From the Guidelines
Intramedullary (IM) nailing is the preferred surgical treatment for midshaft humerus fractures, providing stable fixation while preserving soft tissue, as recommended by recent guidelines 1. The procedure begins with patient positioning in either the beach chair or lateral decubitus position under general anesthesia.
Key Steps:
- After prepping and draping, a 3-5 cm incision is made at the anterolateral acromion for antegrade nailing or at the distal humerus for retrograde approach.
- The rotator cuff is split (for antegrade) or the triceps is split (for retrograde) to access the entry point.
- A guide wire is inserted through the fracture site under fluoroscopic guidance, followed by reaming the medullary canal 1-1.5 mm larger than the planned nail diameter.
- The appropriate sized IM nail (typically 7-9 mm diameter) is then inserted over the guide wire.
- Proximal and distal interlocking screws are placed to prevent rotation and provide axial stability.
Postoperative Care:
- Wound closure follows standard technique, and postoperative care includes arm immobilization in a sling for 2 weeks, followed by progressive range of motion exercises.
- Physical therapy typically begins at 2-4 weeks, with strengthening exercises added at 6-8 weeks.
- Full recovery takes 3-6 months. This technique offers advantages of minimal soft tissue disruption, preservation of fracture hematoma, and earlier mobilization compared to plate fixation, though it carries risks of shoulder pain and rotator cuff injury with the antegrade approach, as noted in recent studies 1.
Important Considerations:
- The choice of approach (antegrade or retrograde) depends on the fracture location and patient anatomy.
- Radiotherapy should follow the orthopedic management 2-4 weeks later, as recommended by guidelines 1.
- The use of intramedullary nailing in combination with other fixation techniques, such as external fixation, may be considered in complex cases, as shown in recent research 1.
From the Research
Procedure for Treating Midshaft Humerus Fracture with Intramedullary Nailing
The procedure for treating a midshaft humerus fracture with intramedullary (IM) nailing involves several steps:
- Preoperative planning: The patient is indicated for humeral nailing given the comminuted nature of the diaphysis and to allow for minimal skin incisions 2.
- Anesthesia and positioning: The patient is positioned on the operating table to allow for easy access to the affected arm.
- Incision and approach: A small incision is made in the skin to allow for the insertion of the intramedullary nail.
- Reduction and fixation: The fracture is reduced, and the intramedullary nail is inserted into the medullary canal of the humerus to stabilize the fracture 2.
- Verification of fixation: The fixation is verified using imaging studies such as X-rays or fluoroscopy to ensure that the fracture is properly aligned and stabilized.
Indications and Contraindications
The indications for intramedullary nailing for midshaft humerus fractures include:
- Comminuted fractures
- Soft-tissue compromise about the arm precluding a large surgical exposure 2
- Fractures that require minimal skin incisions The contraindications for intramedullary nailing include:
- Fractures that are not amenable to closed reduction
- Fractures with significant bone loss or comminution that cannot be stabilized with an intramedullary nail
Advantages and Disadvantages
The advantages of intramedullary nailing for midshaft humerus fractures include:
- Minimally invasive procedure with small incisions
- Reduced risk of complications such as infection and nerve damage
- Faster recovery time compared to open reduction and internal fixation (ORIF) 2 The disadvantages of intramedullary nailing include:
- Limited access to the fracture site for direct reduction and fixation
- Risk of nail malfunction or failure
- Potential for shoulder impingement or elbow problems due to the nail 3
Postoperative Care
The postoperative care for patients who have undergone intramedullary nailing for midshaft humerus fractures includes:
- Pain management with analgesics and anti-inflammatory medications
- Immobilization of the affected arm in a sling or brace to allow for healing
- Early mobilization and rehabilitation to prevent stiffness and promote recovery 4