Anatomic considerations of locked humeral nailing

To investigate the risk of axillary nerve injury by the proximal locking screws in antegrade nailing of humeral fractures, the anatomy of the axillary nerve was examined in 20 fresh anatomic specimen humeri, which subsequently were nailed antegrade with specially designed humeral locked nails. The axillary nerve was found to be on average 45.6 mm below the tip of the greater tuberosity; it was jeopardized by insertion of the lower proximal locking screw in one of the 20 specimens. Short humeri, humeri with small heads, or too deeply inserted nails may increase the risk of nerve injury; likewise, a lower location and more horizontal direction of the locking screws and a greater curvature of the nail can heighten the risk. In addition to the examination of the axillary nerve, a geometric study of these anatomic specimen was performed and was aimed at improving retrograde nailing technique and thus treatment results. The humeral geometry indicated that for the best linearity in the sagittal plane, an entry portal incorporating the superior margin of the olecranon fossa would be recommended for the 14 humeri with a distal humeral offset less than 4 mm, whereas a supracondylar entry portal would be recommended for the six humeri with an offset larger than 4 mm. For best linearity in the coronal plane, the entry portal and nailing direction should be more lateral in humeri with a smaller humeral elbow angle.