Tips and tricks for the fixation of humeral head fractures with a proximal humeral nail

Despite the growing number of reports about antegrade interlocking nailing of humeral head fractures, explanations of differentiated operative techniques that depend on classification and pathological findings are still missing. Based on more than 600 clinical applications of this method, we experienced that, in addition to the number and position of main segments, the properties of the separated tubercles and of the rotator cuff determine the operative procedure. While two-part fractures and fractures with a solid third part can successfully be fixed simply by using a nail and interlocking screws, the application of tension band sutures becomes crucial for fixation of comminuted and displaced osteoporotic tubercles. In this case, the heads of the angular stable locking screws, firmly fixed to the nail, serve as counter points for tension band sutures of the corresponding tendon attachment of the rotator cuff. We call this technique the 'rope-over-bitt' fixation, whereby a certain geometry of the head of the interlocking screw is prerequisite.