Original Article

Management of fracture shaft of humerus open versus closed antegrade nailing

A S Sidhu*, H S Mann**, Gursukhman D S Sidhu***, A Banga****, A Bassi****, M Gupta *****
* Professor and Head, ** Assistant Professor, *** PG Research Fellow, **** PG Student,
Department of Orthopaedics,
Government Medical College, Patiala.

ABSTRACT
Fractures of the shaft of humerus are difficult to treat. Nonunion, stiffness and inconvenience after conservative
treatment of shaft of humerus are very common. So, under present conditions and advancements in surgical
skills, techniques and good quality implants, ORIF has become gold standard for treatment of fracture shaft
of humerus. 20 cases were treated with open antegrade nailing while 20 with closed antegrade nailing of
humerus (with C arm). Fractures were classified according to AO fracture classification. Patients were
assessed clinically and radiologically. Constant scoring system and Mayo Elbow Performance Score were
used to assess the function of the shoulder and elbow. Results were analysed prospectively. Outcome in
Closed Antegrade nailing group was observed to be excellent in 35% cases, good in 50% cases, satisfactory
in 10% cases and poor in 5% cases. Out come in Open Antegrade nailing group was observed to be excellent
in 15% of cases, good in 45% of cases, satisfactory in 30% cases and poor in 2% cases. In our study of 40
cases, radiological union occurred in all cases. Complications like nail protrusion, superficial infection,
delayed union, gap at fracture site, shoulder and elbow pain were encountered. Finally there was no
significant difference in duration of operation, union time and shoulder and elbow function in two groups.
We feel that there is a long learning curve for closed antegrade interlock nailing of humerus and most of the
complications can be avoided and results improved, if correct technique is followed.
Keywords: Humeral Shaft Fractures, Antegrade Nailing, Nonunion
INTRODUCTION
Fractures of the humerus have challenged medical practitioners
since the beginning of recorded medical history1. Fracture shaft
of humerus is very common representing 35 % of all fractures.
The comprehensive AO classification is preferred in studies of
humeral fractures2, 3.
Humeral shaft fractures can be treated nonoperatively,
which includes hanging arm cast, velpeau dressing, coaptation
splint or U slab, shoulder spica cast, functional brace and rarely
skeletal traction4-9. However, non-operative treatment requires
a long period of immobilization, which carries a high risk of
shoulder stiffness and causes great inconvenience to the
Corresponding Author :
Dr A S Sidhu
Professor and Head, Department of Orthopaedics,
Government Medical College, Patiala
E mail: docsidhu12@yahoo.com

patient10. Furthermore, nonunion after conservative treatment

of shaft of humerus is common and treatment of non-union of
any bone is a cumbersome procedure7, 11, 12.
So, under present conditions and advancements in surgical
skills, techniques and good quality implants, open reduction
and internal fixation has become gold standard for treatment of
fracture shaft of humerus. This helps us in allowing early
mobilization and decreasing morbidity to the patient 13.
Kuntscher originally described a locking nail; it was until the
late 1970s when Klemm and Schellmann and later Grosse and
Kempf improved this technique14, 15. Together with improved
fluoroscopy techniques, these new implants made locking
intramedullary nailing very popular, being minimally invasive
method to treat long bone fractures15.
Despite technical improvements of humeral intramedullary
nails, results after Seidels initial good results regarding union
rate and shoulder joint function have been and still are very
controversial8, 16, 17. Humeral nailing is associated with brief

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Fracture shaft humerus - open vs closed antegrade nailing

operative time, minimal morbidity and early return to function

of the extremity, low infection rate and also very good pain
relief in pathological fractures18, 19. When compared to dynamic
compression plating, humeral nailing causes minimal damage
to soft tissue and its vasculature, reduces periosteal stripping
and causes fewer radial nerve palsies18, 20, Also nails are load
sharing devices instead of load bearing19.
MATERIAL AND METHODS
40 Patients of 18 years and above in age and of either sex were
operated. Fractures were both closed and open and were both
fresh and old cases. Cases with nonunion or other implant
failure were also included. Primary treatment was given in the
form of splintage, antiseptic dressing, antibiotics, analgesics,
anti-inflammatory drugs and intravenous fluids. Routine
investigations were done and initial radiographs taken in
anteroposterior and lateral directions. Fractures were classified
according to AO fracture classification2, 3. 20 cases were treated
with open antegrade nailing while 20 with closed antegrade
nailing of humerus (with C arm).
In closed antegrade nailing patients were placed in supine
position and upper portion of table was elevated about 45-50
degrees. A 2cm incision was given from anterolateral corner of
the acromion to lateral aspect of arm. After superficial
dissection, deltoid muscle was split in line of skin incision.
Supraspinatus tendon was identified and is split 1-2cm inline
of its fibres. Entry portal was made just lateral to the articular
margin and just medial to greater tuberosity. Reaming was done
in all cases up to 1mm more than the diameter of nail to be used.
Proper size nail was inserted after achieving reduction under
C-Arm. Distal locking was done first by free hand technique
using C-Arm from anterior to posterior. Then after checking
the reduction the proximal locking was done using proximal jig
from lateral to medial. The wound was closed in layers after
achieving complete haemostasis.
In open antergrade nailing positioning and patient
preparation were same. The skin overlying the fracture site
was split to expose the fracture and to do debridement. After
fracture reduction bone grafting was done. Distal and proximal
locking was done in standard fashion and wound closed in
layers after achieving haemostasis.
Post operatively limb elevation and active finger
movements were advised as soon as pain subsides. Parenteral
antibiotics were given for two days, followed by oral antibiotics
depending upon the wound condition. Active shoulder and
elbow exercises except external rotation and extreme abduction
were started as soon as pain subsided. Sutures were removed
from 11th-14th day.

All patients were followed up at monthly intervals for 6

months. During this period patients were motivated for
physiotherapy and gradual normal use of the affected limb.
Patients were assessed clinically and radiologically. Constant
scoring system21 and Mayo Elbow Performance Score22 were
used to assess the function of the shoulder and elbow. Overall
inference will be assessed as excellent (excellent shoulder score
with excellent elbow score and healing of fracture within 3
months without complications), good (good shoulder score
with good elbow score and healing of fracture within 3 months
with minor complications), satisfactory (fair shoulder score or
fair elbow score and healing of fracture in three to four months
with minor problems) and poor (poor shoulder score/poor elbow
score/nonunion /any major complications/Any case requiring
second surgical procedure). Results were analysed
prospectively.
RESULTS
35% of the cases in closed antegrade nailing group were in age
group of 21-30 years, 25% were in age group of 31-40 years,
25% and 10% were in age group of 41-50 and 51-60 years
respectively. Only a single case 5% was above 60 years of age.
Range of patients in closed antegrade nailing group was
between 21-70 years.
Most of the patients in open antegrade nailing group were
in age group of 31-40 years (35%). 25%, 20% and 20% were in
age group of 21-30 years, 41-50 years and 51-60 years
respectively.
Out of 40 cases, there were 28 males and 12 females (2.3:1).
Most of the patients in both the groups closed (80%) and
Open (60%) were males. Out of 40 cases, mode of injury in 19
cases (47%) was road traffic accident. In remaining 21 cases
mode of injury in 7 cases (35%) was due to assault. Similarly
mode of injury in another 7 cases (35%) was due to fall. In 3
cases (8%) there was failure of previously used implant while
in rest 4 case (10%) the reason was pathological fracture and
nonunion respectively.
Most of the fractures in closed antegrade nailing group
were classified as type A (70%) as per AO classification with
30% in subgroup A2 and 40% in subgroup A3. We had 4 cases
(20%) of fractures of type C, where 1 (5%) case had C2 as
subtype and 3(15%) had subtype C3. Two cases (10%) had
fracture of type B i.e. B1 and B2 respectively. Most of the
fractures in open antegrade nailing group were classified as
type A as per AO classification (90%) with 25% in subgroup A2
and 65% in subgroup A3. We had only 5% of fractures of type
B and subtype B2. 5% cases in open antegrade nailing group
had type C fracture subtype C1.

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Sidhu et al

Figure 1: Results of open antegrade Nailing at 6 months.

Figure 2: Results of closed antegrade nailing at 6 months.

Early operative complications occurred in 4 cases of closed

antegrade nailing group. 1 case (5%) had more than 5mm
proximal nail protrusion of nail. Also in 2 cases (10%) early
superficial infection occurred while in another 1 case (5%) there
was more than 2mm gap at the fracture site. In open ante grade
nailing group only 10% cases had superficial infection as early
operative complication.

to good score and rest 1 case had score between 60-74

corresponding to fair score. In open antegrade nailing
group, 85% of cases had excellent (>90 points) corresponding
to excellent elbow function and 10% of cases had score
between 75-89 corresponding to good elbow function while 1
case had score between 60-74 corresponding to fair elbow
function.

In late operative complications 10 cases were of closed

antegrade nailing and 8 cases were of open antegrade
nailing group. 6 cases (30%) of closed antegrade nailing
had shoulder pain while 2 cases (10%) had elbow pain. 1 (5%)
case each of delayed union and shoulder impairment was also
observed. The cases with elbow pain also had ipsilateral fore
arm plating done. While in open antegrade nailing group
25% had shoulder pain 1 had elbow pain and 2 had delayed
union. In closed antegrade nailing group, union occurred in all
cases although 1 case required secondary bone grafting for
attaining union. In open antegrade nailing group union
occurred in all cases although 2 cases required secondary bone
grafting.

According to inference, outcome in Closed Antegrade

nailing group was observed to be excellent in 35% cases, good
in 50% cases, satisfactory in 10% cases and poor in 5% cases.
Out come in Open Antegrade nailing group was observed to
be excellent in 15% of cases, good in 45% of cases, satisfactory
in 30% cases and poor in 2% cases.

In closed antegrade nailing group 80% cases had excellent

constant score (>90 points) corresponding to excellent shoulder
function, 4 (20%) cases had score between 75-89 corresponding
to good score . In Open Antegrade nailing group, 60% of cases
had excellent constant score21 (>90 points) corresponding to
excellent shoulder function, 30% of cases had score between
75-89 corresponding to good score and 2 (10%) cases had
score between 60-74 corresponding to fair score.
In closed antegrade nailing group, 75% cases had excellent
Mayos score22 (>90 points) corresponding to excellent elbow
function, 20% of cases had score between 75-89 corresponding

DISCUSSION
The indications for surgical management and internal fixation
of fractures of the shaft of the humerus are very clear. Interlock
nailing is emerging as the gold standard for operative treatment,
with high rates of fracture healing and consolidation and good
outcome with no adverse effect of immediate full weight-bearing
on fracture union or alignment. The advocates of Intramedullary
fixation have highlighted various disadvantages of open
reduction and internal fixation with other methods of
osteosynthesis which requires extensive open surgery with
stripping of soft tissues from bone, a longer operative time and
less secure fixation, especially in the elderly with osteoporotic
bone and if crutch walking is required in multiple injuries
patients. The Intramedullary fixation is reported to involve a
simpler technique with minimal exposure and shorter operative
time with less blood loss. The preservation of fracture
hematoma, soft tissue and periosteum around the fracture that
occurs with closed unreamed nailing has been proposed for

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Fracture shaft humerus - open vs closed antegrade nailing

high rates of union and good results, with no risk of iatrogenic

radial nerve palsy. Locked nailing is said to provide a rotationally
stable fixation and avoid the tendency of various unlocked
nails to back out. Most of the studies support our observations
that A type of fracture pattern is most common of AO fracture
classification pattern seen23, 24, 25. It is documented that humerus
responds poorly to distraction and rate of delayed / non-union
is significantly increased in these cases26. Similar finding was
seen in our study; one of the case that had significant
distraction at fracture site went into delayed union and second
procedure in form of bone grafting was required to achieve
union. Flinkkila et al27, in their study concluded that shoulder
joint range of motion and strength does not recover to normal
after humeral shaft fracture, and antegrade Intramedullary
nailing if performed properly is not responsible for shoulder
joint impairment.
CONCLUSION
In conclusion, it can be derived that there is no significant
difference in duration of operation, union time and shoulder
and elbow function in two groups. There is a long learning
curve for closed Antegrade interlock nailing of humerus and
most of the complications can be avoided and results improved,
if correct technique is followed. A larger randomized trial or
may be a multi-center trial can further improve the interpretation
of the results.
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