A rotator cuff sparing deltopectoral approach to intramedullary nail of humeral fractures.

BACKGROUND: Intramedullary nail (IMNs) for humeral fractures have been associated with iatrogenic rotator cuff damage resulting in poor shoulder function and pain. The purpose of this study was to evaluate nail positioning, clinical outcomes, and complications following IMN using a rotator cuff-sparing approach via the rotator interval.

METHODS: A retrospective review of patients who underwent an IMN for a humeral fracture with a minimum of 12 months follow-up at a single institution was carried out. Patients who underwent a mini-open deltopectoral approach utilizing the rotator interval were eligible. Clinical outcomes assessed included the American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores, impingement, patient satisfaction, and range of motion (ROM). Nail positioning was assessed on radiographic follow up as were complications.

RESULTS: There were 22 patients available for radiological follow-up and 20 for clinical follow-up, of which 68.2% were female, the mean age was 67.7 ± 11.7 years, body mass index was 29.7 ± 8.8, and the mean follow-up was 25.9 ± 9.5 months. There were 7 proximal humerus fractures (4 II-part and 3 III-part fractures) and 15 fracture of the proximal shaft. The mean American Shoulder and Elbow Surgeons score was 87.9 ± 12.7, and the mean Single Assessment Numeric Evaluation score was 88.3 ± 12.8. The mean ROM in forward flexion was 149° ± 24°, abduction was 137° ± 27°, and external rotation was 47° ± 16°. There were no significant differences between fracture types for any outcome score or ROM. All nails were buried or flush with the humeral head on lateral x-rays the entry point was graded as central in 77% and anterior in 23% of patients. On AP x-rays, the entry point was graded as central in 87% of cases and lateral in 13%. The mean visual analog scale score was 0.7 ± 1.0, No patients reported persistent shoulder pain, and there were no revision or reoperations required. There was 1 case of delayed union with a broken locking screw and 1 case of adhesive capsulitis.

CONCLUSION: Intramedullary nail of humeral fractures using a third generation nail and a rotator cuff sparing deltopectoral approach results in accurate nail positioning, a low risk of iatrogenic shoulder pain, as well as good ROM and functional outcomes; however, further comparative studies are required.