware, e.g., screw fixation of head split fractures might be necessary.

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Basically two different interlocking concepts are realized. The proximal humeral nail of the AO (PHN) uses a spiral blade in order to give a broader support in the humeral head (Figures 4a to 4c and figures 5a to 5g). This blade is angle-stable locked in the nail itself through an end cap, giving pressure on the blade [8, 26]. Other nail types, like T2-PHN and the Targon nail [37], use instead of a smooth locking hole a threaded hole that corresponds to the thread of the interlocking screws. These multiple interlocking screws are placed multidirectional in order to fix several fracture fragments through the nail’s aiming device. Another advantage of all those short humeral nails is the possibility of distal locking also through the aiming device. Combined Humeral Head and Humeral Shaft Fractures Special cases with combined diaphyseal and proximal metaphyseal fractures have always been difficult to treat. Usually a very long plate osteosynthesis with enormous dissection of soft tissue has been necessary. The new technological features of the short nails are available also for long interlocking humeral nails [8, 27]. The option of an angular stable spiral blade is also possible to be combined with the unreamed humeral nail (UHN/EHN). This enlarges to indication to very proximal diaphyseal fractures as well as to combinations of ipsilateral two- or three-fragment metaphyseal and diaphyseal fractures (Figures 6a to 6e). On the other side, the option gives more stability in osteoporotic bone. The same is valid for the long versions of the T2- and Targon-humeral nails [31, 37]. Pitfalls in Humeral Nailing Besides the advantages of humeral nailing obviously several complications are possible and also experienced. Some of those are general complications, like infections, which are rare and can also be observed in other procedures in the treatment of humeral shaft fractures. Other complications are more specific for humeral nailing and its approaches. Compared to plate osteosynthesis, the rate of intraoperative radial nerve lesions is lower, but still existing. In our experience it ranges actually at 2.4% [2, 19, 22, 23]. Reasons are mostly stress on the nerve during positioning of the patient, mainly when turning the patient for a prone position. Since the procedure is closed, a certain risk remains for fractures at the transition of the middle to the lower shaft, to impinge the nerve in the fracture gap.

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Blum J, et al. Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

Figures 3a to 3c. Retrograde humeral nailing with interfragmentary compression: a) Short oblique humeral shaft fracture, a.p.- and lateral view. b) Retrograde insertion of a 7.5 mm UHNÒ, interfragmentary compression, static interlocking, postoperatively, a.p.- and lateral view. c) Bony healing after 13 weeks, a.p.- and lateral view.

Figures 4a to 4c. Antegrade nailing with proximal humeral nail. a) Surgical neck fracture of the humerus. b) Treatment with proximal humeral nail (PHN)Ò and angle stable spiral blade, postoperatively. c) Bony healing, a.p.- and lateral view after 3 months.

The proximal interlocking process might harm branches of the axillary nerve. Clinically, we hardly have seen damage to this nerve, but our own morphologic-anatomical studies have shown that especially the dorsal-ventral bolt (Figure 7) is in near vicinity to the main branches of this nerve [29]. The distal bolts of the PHN are placed quite proximally. Similar cadaver studies in our laboratory

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showed that these bolts target medially towards the radial nerve. This implicates that drilling for these bolts should be controlled carefully after perforation the medial cortex. Furthermore those bolts should not override the medial cortex by more than 2–3 mm. A known complication of the retrograde approach is the occurrence of fissures or even fractures in the condylar region [2, 19, 25]. Main causes are the selec-

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Figures 5a to 5g. Antegrade nailing with proximal humeral nail and tension band. a-c: Three-part-fracture of the proximal humerus, a.p. a) lateral. b) and axial c) view. d, e) Treatment with proximal humeral nail (PHN)Ò angle stable spiral blade and suture tension band of the greater tubercle, a.p.- and lateral view postoperatively. f, g) Bony healing, a.p.- and lateral view after 14 weeks.

tion of a nail with a too large diameter as well as the creation of an insufficient entry portal. This has not only to be large enough, but needs also an angle of approximately 30° inclination in respect to the shaft, in order to insert the nail almost in line with the intramedullary canal. Furthermore this complication can be caused through the use of a hammer instead of pure rotating hand force. If the shaft isthmus in respect to the general medullary canal diameter is low, hand reamers should be used first [24]. The complication of a nonunion can be avoided in transverse fractures through the use of interfragmentary compression [38–40] in order to close

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the fracture gap completely. In long-distance-spiroid fractures, with dislocated fragments, additional cerclage wires might help to avoid disturbance of bone healing. The angle stable proximal interlocking systems like spiral blade or angle stable screws were developed overall for osteoporotic bone. Still in very osteoporotic bone stock of the humeral head the cutting out phenomenon has been experienced with and maybe because of the very stable fixation. Since the interface between nail and blade or screw is so rigid, the week bone might cut through [26, 27]. An undiscovered head split with following nail insertion through an undis-

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Blum J, et al. Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

Figures 6a to 6e. Antegrade nailing with standard humeral nail and spiral blade. a) Ipsilateral comminuted diaphyseal and proximal metaphyseal humeral fracture. b, c) Treatment with 7.5 mm UHNÒ and spiral blade, postoperatively, a.p.- and lateral view. d, e) Bony consolidation, 4 months after trauma.

Figure 7. Vicinity of axillary nerve branch and dorso-ventral interlocking bolt at the nail tip in retrograde nailing with the UHNÒ (both latero-medial bolts are in a safe distance).

placed but split region might also be a possible origin for following cut out. Discussion Diaphyseal as well as proximal metaphyseal fractures of the humerus are definitively not subjects for ‘‘golden standard therapies’’. Although there exists a

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huge amount of creativity in developing new techniques and implants for the fixation of these fractures, the variety of fracture patterns and situations make clinical studies difficult to be compared with and very often the decision of treatment is led mainly by personal experience, which is connected with very subjective bias. Today nailing for these fractures owns a solid base, but is not without critics. On one side we find general reservations towards operative treatment of these fractures [1]. On the other side, when accepting an indication for internal fixation, some authors prefer plating as a general procedure for humeral fractures, others vote for nailing. Analyzing literature each opinion finds support, which shows that there is no definitive answer. Our experience in humeral shaft fractures is based on a multicenter study with the ‘‘unreamed humeral nail’’. We find a lower rate of radial nerve damage and no significant differences in nonunion rates compared to the literature data of plating. Remarkable is the occurrence of fissures or fractures at the entry portal of the retrograde nailing approach in three out of eightyfour patients, which all healed [2, 19]. Chapman et al. [42] compared the clinical and radiographic results for locked intramedullary nails and plates used in the treatment of humeral diaphyseal fractures. They stated from their results that for patients requiring surgical treatment of a humeral shaft

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fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing. The recovery of shoulder joint function after operative treatment of humeral shaft fracture had been analyzed by Flinkkila et al. [5], in a comparative study between antegrade intramedullary nailing and plate fixation. Shoulder scores and isometric strength measurements showed no difference between the groups, but the shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups. Analyzing the treatment of humeral shaft fractures with humeral locked nails and comparison with plate fixation, Lin [7] found that locked nailing had significantly shorter operation time and less blood transfusion than did plate fixation. Union rate and time to union were not significantly different. He concluded that humeral locked nailing offered a less invasive surgical technique and more favourable treatment results than did plate fixation. A study on treatment of humeral shaft nonunions comparing nailing versus plating by Martinez et al. [13] concluded that both plate fixation and the unreamed humeral locked nail are good alternatives for the treatment of humeral shaft nonunions, although nailing achieves union earlier and has fewer complications. Early results are available of a specific flexible humeral nail system, which can be introduced in a curved fashion and will be straightened and stiffens inside the medullary canal, the Flexnail [43, 44]. Mu¨ller et al. [43] interpreted their data that damage to the rotator cuff and the distal humerus can be avoided due to its flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures. Stannard et al. [44] experienced with their patient series that although the nail functioned well in most of their patients, the use of a small-diameter (7.5-mm) nail was associated with a higher complication rate. For the proximal humeral nails the experiences are still new and limited. Preliminary results of a multicenter study concerning the ‘‘Proximal Humeral Nail PHN (AO)’’ [26, 27] were based on the Constant– Morley and DASH score. In total, 108 patients could be followed up until 1 year postoperatively. Important complications were perforation of the articular surface by screw or spiral blade (n = 8), pain due to the implant (n = 10), dislocation of fragments (n = 2), nonunion (n = 2), humeral head necrosis (n = 3), and wound infection (n = 1). The Constant–Morley score shows in total mean values 1 year postoperatively of

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75.3 in the injured and of 89.9 in the noninjured side. The DASH score preoperatively was in total 5.9 and 9.3, 1 year, postoperatively. Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related to technical failure of nailing. In some cases, the nail has not been introduced profoundly enough or the length for the spiral blade was not determined exactly and probably not controlled intraoperatively. The development of nonunion (2/108) shows a ratio equal or even better to what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments show the limit of this procedure, where in multifragmentary fracture types one spiral blade will not be able to fix all fragments. Using additional hardware is possible, but might reduce the advantages of an initially low invasive approach. Over all Constant-Morley score and Dashscore results perform similar to plate osteosynthesis, where clearly C-type-fractures present the worst results. Mittlmeier et al. [37] used the Targon PH, where instead of a spiral blade, multiple proximal locking screws were used. Mid-term results of a prospective follow-up study of 50 patients with complete examinations after 3, 6 and 12 months postoperatively showed good functional results with 78.8 Constant score points after 1 year, corresponding to 92% of the Constant score of the contralateral intact side. However, numerous complications were observed, mainly related to backing out of the fixation screws. Patients with manifest complications had a less favourable functional result (65.8 Constant score points corresponding to 73% of the contralateral intact side). In consequence modifications of the surgical technique for stabilization of the tubercles (additional suture cerclage fixation of fragmented tubercles) and a novel technical modification preventing the backing out mechanism of the fixation screws has been initialized.

Conclusion The success of intramedullary nailing of humeral shaft fractures is based on its modern concepts. Interlocking options, small nail diameter, unreamed techniques, and the integration of angle stable features together with smaller approaches are the modern pillars of a convincing operative concept. There was a significant increase in acceptance of these nails during the past 6 years. Nevertheless, clinical studies focused on possible complications. They point out that the technique of

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Blum J, et al. Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

intramedullary nailing is not a simple one and should be well planned and carried out carefully. Results of nailing of proximal metaphyseal fractures show that there is still a place for further improvement. May be in the future innovative spirit might also extend the nailing indication toward distal metaphyseal fractures, avoiding the large approaches in this region that still are necessary today. References Sarmiento A, Kinman PB, Galvin EG, et al. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;59:596–601. 2. Blum J, Rommens PM, Janzing H, et al. Retrograde Nagelung von Humerusschaftfrakturen mit dem UHN – eine internationale multizentrische Studie. Unfallchirurg 1998;101:342–52. 3. Bonnaire F, Seif El Nasr M. Indikation und Technik der Plattenosteosynthese am Oberarmschaft. Akt Traumatol 1997;27:86–90. 4. Chen AL, Joseph TN, Wolinksy PR, et al. Fixation stability of comminuted humeral shaft fractures: locked intramedullary nailing versus plate fixation. J Trauma 2002;53:733–7. 5. Flinkkila T, Hyvonen P, Siira P, et al. Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation. Arch Orthop Trauma Surg 2004;124:537–41. 6. Hessmann MH, Blum J, Hofmann A, et al. Internal fixation of proximal humeral fractures: current concepts. Eur J Trauma 2003;29:253–61. 7. Lin J. Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation. J Trauma 1998;44:859– 64. 8. Blum J, Rommens PM. Modern concepts of intramedullary nailing of the humerus. Osteo Trauma Care 2004;13:121–9. 9. Henley MB, Chapman JR, Claudi BF. Closed retrograde Hackethal nail stabilization of humeral shaft fractures. J Orthop Trauma 1992;6:18–24. 10. Schratz W, Wörsdörfer O, Klöckner C, et al. Behandlung der Oberarmschaftfraktur mit intramedullären Verfahren (SeidelNagel, Marchetti-Vicenzi-Nagel, Prevot-Pins). Unfallchirurg 1998;101:12–7. 11. Schmittenbecher PP, Blum J, David S, et al. Treatment of humeral shaft and subcapital fractures in children. consensus report of the child trauma section. Unfallchirurg 2004;107:8–14. 12. Blum J, Rommens PM. Humeral Shaft: Surgical Approaches. In: Duparc J, ed. Surgical Techniques in Orthopaedics and Traumatology Edit. Scient. Médic. Elsevier, Paris, 2000. 13. Martinez AA, Cuenca J, Herrera A. Treatment of humeral shaft nonunions: nailing versus plating. Arch Orthop Trauma Surg 2004;124:92–5. 14. Siebert CH, Heinz BC, Höfler H-R, et al. Plattenosteosynthetische Versorgung von Humerusschaftfrakturen. Unfallchirurg 1996;99:106–11. 15. Derweduwen J. A new intramedullary compression device for fractures and pseudoarthrosis of the long bones. Acta Orthop Belg 1979;45:659–65. 16. Kelsch G, Deffner P, Ulrich C. Die Humerusverriegelungsnagelung nach Seidel - Klinische Ergebnisse nach 100 Anwendungen. Unfallchirurg 1997;100:111–8.

17.

18. 19.

20.

21.

1.

Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL

22.

23. 24.

25. 26.

27.

28. 29.

30.

31.

32.

33.

34.

35.

36.

37.

Riemer BL, Foglesong ME, Burke CJ, et al. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopedics 1994;17:19–29. Varley GW. The Seidel locking humeral nail: the Nottingham experience. Injury 1995;26:155–7. Blum J, Janzing H, Gahr R, et al. Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion. J Orthop Trauma 2001;15:342–9. Blum J, Machemer H, Baumgart F, et al. Biomechanical comparison of bending and torsional properties in retrograde intramedullary nailing of humeral shaft fractures. J Orthop Trauma 1999;13:344–50. Lin JL, Sheng-Mou H, Yi-Shiong H, et al. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop 1997;342:147–55. Rommens PM, Verbruggen J, Broos PL. Retrograde locked nailing of humeral shaft fractures. A review of 39 patients. J Bone Joint Surg Br 1995;77:84–9. Rommens PM, Blum J, Runkel M. Retrograde nailing of humeral shaft fractures. Clin Orthop 1998;350:26–39. Rommens PM, Blum J. Retrograde nailing of fresh and pathologic humeral shaft fractures with a new unreamed humeral nail (UHN). Tech Orthop 1998;13:51–60. Rommens PM, Blum J. Die retrograde Nagelung mit dem UHN – Klinische Ergebnisse. Akt Traumatol 2001;31:125–32. Blum J, Hessmann MH, Rommens PM. Behandlung proximaler metaphysärer Humerusfrakturen mit Verriegelungsmarknagelung und Spiralklinge – erste Erfahrungen mit einem neuen Implantat. Akt Traumatol 2003;33:7–13. Blum J, Hessmann MH, Rommens PM. Humeral nailing with spiral blade in the treatment of proximal diaphyseal and metaphyseal fractures. Phys Rehab Kur Med 2005;15:90–8. Lin JL, Hou SM. Antegrade locked nailing for humeral shaft fractures. Clin Orthop 1999;365:201–10. Blum J, Rommens PM. Proximale Verriegelung von Humerusmarknägeln und Verletzungsrisiko des N. axillaris. Unfallchirurg 2002;105:9–13. Blum J, Högner M, Baumgart F, et al. Die retrograde Eröffnung der Oberarmmarkhöhle. Biomechanische Untersuchung zur Stabilitätsänderung des Humerusschaftes. Unfallchirurgie 1999;25:207–14. Blum J, Hansen M, Sternstein W, et al. Humeral nailing: a biomechanical comparison of Stryker T2 and Synthes UHN. Osteo Trauma Care 2006;14:34–8. Dalton JE, Salkeld SL, Satterwhite YE, et al. A biomechanical comparison of intramedullary nailing systems for the humerus. J Orthop Trauma 1993;7:367–74. Henley MB, Monroe M, Tencer AF. Biomechanical comparison of methods of fixation of a midshaft osteotomy of the humerus. J Orthop Trauma 1991;5:14–20. Hessmann MH, Hansen M, Krummenauer F, et al. Locked plate fixation and intramedullary nailing for proximal humerus fractures: a biomechanical evaluation. J Trauma 2005;58:1194– 201. Schopfer A, Hearn TC, Malisano L, et al. Comparison of torsional strength of humeral intramedullary nailing: a cadaveric study. J Orthop Trauma 1994;8:414–21. Zimmerman MC, Waite M, Deehan M, et al. A biomechanical analysis of four humeral fracture fixation systems. J Orthop Trauma 1994;8:233–9. Mittlmeier TW, Stedtfeld HW, Ewert A, et al. Stabilization of proximal humeral fractures with an angular and sliding stable

157

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38.

39.

40.

41.

42.

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antegrade locking nail (Targon PH). J Bone Joint Surg Am 2003;85A( Suppl 4), 136–46. Blum J, Machemer H, Högner M, et al. Biomechanik der Verriegelungsmarknagelung bei Oberarmschaftfrakturen. Vergleichsuntersuchungen zweier Marknagelsysteme und des Effekts der interfragmentären Kompression beim unaufgebohrten Humerusnagel. Unfallchirurg 2000;103:183–90. Blum J, Rommens PM. Interfragmentäre Kompression bei der Humerusschaftnagelung mit einem speziellen Kompressionsgerät. Akt Traumatol 2001;31:90–4. Blum J, Rommens PM. Die komprimierte Marknagelung bei Oberarmschaftfrakturen. Trauma Berufskrankh 2001;3:188– 94. Blum J, Karagül G, Sternstein W, et al. Bending and torsional stiffness in cadaver humeri fixed with a self-locking expandable or interlocking nail system: a mechanical study. J Orthop Trauma 2005;19:535–42. Chapman JR, Henley MB, Agel J, et al. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma 2000;14:162–6.

43. Müller CA, Henle P, Konrad G, et al. The AO/ASIF Flexnail: A flexible intramedullary nail for the treatment of humeral shaft fractures Unfallchirurg 2006;November 23 [Epub ahead of print]. 44. Stannard JP, Harris HW, et al. Intramedullary nailing of humeral shaft fractures with a locking flexible nail. J Bone Joint Surg Am 2003;85:2103–10.

Address for Correspondence Prof. Dr. med. Jochen Blum Department of Trauma, Hand, and Reconstructive Surgery Academic Teaching Hospital of the University Mainz Gabriel-von-Seidl-Strasse 81 67550 Worms Germany Phone (+49/6241) 501-3200, Fax -3299 e-mail: [email protected]

Eur J Trauma Emerg Surg 2007 Æ No. 2 Ó URBAN & VOGEL

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures.

There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fra...
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