Humeral shaft fractures remain nearly 3% of all fractures occurring in the human body and 20% of all fractures in the humerus [1, 2]. This increases to 76% over the age of 40 years. These fractures have a bimodal distribution occurring in people older than 50 years with low velocity injuries like an accidental fall and in young people following high-energy trauma ^[3]. Conservative management is done in up to 80% of minimally displaced humeral shaft fractures, resulting in satisfactory results. Various techniques of internal fixation using titanium elastic nailing system nail and screws, narrow or broad dynamic compression plates (DCP), external fixators, intramedullary devices, and locking compression plates have been reported but none of these methods has been consistently successful. Good anatomical reduction, stable fixation, and early mobilization are essential for excellent functional recovery ^[4]. Procedures involving extensive exposure and the periosteal stripping and fixation of implants and improper handling the radial nerve through posterior approach may increase the risk of the development of post-operative wrist drop, wound infection, blood loss, long operative hours, and hence less exposure and dissection of the soft tissues at the fracture site with minimal internal fixation have been recommended. Stable reduction provides an environment or healing of the fracture and allows early mobilization of the shoulder. The incidence of injuries and fractures has greatly increased in the present than the olden days. Open reduction and internal fixation (ORIF) with plate osteosynthesis have been the gold standard for the treatment of fractures of the humeral diaphysis. Intramedullary fixation devices have been used very effectively in the treatment of lower limb fractures. Here we propose Halder intramedullary fixation for the humerus fracture. The retrograde Halder nail is a new device which can produce desired results with less soft-tissue dissection.

This study compares and analyses the functional and radiological outcome of Halder nailing with plate fixation for humeral shaft fracture. To study, the time taken for union status in humeral shaft fractures treated with Halder intramedullary nail and plate fixation through radiological assessment and to study the functional assessment by shoulder joint range of movements after surgery. A prospective comparative study of the management of humeral shaft fractures by Halder nail and dynamic compression plating was undertaken at our institution (Government Stanley Medical College and Hospital, Chennai) over a period of (July 2021–June 2024) 3 years.

Inclusion criteria

A total of 102 patients were included for the study in which 54 assigned to the plating group and 48 to the Halder nailing group. It is a randomized controlled trial where patients with humeral diaphyseal fractures were divided into two group’s one receiving Halder nail and the other group will receive narrow or broad DCP plate (4.5 system) fixation. A written informed consent was taken from the patients regarding surgery and randomization was done and allocation made to either group. Patients in the age group of 18–60 years of either gender with extra-articular closed fracture which are <3 weeks old were included in this study.

Exclusion criteria

Exclusion criteria of the study were intra-articular humerus fractures in patients aged <18 years, open fractures, and pathological fractures. All routine investigations including complete hemogram, renal profile, Sr. electrolyte, blood sugar, electrocardiogram, chest X-ray, and anesthetic assessment were obtained before surgery. All the patients were received in the trauma zero delay ward were resuscitated initially. If there are any other major associated injuries or comorbid conditions, they are treated accordingly first. Once the general condition of the patient stabilizes, radiographs (anteroposterior [AP] view and lateral view) of injured arm with a joint above and below are taken. The fractures were reduced in closed manner under adequate analgesia and “U” slab was applied and post-reduction radiographs are taken. Most of the closed cases are taken for elective fixation after obtaining necessary consent (Fig. 1 and Table 1).

Procedure for Halder nail

All surgeries were performed under strict aseptic precautions and under regional anesthesia. Positioning for retrograde Halder nail includes the patient in the supine position with the injured arm placed on a radiolucent forearm table with shoulder abducted 90°. The image intensifier is positioned in such a way that it does not interfere with the surgical field. Skin incision of about 5 cm is made over the distal humerus, posteriorly just above the tip of the olecranon extending proximally. Skin and subcutaneous tissue dissected, and the triceps tendon split to expose the olecranon fossa and the distal humerus. Several drill holes are made in the near cortex using a template guide and connected to make an entry portal in the posterior cortex of the distal humerus at the roof of the olecranon fossa. It is noted that the tip of the olecranon on complete extension lies 1 cm distal to the beginning of the olecranon fossa and this entry will not hinder elbow extension. Guide wire inserted through the entry portal and the fracture reduced under fluoroscopic guidance. Serial reaming is done using 6, 7, and 8-sized reamers. Nail inserted with the guide wire in place. Guidewire was removed and tri wire of one size lesser than the nail inserted. Two distal screws are 3.5 mm screws which anchors to the medial and lateral cortex, proximal interlocking bolts inserted, and tri wire gently pushed through the middle of the Halder nail which opens up proximally, and an end cap is applied through the distal end to prevent back-out of tri-wire inserted. Wound was washed and closed in layers. Sterile dressing is done.

Procedure for plating

All Patients operated through a posterior approach (Campbell approach) and hence they were placed in the lateral decubitus position with the fractured side up. The arm was completely free and placed on the arm holder, and parts were painted and draped sterile without applying a tourniquet. The incision was made by centering the fracture line by taking the angle of the acromion in the proximal and the olecranon in the distal. After superficial exposure, the triceps were divided into two by blunt dissection. The radial nerve and the brachial profunda brachial artery were dissected and preserved and tagged using umbilical tape. Fracture reduction was attempted. After satisfactory reduction plate fixation was done and wound closed after thorough wound wash (Fig. 2 and 3).

Post-operative protocol

Appropriate IV antibiotics were given for 3–5 days once the surgery was completed and converted to oral, till suture removal. On the 5^th–14^th day after surgery, the patient status was evaluated, and discharged from the hospital. Physiotherapy was initiated in the first post-operative day (POD). Patients were called for follow-up at 2 weeks and 4 weeks, pendular shoulder exercises started after suture removal on 12^th POD, and serial X-ray were taken at 3, 6 months, and 1 year for both groups.

In our study, 48 cases were treated by HALDER intramedullary humerus nail. Clinically, we look for evidence of infection, tenderness at the fracture site, shoulder and elbow range of movements, and return to activity of daily living at each follow-up. The results were analyzed with standard AP and lateral radiographs. Clinical and radiological signs of the union were analyzed at each follow-up. Of the 48 cases, all of them are available for follow-up. Union status of the fracture is assessed and found to be 12–16 weeks for 35 cases (73.33%) and 16–20 weeks for 13 cases (26.66%). Duration of surgery was found to be 45–60 min for 33 cases (66.66%) and more than 60 min for 15 cases (33.33%). Out of 54 plate fixation cases, 38 were male (70.37%) and 16 were female (29.62%). Radiological union status is seen at about 12–16 weeks for 35 cases (64.81%) and 16–20 weeks for 19 cases (35.18%). In some cases, complications were noted like delayed union (4 cases), wrist drop (5 cases), non-union with implant failure in (1 case) (Table 2 and 3).

Case 1: 50 years/female, self-fall, left shaft of humerus fracture fixed with Halder nail.

Case 2: 36 years/male, road traffic accident, left humerus fracture fixed by ORIF with plating, had a complication of non-union and implant failure.

The results of the use of intramedullary Halder nailing for humeral shaft fractures have shown mixed outcome with some studies showing good results and some showing moderate results. Patient was discharged with advice to avoid pendular exercises of the shoulder until 6 weeks post-operative, to avoid tri-wire breakage. Patients were allowed active shoulder and elbow mobilization. Delayed union and minimal angular deformity are the complications encountered postoperatively in a few patients in various studies. Our union rate was 99% which was in accordance with international studies which mention a union rate of 80–100% [5,9,10,22]. On the other hand gold standard, open reduction and plate osteosynthesis show a union rate of 93–98% [15, 20]. Functional bracing for the humeral fracture gives a union rate of 90–95% [7, 9, 13]. The average time of union in our series was 12.71 (12–16 weeks) which is comparable to other series, which shows a union time of 12.3–16 weeks [1, 11, 21]. In open reduction and plate osteosynthesis, the union was achieved between 12 and 18 weeks [9, 15]. On the other hand, functional bracing shows an average time of 12.5 weeks for the evidence of clinical and radiological union ^[18]. None of the cases were infected in the nailing group of our series, which is consistent with other international series ^[5]. This can be attributed to the lesser exposure time, smaller incision, and closed reduction with intramedullary Halder nail. One case had an iatrogenic nerve injury (Graph 1).

Many studies show post-operative wound infections, cosmetic issue, and supraspinatus tendinitis were encountered as main complications in the anterograde humerus nail and plating for humerus fractures as like our study.

One case of transient radial nerve palsy postoperatively which recovered in 6 weeks. Forty-two of the 48 cases of the diaphyseal fractures treated by retrograde Halder nailing have attained near the normal range of motion of the shoulder joint, that is, <20° of the restriction of the shoulder joint movement [5, 10-14]. It was observed that the movement and functional disability of the shoulder depends mainly on the post-operative rehabilitation [6-8, 16-19]. Shoulder impingement can be overcome by retrograde insertion which proved another superiority of retrograde nailing over other methods like antegrade intramedullary interlocking nail. Forty-eight out of 48 cases had a full range of elbow motion. Even though it is a retrograde insertion there was no restriction in the range of elbow motion. Post-operative shoulder and elbow mobilization were very crucial in regaining the preoperative range of movements. Patients who adhered to the rehabilitation program had a better functional result compared to others. In our studies, 42 out of the 48 fractures united, while two cases for which union achieved by 5 months postoperatively. Considering the excellent results and number of cases with surgical treatment of diaphyseal humeral fractures with the retrograde HALDER nailing was justifiable for these fractures. HALDER nail is a safe and reliable method in treating diaphyseal fractures of the humerus particularly with osteoporosis and polytrauma where reduction in operating time and early rehabilitation is primary objective and it lessens morbidity. The shoulder impingement and supraspinatus bursitis can be reduced due to retrograde entry site and early rehabilitation program which promotes good functional outcome.

Hence, we conclude retrograde Halder nail is a reliable method of surgical treatment of diaphyseal fractures of humerus due to the following reasons. The concept of biological fixation in terms of closed nailing and minimal soft-tissue handling preserves fracture hematoma thus promoting early union and rehabilitation. It provides good axial and rotational stability. Closed nailing avoids fracture exposure to the external environment thereby minimizing the chance of infection. Closed nailing minimizes the risk of iatrogenic radial nerve injury. It avoids extensive soft-tissue dissection, periosteal stripping, and devitalization of bony fragments particularly in comminuted and segmental fractures thereby preserves vascularity and minimizes the chance of non-union. Closed retrograde nail reduces the operative time and blood loss, avoiding the need for blood transfusion and its complications. Halder nail allows early post-operative mobilization of shoulder and elbow joints thereby preventing joint stiffness. Furthermore, it prevents complications such as shoulder impingement, radial nerve injury, and supraspinatus bursitis encountered during antegrade intramedullary nailing. The duration of hospital stay is minimal, and the procedure is cost-effective with the highest patient satisfaction due to the early return of his work. In conclusion, retrograde Halder humeral nail is a novel and effective alternative in the management of humerus fractures being done in INDIA for the 1^st time at our institution.

In the current scenario of increasing road traffic accidents with poly trauma, delay in upper limb fracture fixation due to prolonged duration of surgery and open reduction. Retrograde Halder intramedullary nailing for humerus shaft fractures would be the choice of implant in future in which duration of surgery is significantly less comparing other modalities of fixation.