To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of 1) fracture reduction, bone healing 2) osteonecrosis 3) functional consequences of osteonecrosis and malunion.

Prospective, consecutive, multicenter based.

Academic Trauma Centers; Approval was received from the ethics committee of the institutions involved in the study.

Fifty-one patients were enrolled prospectively, with 31 three-part and 20 four-part displaced fractures (head displacement>45°, tuberosity-head gap>10mm, diaphyseal gap >10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.

There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29 % of the remaining 38 patients and osteonecrosis in 32 %. Both complications were more frequent and extensive in patients with four-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was<30 %, 50.6 points between 30 and 50 %, and 38 points when larger than 50 %. Head malunion affected the Simple Shoulder Test and the Constant score.

Nailing may thus be recommended for three-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with four-part fractures.

Prospective study.