Extended Neviaser portal approach to antegrade humeral nailing

Certain arthropathies can distort the normal acromiohumeral relationship and make traditional anterolateral access to the proximal humerus for nailing difficult or impossible. This article presents a case of bilateral antegrade humeral nailing in which the Neviaser portal approach was used for humeral shaft fractures in a patient with distorted shoulder anatomy secondary to severe cuff tear arthropathy and rheumatoid arthritis. Based on a literature review, extending the traditional superomedial (Neviaser) portal to the shoulder to perform humeral nailing has never been described clinically. An 85-year-old woman with rheumatoid arthritis and bilateral cuff tear arthropathy presented after a mechanical fall from standing height with bilateral acute humeral shaft fractures. Preoperative fluoroscopy confirmed the inability to access the traditional starting point with an anterolateral approach due to a shield acromion resulting from cuff tear arthropathy and rheumatoid arthritis. Bilateral locked antegrade humeral nails were successfully placed through a 3-cm incision just off the medial border of the acromion and directly posterior to the acromioclavicular joint (the extended Neviaser portal approach). Postoperatively, the patient demonstrated early evidence of clinical and radiographic union. She was able to return to her preinjury function level, with an active range of motion comparable with her baseline. The Neviaser portal approach to antegrade humeral nailing is an effective solution to diaphyseal humeral fractures when access to the traditional anterolateral proximal humeral starting port is not possible due to distorted shoulder anatomy.