Authors of section

Authors

Pol Rommens, Peter Trafton, Martin Jaeger

Executive Editors

Chris Colton, Steve Krikler

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Antegrade nailing

1. Principles

General considerations

Acute and pathological fractures can be nailed. The best indications for humeral shaft nailing are fractures located between the surgical neck and approximally 5 cm above the olecranon fossa.

There are many different nails on the market; the main difference between them relates to their nail design (straight vs bent nails) and their locking configurations. Some nails allow compression at the fracture site.

To demonstrate the principles, the illustrations below show the use of a straight nail. Some details may not be applicable with other nailing systems.

For antegrade nailing with a bent nail click here.

See also the discussion of bent vs straight nails.

Straight humeral nail

Note on illustrations

In some illustrations generic fracture patterns are shown, as four different types:

A) Unreduced fracture
B) Reduced fracture
C) Fracture reduced and fixed provisionally
D) Fracture fixed definitively
Generic fracture patterns

Open fractures in the humeral shaft

Adequate surgical debridement is the crucial first step in the care of any open fracture.

Read more about the treatment of open fractures in the humeral shaft.

Interlocking

In general, static interlocking with at least two screws on each side of the fracture is recommended. Depending on the fracture morphology/extension and the bone quality, additional locking screws may be used.

Interlocking

If an anatomic reduction is obtained it is easiest to start with the proximal interlocking of the nail (left).

If retrograde closure/compression of the fracture site is intended, start with the distal interlocking to allow for later retrograde movement of the nail (right). In this case the top of the nail should be inserted into the humeral head far enough for it to remain below the articular surface after fracture reduction.

Starting with proximal interlocking

2. Patient preparation and approach

Patient positioning

For antegrade nailing, the beach chair is the preferred position.

If no beach chair is available, a supine position may be used.

Beach chair position

Approach to entry point

The entry point is accessed through an antegrade nailing approach.

antegrade nailing

3. Determining nail diameter and length

Nail diameter

Place a radiographic ruler anteriorly on the upper arm over the medullary canal.

Visualize the medullary canal under image intensification in AP view and compare with the diameters of the marks on the ruler.

The correct diameter of the humeral nail corresponds to the diameter of the mark that fits completely into the medullary canal. Look carefully at the distal humeral canal. It may be narrower than the rest. If the isthmus is very narrow, consider reaming to allow the insertion of a larger diameter nail.

In our example, a nail of 7.5 mm diameter is chosen.

The diameter of the medullary cavity can also be measured on digital x-rays of the humerus. Take care to estimate the diameter on the narrowest site.

Nail diameter

Nail length

Provisionally reduce the humeral fracture.

Place the ruler parallel to the arm, with the top-of-nail mark at the level of the anticipated insertion site in the humeral head.

Take an AP image intensifier view of the distal humerus together with the ruler.

The humeral nail should be as long as possible in the distal canal, consistent with its diameter. Determine this length with the aid of the ruler.

Keep in mind that the top of the nail should lie just below the surface of the bone.

The length of the nail can also be estimated by measurements of digital preop x-rays. Care should be taken that the whole humerus is pictured.

Nail length

4. Entry point

Location of entry point

Different nailing systems have nails of different shapes, and so may require different entry points. Refer to the manufacturers' operative technique guides for further details.

The insertion point for the straight nail is in line with the medullary cavity. Typically, it ends up at the highest point of the humeral head. In contrast to bent nails it is located intraarticularly completely, well away from the insertion of the supraspinatus tendon.

Location of entry point

Insertion of guide wire

Insert a guide wire through the correct entry point and confirm proper placement by image intensification.

Insertion of guide wire

Opening the canal

A cannulated drill bit is recommended for opening the proximal humerus.

Insert this drill bit over the guide wire and advance into the proximal medullary canal.

Opening the canal

Alternatively, use an awl to open the humerus.

Opening the canal

5. Reaming

Indication

If the canal is very narrow rather than inserting a narrow nail, reaming will allow for the insertion of a larger diameter (ie stronger) nail. This may be particularly useful when nailing a nonunion.

Procedure

Pass an olive tipped guide wire across the fracture site. With experience it is usually possible to feel the tip of the wire is in the cancellous bone, but this should be confirmed with image intensifier.

Reaming

Ream up sequentially to an appropriate size for the desired nail. In segmental or multifragmentary fractures take care to avoid soft-tissue damage, particularly to the nerves and vessels, as the reamer is passed through the fracture zone.

Exchange the olive tipped wire to a straight guide wire, and then insert the nail over the guide wire. Alternatively, some nails may be introduced without a guide wire.

antegrade nailing middle 1 3

6. Nail insertion

Insertion handle

Mount the humeral nail on the insertion handle. The nail must be rotated correctly relative to the insertion handle.

Insertion handle

Insert the nail with slightly rotating movements down to the fracture line.

Do not use a hammer, as this may increase the risk of fissure or fracture at the insertion site.

Nail insertion

Advance the nail under image intensification just beyond the fracture site.

If inserting an unreamed nail a guide wire may be helpful but may not be necessary.

Advance the nail under image intensification just beyond the fracture site.

Reduction

Pass the fracture zone under image intensification and make sure that the nail enters the distal fragment properly.

Use the nail tip as a reduction aid. Alternatively, it may be easier to pass a guide wire with a bent tip across the fracture zone, and then pass the nail over the guide wire.

After passing the fracture zone, adjust humeral shaft alignment, rotation, and length.

Confirm under image intensification in two different planes.

Reduction

Pearl: F-tool for reduction

To lower the radiographic exposure to the surgeon’s hands use a radiolucent reduction tool (ie “F-tool”).

Pearl: F-tool for reduction

Open reduction

In some cases, there may be soft tissues interposed between the fragments. This prevents reduction and necessitates open reduction to remove any soft tissue.

If several attempts at introducing the nail into the distal fragment are unsuccessful the fracture site should be opened. Use a finger, bone hook or reduction clamp to reduce the fracture and pass the nail across the fracture site. This also reduces the radiographic exposure.

Open reduction

Definitive nail position

Gently advance the nail until it has reached the desired position just above the olecranon fossa. Avoid fracture distraction.

If a guide wire was used, remove it once the nail is in place.

Definitive nail position

Make sure the proximal end of the nail is placed beneath the bony surface of the humeral head.

No protrusion of the nail may be tolerated. Confirm with appropriately oriented C-arm images that the nail is below the bone.

If retrograde compression is planned insert the top of the nail into the humeral head far enough for it to remain below the articular surface after fracture reduction. See below for more details.

Make sure the proximal end of the nail is placed beneath the bony surface of the humeral head.

A K-wire placed through an aiming device may help to adjust the appropriate insertion depth.

A K-wire placed through an aiming device may help to adjust the appropriate insertion depth.

Rotational reduction

Confirm the fracture reduction under image intensification. Ideally the fracture line should be closed anatomically.

In cases of comminution indirect signs can be helpful such as the width of the cortices proximal and distal to the fracture site. Both should have the same width. Any difference suggests rotational malalignment.

Alternatively, if the proximal fragment is in the correct anatomic position, confirmed with image intensification, the forearm should lie in 25° external rotation.

Rotational reduction

Rotational implant position

To lock the nail in the correct rotation, swivel the aiming arm approximately 25° anteriorly. Due to the physiological retrotorsion of the humeral head, the axis of the humeral head is directed approximately 25° posteriorly to the condylar plane of the distal humerus.

Rotational implant position

To obtain a true AP view of the proximal humerus, rotate the forearm approximately 25° externally relative to the sagittal plane.

Rotational implant position

Pitfalls

To achieve correct locking of the nail and avoid complications it is crucial to obtain the correct rotation of the nail in the humerus.

Typical problems arising after incorrect rotation of the nail are:

  • Proximally: interference of the long head of the biceps
Pitfall: interference of the long head of the biceps
  • Distally: interference of the screw insertion with neurovascular structures
Pitfall: interference of the screw insertion with neurovascular structures

Longitudinal reduction

Confirm reduction of the fracture under image intensification. Take care that there is no fracture gap as this has a high risk of nonunion.

If there is a gap, it may be possible to close it with manual compression along the axis of the humerus, telescoping the distal fragment over the nail.

Longitudinal reduction

Alternatively, the gap can be closed with retrograde pulling of the nail after initial distal locking or by use of a compression mechanism implemented in the nailing system.

Both these techniques require the nail to be inserted deeper into the proximal fragment, so that as the fracture gap is closed the top of the nail comes to lie in the correct position. Otherwise an intraarticular, proximal protrusion of the nail will cause injury to the rotator cuff and impingement.

Longitudinal reduction

7. Proximal interlocking

Trocar insertion

Place the trocar for the planned screw fixation through the aiming device, if necessary through a separate skin incision. Perform blunt dissection down to the bone so that the trocar may be placed without interposition of soft tissue.

Trocar insertion

Predrilling

Check once more the correct retrotorsion.

Drill with the calibrated drill bit carefully just to the level of the subchondral bone. The final position of the drill bit can be checked with the image intensifier. The screw length can be determined from the measurements of the drill bit.

Predrilling

Screw hole widening in the lateral cortex

If the proximal locking bolts have enlarged heads the lateral hole must be overdrilled with the appropriate drill to avoid fracturing the lateral cortex.

Screw hole widening in the lateral cortex

Screw insertion

Attach the screw to the screw driver and insert the screw.

In some systems, as the one shown in this illustration, a screw-in-screw fixation is possible (see below) and may help in fractures involving the humeral head. If so and if also intended, the plane of the handle of the screw driver should be horizontal and the arrow should point posteriorly once the final position of the screw is reached.

Screw insertion

Insertion of further screws

Insert further screws using the aiming device according to the fracture pattern.

Remove the aiming device.

Insertion of further screws

8. Distal interlocking

Position of the arm

Distal interlocking is typically performed using a freehand technique. Therefore, the arm has to be placed in a stable position for distal locking under image intensification.

Position of the arm

Defining the correct position of the arm/C-arm

It is crucial for a proper freehand interlocking to define the correct position of the arm/C-arm. This is defined under image intensification showing a perfectly round circle of the nail’s locking holes within the center of the image.

Defining the correct position of the arm/C-arm

Pitfall: unrecognized malrotation

While positioning the arm and determining the proper position of the C-arm pay special attention not to produce an unrecognized malrotation by just rotating the forearm.

Pitfall: unrecognized malrotation

Skin incision

A rare but serious complication is injury to either the brachial artery and/or the median nerve while inserting the distal locking screw.

Therefore, take special care, using blunt dissection. If in any doubt widen the exposure and use retractors to protect the neurovascular structures.

Skin incision

Position the tip of the scalpel over the proximal hole, as shown under image intensification, and incise the skin.

Skin incision

Soft-tissue dissection

Use small scissors or artery forceps to prepare a track for insertion of the drill bit.

Soft-tissue dissection

Drilling

Perform the positioning of the drill tip, its fine adjustment, and the drilling procedure under image intensification.

Many surgeons prefer a radiolucent drill attachment if it is available.

Drilling

Center the radiopaque circles of the radiolucent drill on the locking hole.

Measure the length of the required screw with a depth gauge.

Center the radiopaque circles of the radiolucent drill on the locking hole.

Insertion of interlocking screws

Insert the first interlocking screw and check for the correct position and length under image intensification in two planes.

Insert further interlocking screws as described above.

Insertion of interlocking screws

Pearl: absorbable suture around screw

To avoid losing the screw in the soft tissues during insertion and tightening, fasten an absorbable suture around the screw’s head beforehand.

Pearl: absorbable suture around the screw

Final remark

When interlocking is completed, check the definitive position of the implant under image intensification in two planes.

When interlocking is completed, check the definitive position of the implant under image intensification in two planes.

Take particular notice of the position of the proximal end of the nail, the location and length of all interlocking screws.

Particular notice is taken of the position of the proximal end of the nail, the location and length of all interlocking screws.

9. Option: fracture reduction/compression after distal locking

Distal locking

Insert the distal locking screws first as described above, ensuring that the top of the nail is sufficiently buried in the humeral head.

Distal locking

Manual reduction

Attach the removal device. Reduce the distal humeral fragment with gentle hammer blows, bringing the nail proximally within the proximal fragment. Confirm satisfactory reduction with image intensifier.

Manual reduction

Reduction with compression device

Prior to compression insert a proximal gliding screw, which is applied through the dedicated guide hole in the aiming device.

Reduction with compression device

Compression of the fracture site or closure of a gap is applied by inserting a compression screw from the top of the nail. By tightening the screw, the whole nail with the distal fragment is pulled retrogradely.

Confirm the effect under image intensification.

After achieving satisfactory reduction remove the compression screw.

Proceed with the proximal locking as described above for static interlocking.

Compression of the fracture site or closure of a gap is applied by inserting a compression screw from the top of the nail.

10. Nail capping

Remove the insertion handle/aiming guide and its connecting screw.

Insert an end cap to prevent ingrowth of bony tissue.

Nail capping

End caps of different lengths may be available. The top of the end cap should lie just below the articular cartilage, to facilitate later implant removal, but must not protrude above the humeral surface.

Check the proper dimension of the end cap under image intensification.

Nail capping

11. Aftercare

Principles

The aim of any surgical fixation of humeral shaft fractures is a stable osteosynthesis of the fracture allowing early passive and active motion. This is crucial to prevent shoulder stiffness.

The rehabilitation regimen should take account of the quality of the rotator cuff, its split and fixation.

Immediate postoperative care

Carefully examine the patient for neurological deficits and pulses.

Early treatment

In the beginning lymph drainage and elastocompressive bandages may be helpful.

Consider a sling for pain relief within the first days.

Treatment for rotator cuff split fixation at risk

If the rotator cuff quality is poor, or the split was not in line with the fibers and/or there was detachment of the rotator cuff footprint, active shoulder abduction should be delayed within the first six weeks. Consider a shoulder abduction pillow and a continuous passive motion chair.

Mobilization

In the early phase the rehabilitation consists of classic maneuvers eg overhead motion exercises.

Rehabilitation should address the entire upper limb.

antegrade nailing middle 1 3

Exercise against resistance

Depending on the bone quality and compliance of the patient, exercise against resistance might be limited.

Follow-up

Clinical and radiological follow-up should be scheduled at least 6 weeks, 12 weeks and 6 months after surgery and continued until a bony healing is confirmed.

Hardware removal

Typically, humeral nails are left in situ indefinitely.

If the head of the nail is prominent and causing impingement or partial shoulder stiffness, it may require removing. If individual locking screws cause problems, they may be removed without having to remove the nail.

When removing a nail minimize any damage to the rotator cuff and take care to perform a secure repair, especially in poor rotator cuff quality.