Arthroscopical Findings after Antegrade Nailing of a Proximal Humeral Fracture

Abstract

Proximal humeral fractures represent up to five percent of all fractures in adults, commonly found in elderly patients. The final functional results after different operative procedures are among other factors dependent on whether or not a rotator cuff lesion is pre-existent, prior to the fracture, and how its surgical therapy is carried out. However, to what extent prior rotator cuff tears in this special patient group contribute to the functional outcome remains widely unclear. In our institution antegrade intramedullary nailing is the treatment of choice for proximal humeral fractures. One critical point of this technique is the unavoidable split of the rotator cuff on the approach to the proximal humerus and the insertion of the nail through the incised cuff. We report on a case of an impingement after antegrade intramedullary nailing of a proximal humeral fracture. Diagnostic glenohumeral arthroscopy revealed neither a residual lesion of the former rotator cuff incision nor a chondral lesion at the former insertion site of the nail. In the same session subacromial decompression and a nettoyage of adhesions were performed. We assume that splitting the rotator cuff for the insertion of an antegrade nail in a proximal humeral fracture is less relevant than previously assumed and described.

A Modified Rotator Cuff Sparing Approach to the Proximal Humerus in Antegrade Nail Osteosynthesis with Transosseous Supraspinatus Tendon Refixation

“…described a patient without arthroscopically evident damage to the rotator cuff after antegrade humerus medullary nailing, but considered that the outcome was often unsatisfactorywhatever the surgical procedure [4]. They also pointed out that, in this context, other authors emphasise the influence of an intact rotator cuff, but only a few older studies evaluate the association between rotator cuff damage, proximal humerus fractures and functional outcomes [4,8,16,17]. OʼDonnell et al described 33 patients with shoulder injuries accompanied by diaphyseal fractures that were treated with antegrade humerus medullary nailing.…”

“…[1,2]. As many as 5 % of all adult fractures are fractures of the humerus shaft in older womenso that this is a common clinical entity [3,4]. The most common cause is a fall with an extended arm, or more rarely an impact trauma.…”

“…In this context, rotator cuff function is often neglected. After fractures to the humerus head, there have been reports of unsatisfactory results for osseous reconstruction, with inadequate clinical and functional outcomes due to malfunction of the rotator cuff [4,8]. Moreover, some studies have shown that antegrade humerus intramedullary nailing can be accompanied by chronic postoperative shoulder pain, impingement and restriction to movement; this may be associated with damage to the rotator cuffeither intraoperatively or pre-existing [9 -11].…”

Impacto clínico en el hombro del enclavijamiento endomedular anterógrado en el tratamiento de fracturas de la diáfisis humeral

“…However, available evidence on these effects is contradictory. In this regard, some studies report that function after shoulder surgery is good and that patients with rotator cuff tears are usually asymptomatic, 1,5,6 but other studies report changes in shoulder function. 7,8 Hence, some authors report that plate osteosynthesis has a superior performance due to the possible effects of IN in the shoulder.…”