Closed Reduction Internal Fixation of Humeral Head Fracture with Ender's Nail and CC Screw
Critical Note on Evidence Availability
The provided evidence does not contain specific guidelines or research describing the CRIF technique using Ender's nail combined with cannulated compression screws for humeral head fractures. The available guidelines address pediatric supracondylar fractures 1, imaging protocols 1, and research on humeral shaft (not head) fractures 2, 3, 4. One study describes modern straight antegrade locking nails for proximal humeral fractures 5, which represents current standard practice rather than the Ender's nail technique you're asking about.
Historical Context
Ender's nails were historically used for humeral shaft fractures with reported advantages of shorter operative time (mean 51 minutes), less blood loss (mean 70 ml), and shorter hospital stays (5.8 days) compared to plating 2. However, this technique is largely obsolete for humeral head fractures in contemporary practice.
General Procedural Framework (Based on Intramedullary Nailing Principles)
Patient Positioning
- Beach-chair position with head of bed elevated approximately 45° 5
- Ensure adequate fluoroscopic access for anteroposterior and lateral views
Fracture Reduction
- Achieve closed reduction first using traction and manipulation 5
- Verify reduction quality on orthogonal fluoroscopic views
- Consider percutaneous Kirschner wire temporary fixation if reduction is unstable 5
Entry Point and Nail Insertion
- Make 1-cm incision at the superior aspect of the humeral head 5
- For Ender's nail technique specifically: Entry point would typically be lateral to avoid rotator cuff injury
- Bluntly dissect to bone to avoid axillary nerve injury 5
- Create starting point with awl or cannulated reamer
- Insert Ender's nail(s) in retrograde fashion from proximal to distal
- Advance nail while maintaining reduction until proximal end is buried beneath subchondral bone
CC Screw Fixation
- Verify nail position and fracture reduction fluoroscopically before screw insertion 5
- Use percutaneous drill sleeves for cannulated screw placement
- Pre-drill screw trajectories through targeting guides
- Insert cannulated compression screws through greater tuberosity into humeral head
- Ensure screws achieve adequate purchase in subchondral bone without penetrating articular surface 5
- Verify final screw position on orthogonal fluoroscopic views
Wound Closure
- Copious irrigation of all incisions 5
- Layer closure with absorbable sutures
- Sterile dressing application
- Place arm in abduction sling postoperatively 5
Major Complications to Avoid
- Iatrogenic radial nerve palsy (reported in 3.3% of cases with internal fixation) 2
- Shoulder impingement from prominent proximal hardware (may require removal) 2
- Inadequate fracture reduction leading to malunion
- Screw penetration of articular surface 5
- Injury to axillary nerve during percutaneous approaches 5
Contemporary Alternative
Modern straight antegrade locking nails with proximal locking screws represent the current standard and offer superior outcomes with mean active elevation of 132-136°, external rotation of 37-52°, union rates of 95-100%, and patient satisfaction rates of 97% 5. This technique provides angular stability in osteopenic bone while preserving soft tissue vascularity through minimal dissection 5.