Intramedullary Locking Nail Fixation of Proximal Humerus Fractures: Rationale and Technique

  • Pascal BoileauEmail author
  • Thomas d’Ollonne
  • Armodios M. Hatzidakis
  • Mark E. Morrey


Displaced, unstable two-, three-, and four-part proximal humerus fractures with a vascularized and attached head fragment require reduction and internal fixation. However, optimal surgical treatment remains controversial. Based on our experience, intramedullary (IM) nailing with interlocking screws does provide a suitable alternative to percutaneous pinning and locking plating with the benefits of both (minimal soft-tissue dissection, adequate fixation strength). Analysis of the common complications and technological problems related to previous conventional IM nails have allowed us to define the rationale and characteristics of the ideal IM locking nail. The novel design of the Aequalis IM locking nail combines unique features that allow a less invasive surgical intervention, sustain the vascularization of the fracture fragments, angular stability of proximal fixation, and optimal screw orientation for fixation of the tuberosities. The percutaneous approach for a two-part fracture and the superior transdeltoid approach to fix a three- or four-part fracture are described, and the encouraging results of this novel IM locking nail are reported.


Rotator Cuff Humeral Head Great Tuberosity Proximal Humeral Fracture Proximal Humerus Fracture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Neer II CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–89.PubMedGoogle Scholar
  2. 2.
    Neer CS. Displaced proximal humeral fractures. Part II. Treatment of three and four-part displacement. J Bone Joint Surg Am. 1970;52A:1090–103.Google Scholar
  3. 3.
    Boileau P, Pennington SD. Common pitfalls in the management of proximal humeral factures: how to avoid them. In: Boileau P, editor. Shoulder fractures. Montpellier: Sauramps; 2008.Google Scholar
  4. 4.
    Drosdowech DS, Faber KJ, Athwal GS. Open reduction and internal fixation of proximal humerus fractures. Orthop Clin North Am. 2008;39(4):429–39. vi. Review.PubMedCrossRefGoogle Scholar
  5. 5.
    Gradl G, Dietze A, Arndt D, et al. Angular and sliding stable antegrade nailing (Targon PH) for the treatment of proximal humeral fractures. Arch Orthop Trauma Surg. 2007;127(10):937–44.PubMedCrossRefGoogle Scholar
  6. 6.
    Misra A, Kapur R, Maffulli N. Complex proximal humeral fractures in adults: a systematic review of management. Injury. 2001;32(5):363–72.PubMedCrossRefGoogle Scholar
  7. 7.
    Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg. 2008;17(1):42–54.PubMedCrossRefGoogle Scholar
  8. 8.
    Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am. 2007;89:44–58.PubMedCrossRefGoogle Scholar
  9. 9.
    Krishnan SG, Lin KC, Burkhead WZ. Pins, plates, and prosthesis: current concepts in treatment of fractures of the proximal humerus. Curr Opin Orthop. 2007;18:380–5.CrossRefGoogle Scholar
  10. 10.
    Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009;91(7):1689–97.PubMedCrossRefGoogle Scholar
  11. 11.
    Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audigé L, Babst R. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23(3):163–72.PubMedCrossRefGoogle Scholar
  12. 12.
    Owsley KC, Gorczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures. J Bone Joint Surg Am. 2008;90:233–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91(6):1320–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg. 2010;19(4):489–94.PubMedCrossRefGoogle Scholar
  15. 15.
    Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg. 2004;13:191–5.PubMedCrossRefGoogle Scholar
  17. 17.
    Cuny C, Pfeffer F, Irrazi M, Chammas M, Empereur F, Berrichi A, Metais P, Beau P. A new locking nail for proximal humerus fractures: the Telegraph nail, technique and preliminary results. Rev Chir Orthop Reparatrice Appar Mot. 2002;88(1):62–7.PubMedGoogle Scholar
  18. 18.
    Kazakos K, Lyras DN, Galanis V, et al. Internal fixation of proximal humerus fractures using the Polarus intramedullary nail. Arch Orthop Trauma Surg. 2007;127(7):503–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Koike Y, Komatsuda T, Sato K. Internal fixation of proximal humeral fractures with a Polarus humeral nail. J Orthop Traumatol. 2008;9:135–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Lin J. Effectiveness of locked nailing for displaced three-part proximal humeral fractures. J Trauma. 2006;61:363–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Mittlmeier TW, Stedtfeld HW, Ewert A, et al. Stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail (Targon PH). J Bone Joint Surg Am. 2003;85 Suppl 4:136–46.PubMedGoogle Scholar
  22. 22.
    Parsons M, O’Brien J, Hughes J. Locked intramedullary nailing for displaced and unstable proximal humerus fractures. Tech Shoulder Elbow Surg. 2005;6(2):75–86.CrossRefGoogle Scholar
  23. 23.
    Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elbow Surg. 2001;10:7–10.PubMedCrossRefGoogle Scholar
  24. 24.
    Sosef N, Stobbe I, Hogervorst M, et al. The Polarus intramedullary nail for proximal humeral fractures: outcome in 28 patients followed for 1 year. Acta Orthop. 2007;78(3):436–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Bernard J, Charalambides C, Aderinto J, Mok D. Early failure of intramedullary nailing for proximal humeral fractures. Injury. 2000;31:789–92.PubMedCrossRefGoogle Scholar
  26. 26.
    Cuomo F, Flatlow EL, Maday M, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two and three part surgical neck fractures of the proximal humerus. J Shoulder Elbow Surg. 1992;1:287–95.PubMedCrossRefGoogle Scholar
  27. 27.
    Smith AM, Mardones RM, Sperling JW, Cofield RH. Early complications of operatively treated proximal humeral fractures. J Shoulder Elbow Surg. 2007;16:14–24.PubMedCrossRefGoogle Scholar
  28. 28.
    Van den Broek CM, Van den Besselaar M, Coenen JM, et al. Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment. Arch Orthop Trauma Surg. 2007;127(6):459–63.PubMedCrossRefGoogle Scholar
  29. 29.
    Young AA, Hughes JS. Locked intramedullary nailing for treatment of displaced proximal humerus fractures. Orthop Clin North Am. 2008;39(4):417–28.PubMedCrossRefGoogle Scholar
  30. 30.
    Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br. 1997;79(5):857–65.PubMedCrossRefGoogle Scholar
  31. 31.
    Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Edelson G, Safuri H, Salami J, Vigder F, Militianu D. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008;17(3):399–409.PubMedCrossRefGoogle Scholar
  33. 33.
    Boileau P, et al. Intramedullary nail for proximal humerus fractures: an old concept revisited. In: Shoulder concepts 2010—Arthroscopy & Arthroplasty. Montpellier: Sauramps; 2010. p. 201–23.Google Scholar
  34. 34.
    D’Ollonne T, Challali M, Bronsard N, Boileau P. Tridimensional geometry of proximal humeral fractures: the three- and four-part concept revisited. In: Boileau P et al., editors. Shoulder concepts 2012. Arthroscopy, arthroplasty and fractures. Montpellier: Sauramps; 2012. p. 283–93.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Pascal Boileau
    • 1
    Email author
  • Thomas d’Ollonne
    • 1
  • Armodios M. Hatzidakis
    • 2
  • Mark E. Morrey
    • 3
  1. 1.Department of Orthopaedic Surgery and Sports TraumatologyL’Archet 2 HospitalNiceFrance
  2. 2.Western Orthopaedics PCDenverUSA
  3. 3.Department of OrthopedicsMayo ClinicRochesterUSA

Personalised recommendations