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Intramedullary Fixation of Proximal Humerus Fractures
The factors involved in decision making for surgical management of proximal humerus fractures include the fracture pattern, the bone quality, the status of the rotator cuff, and the age and activity level of the patient. The goal of surgery is restoration of near anatomic alignment with secure fixation to allow for early range of motion. In general, displaced proximal humerus fractures in active patients are managed surgically. Most commonly, intramedullary nails are used for the treatment of patients who have displaced two-part surgical neck fractures; however, they also can be used for the treatment of patients who have displaced three-part proximal humerus fractures involving the greater tuberosity and displaced four-part proximal humerus fractures with minimal or no displacement of the lesser tuberosity. Intramedullary implants are particularly useful for the treatment of patients who have segmental humerus fractures in which a diaphyseal component is present in combination with a proximal fracture pattern. Intramedullary nails also can be used for the treatment of patients who have pathologic fractures or impending pathologic fractures, offering the advantage of minimal soft-tissue dissection for insertion and the ability to stabilize any potential skip lesions that occur more distal in the shaft. In a multiply injured patient, intramedullary nail fixation of a proximal humerus fracture may be a minimally invasive technique that enables early mobilization with weight bearing. This chapter reviews the indications, contraindications, results, and techniques for intramedullary fixation of proximal humerus fractures. Technical keys, rehabilitation protocols, and tips for avoiding pitfalls and complications are also discussed.