Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing


      Introduction and objective

      Proximal humerus fractures with metaphysodiaphyseal extension represent a challenge for the orthopedic surgeon due to their reduced incidence and the difficulty in the treatment decision. These can be treated with an intramedullary nail or using the MIPO technique, associating different advantages and complications depending on the procedure. The objective of this study was to compare metaphyseal-diaphyseal fractures of the humerus treated with antegrade intramedullary nailing and those operated using the MIPO technique to see if there were significant differences in terms of functional, clinical, and radiological results.

      Material and methods

      retrospective, analytical and unicentric review of 29 patients with proximal fracture with metaphyseal-diaphyseal extension treated by MIPO technique and 33 patients surgically treated by antegrade intramedullary nailing (IMN) in our hospital from 2014 to 2020. Demographic, functional, radiographic and clinical data were obtained..


      No significant differences were observed between both groups in terms of fracture mechanism (p=0.34), fracture type (p=0.13) or Maresca classification (p=0.32). Surgical time was significantly shorter in the IMN group compared to the MIPO technique (p=0.014). No significant difference was observed regarding the need for blood transfusion (p=0.32). The mean consolidation in the MIPO group was 21 weeks compared to 21 weeks in the IMN, with no significant differences between both groups (p= 0.88). No significant differences were observed between CONSTANT test at one year in the MIPO group versus the IMN group (p=0.79), nor in radial nerve palsies (p=0.28).


      Proximal fractures with metaphyseal-diaphyseal extension are a challenge for the orthopedic surgeon due to the infrequency, the complexity of these fractures and the fact that there is no established consensus on the ideal treatment for this type of injury. Both the MIPO technique with the Philos plate and the intramedullary nail are valid options for the treatment of these fractures, with no differences observed in terms of fracture consolidation time or in terms of functional results.


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        • Singisetti K.
        • Ambedkar M.
        Nailing versus plating in humerus shaft fractures: a prospective comparative study.
        Int Orthop. 2010; 34: 571-576
        • Cole P.A.
        • Wijdicks C.A.
        The operative treatment of diaphy- seal humeral shaft fractures.
        Hand Clin. 2007; 23: 437-448
        • Apivatthakakul T.
        • Arpornchayanon O.
        • Bavornratanavech S.
        Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report.
        Injury. 2005; 36: 530-538
        • Maresca A.
        • Pascarella R.
        • Bettuzzi C.
        • Amendola L.
        • Politano R.
        • Fantasia R.
        • Del Torto M.
        Multifocal humeral fractures.
        Injury. 2014; 45 (Feb): 444-447
        • Changulani M.
        • Jain U.K.
        • Keswani T.
        Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study.
        Int Orthop. 2007; 31: 391-395
        • Zogbi D.R.
        • Terrivel A.M.
        • Mouraria G.G.
        • Mongon M.L.
        • Kikuta F.K.
        • Filho A.Z.
        Fracture of distal humerus: MIPO technique with visualization of the radial nerve.
        Acta Ortop Bras. 2014; 22: 300-303
        • Zhao J.G.
        • Wang J.
        • Wang C.
        • Kan S.L.
        Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping metaanalyses.
        Medicine (Baltimore). 2015; 94: e599
        • Baltov A.
        • Mihail R.
        • Dian E.
        Complications after interlocking intramedullary nailing of humeral shaft fractures.
        Injury. 2014; 45: S9-15
        • Livani B.
        • Belangero W.D.
        • Castro de Medeiros R.
        Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis.
        J Bone Joint Surg Br. 2006; 88: 1625-1628
        • Bradley D.
        • Arshad M.S.
        • Aster A.
        • Jeyam M.
        Spontaneous recovery of radial nerve function following axonamonosis caused by impingement from distal locking screws during humeral nailing.
        Should Elb. 2013; 5: 202-205
      1. Garvanos C. Rockwood and Greens fracture in adults. 8th edition ed. M C, editor: Wolter Kluwer; 2015. 53 p.

        • Lian K.
        • Wang L.
        • Lin D.
        • Chen Z.
        Minimally invasive plating osteosynthesis for mid-distal third humeral shaft fractures.
        Orthopedics. 2013; 36: e1025-e1032
        • Wang Y.
        • Chen H.
        • Wang L.
        • Chen X.
        • Zhi X.
        • Cui J.
        • Cao L.
        Comparison between osteosynthesis with interlocking nail and minimally invasive plating for proximal- and middle-thirds of humeral shaft fractures.
        Int Orthop. 2021; 45 (Aug): 2093-2102
        • Kumar B.S.
        • Soraganvi P.
        • Satyarup D.
        Treatment of Middle Third Humeral Shaft Fractures with Anteromedial Plate Osteosynthesis through an Anterolateral Approach.
        Malays Orthop J. 2016; 10: 38-43
        • Shetty M.S.
        • Kumar M.A.
        • Sujay K.
        • Kini A.R.
        • Kanthi K.G.
        Minimally invasive plate osteosynthesis for humerus diaphyseal fractures.
        Indian J Orthop. 2011; 45: 520-526
        • Lee T.
        • Yoon J.
        Newly designed minimally invasive plating of a humerus shaft frac- ture; a different introduction of the plate.
        Int Orthop. 2016; 40: 2597-2602
        • Concha J.M.
        • Sandoval A.
        • Streubel P.N.
        Minimally invasive plate osteosyn- thesis for humeral shaft fractures: are results reproducible?.
        Int Orthop. 2010; 34: 1297-1305
        • Kulkarni V.S.
        • Kulkarni M.S.
        • Kulkarni G.S.
        • Goyal V.
        • Kulkarni M.G.
        Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures.
        Injury. 2017; 48 (Aug): S8-S13
        • Hu X.
        • Xu S.
        • Lu H.
        • Chen B.
        • Zhou X.
        • He X.
        • Dai J.
        • Zhang Z.
        • Gong S.
        Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis.
        J Orthop Surg Res. 2016; 11 (May 11): 59
        • Konda S.R.
        • Saleh H.
        • Fisher N.
        • Egol K.A.
        Humeral shaft fracture: intramedullary nailing.
        J Orthop Trauma. 2017; 31: S38
        • Fan Y.
        • Li Y.W.
        • Zhang H.B.
        • Liu J.F.
        • Han X.M.
        • Chang X.
        • Weng X.S.
        • Lin J.
        • Zhang B.Z.
        Management of humeral shaft fractures with intramedullary interlocking nail versus locking compression plate.
        Orthopedics. 2015; 38: e825-e829
        • Ma J.X.
        • Xing D.
        • Ma X.L.
        • Gao F.
        • Wei Q.
        • Jia H.B.
        • Feng R.
        • Yu J.T.
        • Wang J.
        Intramedullary nail versus dynamic compression International Orthopaedics (SICOT) plate fixation in treating humeral shaft fractures: grading the evi- dence through a meta-analysis.
        PLoS One. 2013; 8 (ARTN): e82075
        • Ikpeme J.O.
        Intramedullary interlocking nailing for humeral fractures: experiences with the Russell-Taylor humeral nail.
        Injury. 1994; 25: 447-455
        • Ingman A.M.
        • Waters D.A.
        Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results.
        J Bone Joint Surg Br. 1994; 76: 23-29
        • Raghavendra S.
        • Bhalodiya H.P.
        Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective study.
        Indian J Orthop. 2007; 41: 214-218
        • Chen Y.N.
        • Chang C.W.
        • Lin C.W.
        • Wang C.W.
        • Peng Y.T.
        • Chang C.H.
        • Li C.T.
        Numerical investigation of fracture impaction in prox- imal humeral fracture fixation with locking plate and intramedullary nail.
        Int Orthop. 2017; 41: 1471-1480
        • An Z.
        • He X.
        • Jiang C.
        • Zhang C.
        Treatment of middle third humeral shaft fractures: minimal invasive plate osteosynthesis ver- sus expandable nailing.
        Eur J Orthop Surg Traumatol. 2012; 22: 193-199
        • Livani B.
        • Belangero W.D.
        • Castro de Medeiros R.
        Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis.
        J Bone Joint Surg Br. 2006; 88: 1625-1628
        • Davies G.
        • Yeo G.
        • Meta M.
        • Miller D.
        • Hohmann E.
        • Tetsworth K.
        Case-match con- trolled comparison of minimally invasive plate osteosynthesis and intramed- ullary nailing for the stabilization of humeral shaft fractures.
        J Orthop Trauma. 2016; 30: 6