Proximal humeral fractures are on the rise due to demographic changes and have become the third most common fracture in the elderly population (after fracture of hip and distal radius) [1–3].
It has been predicted that proximal humeral fractures will increase considerably in the next 30 years [4].
The management of proximal humeral fractures is challenging. These fractures pose a problem for choosing the best management modality, especially to preserve bone alignment and joint surface congruity and yet maintain the vascularity of the humeral head. This is especially the case with complex fractures, where there is a significant complication rate; however, they are managed.
Conservative management has a role in un-displaced and minimally displaced fractures but shows consistently inferior results in terms of pain relief and return of functional range of motion [4, 5].
Currently, operative treatment appears to be the preferred method of treatment of these fractures. Surgical management will result in better restoration of anatomy and early physiotherapy will decrease the risk of shoulder stiffness and lead to a better definitive functional outcome [6, 7] which is fundamentally important in keeping the elderly patient independently mobile.
Hertel et al. [8] described predictors of humeral head ischaemia and especially ascribed importance to the integrity of the medial hinge.
Gardner et al. [9] pointed out that achieving mechanical support of the inferomedial region of the proximal humerus is important for maintenance of reduction and eventual healing.
The cancellous bone quality has been already investigated using various techniques in the humeral head based on anatomical landmarks [10–13]. Biomechanical studies and dissection model with 3-D reconstruction had shown the strong bone sites in the humeral head to have good purchase of the screws [14].
The main factors predicting poor outcome are age, fracture pattern especially the medial support, osteoporosis, head-neck shaft angle and co-morbidity [15, 16]. Anatomical reduction and medial support are the only factors that can be influenced.
Recent advances in anatomically designed locking plates and nails have significantly improved the stability of fixation [17–19].
By combining axial and angular stability, locking plate fixation provides increased osseous anchorage and high failure loads [20]. Although locking plate fixation has become a standard treatment with good short-term functional results–complication rates are still unsatisfactory especially the avascular necrosis due to soft-tissue stripping and screw penetration [21].
By comparison, proximal nails have also gained popularity in the management of these fractures due to minimal soft-tissue stripping and ease of use. The nails are load-sharing devices and demonstrate higher stiffness values.
The main objection against nail usage is their insufficient primary stability and loss of medial support and rotator cuff damage at insertion [22].
We present a new locking blade nail with straight design, distally inserted locking blade for medial support and locking screws with mobile washers.
The straight design helps prevent rotator cuff damage through entry point medial to rotator cuff insertion, and the locking blade provides triangular stability to maintain continued medial calcar support and locking screws with washers provide primary stability and fixation of greater and lesser humeral tuberosities.