Locking plate fixation versus intramedullary nail fixation for the treatment of proximal humerus fracture: a review

INTRODUCTION

Proximal humerus fractures account for approximately 4-6% of all fractures, representing the third most common fracture type in the elderly after hip and distal radius fractures.¹ Non-operative management is often appropriate for minimally displaced fractures; however, surgical fixation is indicated for displaced, unstable, or multi-fragmentary injuries.² Several studies have clinically reported that both locking compression plates (LCPs) and intramedullary nails (IMNs) are effective in restoring anatomy and function, yet their optimal indications and comparative outcomes remain debated.^3-5 This review aims to compare LCP and IMN fixation in the treatment of proximal humerus fractures with emphasis on indications, functional outcomes, and complications.

LOCKING PLATE FIXATION

Locking plates provide rigid fixation with angular stability and allow direct visualization and anatomical reduction. Multiple screw trajectories in the humeral head ensure strong fixation, and medial calcar screws can prevent varus collapse. However, the technique requires extensive surgical exposure, which may disrupt humeral head vascularity and increase the risk of avascular necrosis.⁶ Hardware-related issues such as screw cut-out, plate prominence, and subacromial impingement are also reported.⁷

INTRAMEDULLARY NAIL FIXATION

Intramedullary nailing is a minimally invasive procedure that preserves periosteal blood supply and reduces soft tissue trauma. It offers biomechanical load sharing and generally shorter operative time.⁸ Nevertheless, it can be challenging to achieve anatomical reduction in comminuted fractures, and the entry point through the rotator cuff may cause postoperative shoulder dysfunction.⁹ In osteoporotic bone, fixation may be less stable compared to locking plates.¹⁰

COMPARATIVE OUTCOMES

Union rates are generally comparable between LCP and IMN fixation.¹¹ Functional outcomes measured by Constant and DASH scores have shown mixed results across studies, with some favoring nails for early motion and others plates for anatomical reduction.¹² Complication profiles differ—locking plates carry higher risks of screw perforation and varus collapse, while intramedullary nails more often cause shoulder impingement and rotator cuff irritation.¹⁴ Overall, reoperation rates are similar, and outcomes depend on fracture pattern, patient bone quality, and implant design.¹⁴

DISCUSSION

The optimal fixation method for proximal humerus fractures remains a topic of active debate. While locking plates offer strong angular stability suitable for complex and osteoporotic fractures, intramedullary nails provide a less invasive alternative with reduced soft tissue damage.¹⁵ Biomechanically, plates resist varus collapse better, whereas nails demonstrate superior load-sharing capacity along the humeral shaft. However, these mechanical advantages do not consistently translate into superior clinical outcomes.¹⁶

Recent randomized and observational studies have suggested that patient-specific factors such as age, bone density, and fracture configuration play a decisive role in selecting the fixation method. For elderly patients with osteoporotic bone, augmentation with bone grafts or calcium phosphate cement may enhance fixation strength in plate constructs.¹⁷ In contrast, nails may provide satisfactory outcomes in simple two-part fractures, particularly where soft tissue preservation is critical.¹⁸ Minimally invasive plate osteosynthesis (MIPO) and improved entry-point techniques for nails have further minimized soft-tissue disruption and reduced complication rates.

Despite extensive research, the literature remains heterogeneous in terms of study design, follow-up duration, and outcome measures. Meta-analyses indicate no statistically significant difference in long-term functional scores between the two techniques.¹⁹ Thus, the current trend emphasizes individualized treatment planning based on fracture morphology and surgeon experience rather than a one-size-fits-all approach.²⁰

CONCLUSION

Locking plate and intramedullary nail fixation are both effective for managing proximal humerus fractures, with comparable union and functional outcomes. The choice of technique should be individualized, considering fracture pattern, bone quality, and surgeon expertise. Locking plates provide superior stability in complex and osteoporotic cases, while intramedullary nails offer a minimally invasive alternative with faster recovery potential. This review consolidates current evidence, clarifying that no single method is universally superior; instead, careful patient selection and adherence to sound surgical principles remain key to optimizing results and advancing clinical understanding in the field of proximal humerus fracture management.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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