REVIEW ARTICLE
SIGN Nailing of Humeral Fractures and Nonunions
Oleg Gendin, MD,* and Robert Schultz, MD†
Summary: This article outlines the Russian experience with the
Surgical Implant Generation Network tibial nail in treating diaphyseal
fractures of the humerus. This solid stainless steel nail has a unique
targeting technique for the placement of distal interlocking screws. The
surgical technique is reviewed and the results of treatment of 168 acute
fractures and nonunions is presented.
Key Words: humeral shaft fractures—intramedullary nailing—SIGN
nail—antegrade humeral nailing.
(Tech Orthop 2009;24: 253–257)
F
ractures of the humerus comprise 1% to 3% of all fractures.
The incidence has a bimodal age distribution with peaks in
adolescence and the 5th and 6th decades of life.1 Most shaft
fractures of the humerus can be treated successfully nonsurgically with the use of splints or humeral orthoses.
Operative treatment of humeral fractures is also predictable with the relative indications being:
Open fractures
Multiple trauma
Unacceptable alignment after closed reduction
Delayed or nonunion
Associated vascular injury
Other ipsilateral upper extremity fracture (“floating elbow”)
Bilateral upper extremity injury
Inability to use humeral brace secondary to obesity or large
breasts
Need for early weightbearing
Pathologic fractures
Transverse midshaft fractures
FIGURE 1. Patient positioned on table with bump under scapula and additional support under forearm.
TECHNIQUE
Preoperative full-length radiographs should be available to assess the location of the fracture and the integrity of
the proximal and distal aspects of the humerus. Measurement of the uninjured humerus from the lateral acromial tip
to the lateral epicondyle and subtracting 5 cm gives the
approximate length of the nail. Several nail lengths shorter
and longer of multiple diameters should be sterilized and
available. The injured extremity if possible should be
scrubbed with chlorhexidine soap preoperatively. Intravenous broad-spectrum antibiotics such as cephalexin should
Contraindications include active regional or systemic infection,
too proximal or distal fractures, and severe osteoporosis. Operative treatment can be by plating, intramedullary nailing with
flexible or rigid locking nails, and external fixation.1–3 This
article outlines the technical aspects of the use of the Surgical
Implant Generation Network (SIGN) interlocking nail in the
treatment of diaphyseal humeral fractures and nonunions as
well as the review of outcomes in 98 cases.
The SIGN nail is a solid stainless steel nail originally
designed to treat tibia fractures. Its use has been expanded to
nailing femoral and humeral shaft fractures. The SIGN nail is
unique in its ability to be placed and screw interlocks to be
performed without intraoperative imaging. Details of its design
are included in other articles in this journal.
From the *Emergency Hospital, Krasnoyarsk, Russia; and †Billings
Clinic, Billings, MT.
Address correspondence and reprint requests to Robert Schultz, MD,
2702 8th Ave North, Billings Clinic, Billings MT 59101. E-mail:
[email protected] or [email protected].
Copyright © 2009 by Lippincott Williams & Wilkins
ISSN: 0148-703/09/2404-0253
Techniques in Orthopaedics姞 • Volume 24, Number 4, 2009
FIGURE 2.
groove.
Entry point one finger-breadth posterior to bicepital
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Gendin and Schultz
Techniques in Orthopaedics姞 • Volume 24, Number 4, 2009
FIGURE 3. All reductions are done open with a small anterolateral incision over the fracture. If mobile, it may be reduced with
finger manipulation. Clamps may be necessary to reduce subacute fractures.
be given at appropriate doses within 30 minutes of incision.
The patient is given a general anesthetic and placed supine
on a regular operating table with a bump under the shoulder
to stabilize the scapula and elevate the lateral entrance site
(Fig. 1). A mayo stand or other support is placed next to the
table to support the arm during the procedure. Because
fluoroscopy is not being used, the support need not be
radiolucent. The entire shoulder from nape of neck to mid
chest wall down to the wrist is prepared with the antiseptic
of surgeon’s choice. The arm is draped free.
An anterolateral skin incision is made from the tip of
the acromiom distally extending 6 to 8 cm in length (Fig. 2).
The deltoid muscle is split bluntly in line with the muscle
fibers. Access to the sub-acromial space is thus obtained and
the bicepital groove palpated. A 1 to 2 cm longitudinal
incision through the supraspinatus tendon is made 1 fingerbreadth posterior to the biceps tendon. The edges of the
supraspinatus tendon can be tagged with retention sutures
(Fig. 3). A pointed awl is used to open the canal at the
junction of the articular surface and the greater tuberosity
(Fig. 4).
Reduction is always done in an open fashion with a
small incision made laterally at the fracture site (Fig. 5). If
the fracture is freely mobile, usually just a finger placed on
the shaft at the fracture site can be used to guide the reamers
and nail across the fracture. If operative treatment has been
delayed or a delayed or nonunion is being treated, then a
larger incision with formal exposure and reduction of the
fracture may be necessary. The canal is reamed with handpowered reamers until cortical chatter is felt. A reamer may
be left in the canal to maintain reduction while the nail is
prepared.
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FIGURE 4. Nail is inserted with proximal bend placed laterally.
Interlocking screws are placed anterior to posterior.
A nail at least 1 mm smaller in diameter of the appropriate length is attached to the insertion device. The target
arm is attached and confirmation of alignment of the interlocking guides both proximal and distal is made. The target
arm is then removed and the nail introduced into the canal
FIGURE 5.
Distal screws are placed first using SIGN technique.
© 2009 Lippincott Williams & Wilkins
Humeral Fractures
Techniques in Orthopaedics姞 • Volume 24, Number 4, 2009
FIGURE 6.
Proximal interlocks are done with target arm.
proximally (Fig. 6). The nail is passed carefully with small
twisting motions and gentle taps of the mallet. The proximal
bend in the nail is aimed laterally leaving the interlocking
holes in an anterior to posterior alignment. Heavy striking of
the nail may lead to comminution of the fracture or incarceration of the nail in the canal. The nail is guided by
palpation across the fracture site and driven at least 1 cm
below the level of the proximal articular cartilage to prevent
subacromial impingement. Counter pressure is placed on the
olecranon as the nail is being passed to prevent distraction of
the fracture.
The distal interlock is performed first by reattaching the
target arm and making a small incision beneath the guide
bluntly dissecting down to bone (Fig. 7). One screw is
placed in the most proximal slot with the standard SIGN
technique if there is at least 10 cm from the slot to the
fracture site. Two screws are placed if the fracture is less
than 10 cm to the slot (Fig. 8). If the fracture is not apposed
as assessed by finger palpation, the nail is backslapped with
the appropriate device or gentle thrusts against the olecranon
will compress the fracture. Care must be taken to assure the
nail remains below the condylar surface to prevent impingement. The proximal target arm is then used to place 2
proximal interlocking screws (Fig. 9).
The supraspinatus tenotomy is repaired with nonabsorbable suture and the deltoid and skin closed in a routine
fashion. Wounds are dressed and a sling applied.
Postoperative care allows early active motion of the
elbow and wrist but active and aggressive passive motion at
the shoulder is restricted for 4 weeks. A sling is encouraged
during that time. Follow-up evaluation including radiographs is done at routine intervals. Nails are not routinely
removed unless they are causing impingement or pain.
© 2009 Lippincott Williams & Wilkins
FIGURE 7.
Incisions at closure.
RESULTS
A total of 168 nailings for acute fractures and nonunions
have been performed to date. Ninety-eight have follow-up of at
least 6 months. Three iatrogenic radial nerve palsies developed
and all resolved spontaneously without intervention by 3
months postoperatively.4,5 Two cases of proximal impingement
were noted early in the series.6 One patient had exchange
nailing performed and the other refused further intervention.
There was 1 nonunion of a distal fracture that required bone
grafting and exchange nailing. That fracture healed. There were
no losses of fixation or alignment at follow-up. There were no
broken screws or nails. All fractures eventually healed including the 10 nonunions treated. There were 2 deep infections
requiring nail removal and placement of an antibiotic polymethylmethacrylate coated nail with concomitant intravenous
antibiotics and delayed exchange nailing. Both infections
cleared and both fractures united.
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Gendin and Schultz
FIGURE 8.
Techniques in Orthopaedics姞 • Volume 24, Number 4, 2009
Pre- (A) and postoperatively (B) radiographs of a comminuted midshaft fracture in a multiply injured female.
DISCUSSION
Controversy remains as to the most appropriate method
for treating humeral shaft fractures.2,3,7 The experience with
the SIGN nail in treating humeral shaft fractures confirms
the predictable success of intramedullary nailing in treating
these fractures. Nailing of humeral shaft fractures allows
early mobilization of the upper extremity which is beneficial
in multiply injured patients.8 Complications in this series of
patients were few and resolved with standard treatment.
Violation of the rotator cuff during nail insertion led to few
cases of shoulder stiffness. Alternative entry portals may
improve this problem.9,10 Few radial nerve palsies were
noted and as with other surgeons’ experiences, all palsies
resolved spontaneously.4,5
CONCLUSIONS
1. SIGN nail is a predictable and dependable method of treating diaphyseal humeral shaft fractures.
2. This technique has a low complication rate.
3. The SIGN nail is a novel inexpensive interlocking nail with
a predictable distal interlocking screw technique performed
without fluoroscopy.
4. Most humeral fractures require open reduction when using
this technique.
5. No postoperative bracing is needed.
REFERENCES
1. Cole PA, Wijdicks CA. The operative treatment of diaphyseal humeral
shaft fractures. Hand Clin 2007;23:437– 448.
2. Chapman JR, Henley MB, Agel J, et al. Randomized prospective study
of humeral shaft fracture fixation intramedullary nails versus plates
J Orthop Trauma 2000;14:162–166.
3. Bhandari M, Devereauz PJ, McKee MD, et al. Compression plating
versus intramedullary nailing of humeral shaft fractures—a metaanalysis Acta Orthop 2006;77:279 –284.
4. Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated
with fractures of the shaft of the humerus: a systematic review J Bone
Joint Surg Br 2005;87:1647–1652.
FIGURE 9. Distal fracture less than 10 cm from tip of nail
requiring 2 interlocking screws to control fracture.
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5. Wang JP, Shen WJ, Chen WM, et al. Iatrogenic radial nerve palsy after
operative management of humeral shaft fractures J Trauma 2009;66:
800 – 803.
© 2009 Lippincott Williams & Wilkins
Techniques in Orthopaedics姞 • Volume 24, Number 4, 2009
6. Flinkkila T, Hyvonen P, Siira P, et al. Recovery of shoulder function
after humeral shaft fracture: a comparative study between antegrade
intramedullary nailing and plate fixation Arch Orthop Trauma Surg
2004;124:537–541.
7. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture
J Trauma 2008;65:94 –102.
8. Tingstad EM, Wolinsky PR, Shyr Y, et al. Effect of immediate weight
© 2009 Lippincott Williams & Wilkins
Humeral Fractures
bearing on plated fractures of the humeral shaft J Trauma 2000;49:
278 –280.
9. Park JY, Pandher DS, Chun JY, et al. Antegrade humeral nailing
through the rotator cuff interval: a new entry portal J Orthop Trauma
2008;22:419 – 425.
10. Dimakopoulos P, Papadopoulos AX, Papas M, et al. Modified extra
rotator-cuff entry point in antegrade humeral nailing. Arch Orthop
Trauma Surg 2005;125:27–32.
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