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Technique Spotlight: ORIF Proximal Humerus Fracture with IMN
Intramedullary Fixation for Proximal Humerus Fractures
Indications
Proximal humeral fractures continue to increase in frequency with projected rates of emergency visits in the United States alone annually to exceed 275,000 by 2030 and well over a million visits worldwide. Although many fractures can be treated nonoperatively, significantly displaced or angulated fractures in certain patients may benefit from surgical intervention. Intramedullary nail fixation has gained interest in conjunction with evolution of implant design. This surgical technique with modern devices allows for the predictable healing of two-part surgical neck fractures, capture of tuberosity fracture fragments, the option for percutaneous device placement, and protection of vascularity to the fracture and head segment as a result of minimally invasive exposure and insertion. As a result, almost all two-part fractures and an increasing number of three- and four-part fractures can predictably be managed with intramedullary fixation. ,
Preoperative Evaluation (Examination and Imaging)
Preoperative evaluation mandates close neurovascular examination as some patients can present with an associated axillary nerve or brachial plexus neuropraxic injury. Serious vascular complications have been reported with even minimally displaced fractures. Routine images include Grashey, Scapular-Lateral, and axillary views of the injured shoulder to evaluate fracture pattern and displacement, and confirm humeral head location. Computed tomography (CT) imaging including 2D and 3D reconstructions can be valuable for preoperative planning as it may allow improved appreciation of calcar comminution, three- and four-part tuberosity fracture segment displacement, and nondisplaced fracture planes. If patients report preinjury shoulder pain or weakness, preoperative magnetic resonance imaging (MRI) is indicated to evaluate for preexisting rotator cuff pathology that may shift treatment options toward arthroplasty.
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