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1 MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE MILITARY MEDICAL UNIVERSITY DUONG HOANG LUONG SURGICAL PROCEDURE OF HUMERUS SURGICAL CLOSED NECK FRACTURE WITH METAIZEAU NAIL Major Surgery Num[.]

AND TRAINING

MILITARY MEDICAL UNIVERSITY

DUONG HOANG LUONG

SURGICAL PROCEDURE OF HUMERUS SURGICAL CLOSED NECK FRACTURE

WITH METAIZEAU NAIL

Major: Surgery Number code: 9 72 01 04

SUMMARY OF MEDICAL DOCTORAL THESIS

STUDY COMPLETED AT VIET NAM MILITARY

MEDICAL UNIVERSITY

Supervisor:

1 Assoc., Prof PhD Tran Dinh Chien

2 Assoc., Prof PhD Nguyen Thai Son

Reviewer 1: Assoc., Prof PhD Vo Thanh Toan

Reviewer 2: Assoc., Prof PhD Luu Hong Hai

Reviewer 3: Assoc., Prof PhD Pham Dang Ninh

1 The topicality of the thesis

Surgical neck fractures of humerus can be commonly seen

at all ages, especially among the elderly and the adolescents.This type usually occurs close to the shoulder joint whosereduction and fixation are technically difficult. Poor treatmentcan leave severe sequeals affecting shoulder joint Forundisplaced or minimally displaced fractures, most of injuriesare treated conservatively by immobilizing the injured arm in

a cast or in a Desault shirt Immobilisation by a cast is,however, lengthy which greatly affects the glenohumeraljoint  

The widely employed surgical treatment forthe osteosynthesis of proximal humerus fractures in healthfacilities is open reduction and internal fixation usingscrew/plate, locking intramedullary nails, Kirschner wires andshoulder arthroplasty Open fractures have manydisadvantages including a skin incision 6–15 cm in length,more damage to the surrounding soft tissue, the periosteum,axillary nerve and rotator cuff, infection, delayed bonehealing, long scar and prolonged hospital stay With a view toovercoming these disadvantages, some authors advocateminimally invasive surgery and fracture fixation withintramedullary nails such as Rush nails, Ender’s nails,Metaizeau nails based on basic principle of three-pointfixation provided by symmetrical bracing action of two elasticnails, which facilitates the healing process The advantage ofthis method is to avoid direct exposure of fracture site, lessinjuried soft tissue; reduced blood loss; restricted antibioticuse, short treatment, stable fixation under C-armimage intensifier control, faster bone healing and earlyfunctional recovery

There have been various reports on surgical proceduresand techniques of surgical neck fractures of humerus usingtitanium elastic nail (TEN) without exposing the fracture.Nevertheless, no consensus on surgical procedures applicable

to all patients have achieved Each techniques has their prosand cons, especially some procedures have no clearguidelines in selection of intramedullary nails, techniques offracture correction and nail insertion into fracture site;

techniques of stabilizing the nail in the metaphyseal part Inrecent years, treatment of the surgical neck fractures ofthe humerus with TEN has been implemented in healthfacilities thoughout Vietnam Nonetheless, the number ofthese facilities is relatively small and no consensusprocedures has yet been reached on the technique of fracturefixation, C-arm image intensifier control, nail insertion forprevention of nail jamming, broken nail extractor  Fromthese above-mentioned reasons, we conducted the study:

“Technical procedure of humerus surgical closed neck

fracture with Metaizeau nail”

In Vietnam, there have been a number of reports on theapplication of this procedure However, there exists debates onthis issue This present study might be the first to address thesurgical procedure and outcome of humerussurgical closed neck fracture with Metaizeau nail in asystematic way

4 Organization of the thesis

The thesis is comprised of 127 pages, of which there are

02 pages for Introduction, 33 pages for Overview, 27 pagesfor Subjects and Methods, 31 pages for Results, 31 pages forDiscussion; 02 pages for Conclusion; 01 page forRecommendations; 01 page for Lists of published researchresults of thesis The thesis also includes 39 tables, 36 figures,with a total of 111 references numbering 14 ones inVietnamese, 02 in French and 95 in Enlgish

CHAPTER 1: OVERVIEW

1.1 ANATOMICAL AND PHYSIOLOGICAL FEATURES OF PROXIMAL HUMERUS 

1.1.1 Proximal humerus 

The proximal humerus consists of the humeral head,anatomical neck, greater and lesser tuberosity and surgicalneck The surgical neck is the part between the tuberositiesand the humeral shaft

1.1.2 Blood supply to proximal humerus 

Proximal humerus is supplied by anterior andposterior humeral circumflex artery and the arteries ofthe humeral head

1.1.3 Shoulder range of motion

Function of humerus is chiefly assessed via range ofmotion for elbow and glenohumeral joints Shoulder joints has

a greater range of movement than any other body joint

1.2 CLASSIFICATION OF HUMERUS SURGICAL NECK FRACTURE

1.2.1 Anatomical features of the proximal humerus fractures (PHFs)

1.2.1.1 Features of fracture line

1.2.1.2 Features of the displaced fractures of the proximal humerus

1.2.1.3 Soft tissue injury

1.2.2 Classification of the PHFs

1.2.1 According to AO

This system divides PHFs into three main types (A, B, C)according to extent of injury and risk of developingosteonecrosis of the humeral head

1.2.2 According to Neer et al.

This classification system is based on conventional

anteroposterior and lateral radiographs aiming to identify the

extent of displacement of each segment (humeral head,anatomical neck, greater and lesser tuberosity and surgicalneck) The Neer classification is considered to be of greatvaluein assessing the extent of displacement and predictingthe risk of osteonecrosis of the humeral head due to vasculardamage

1.3 TREATMENT OF HUMERUS SURGICAL NECK FRACTURE

1.3.1 Conservative treatment

Surgical neck fractures of humerus is treated conservativelywith over 90% of bone healing, especially for undisplaced andminimally displaced fractures

1.3.2 Surgical treatment

1.3.2.1 AO internal fixation with screws and plates

This procedure is widely employed in dosmetic healthfacilities in treatment of humerus surgical neck fracturebecause it allows anatomically good fracture reduction anddirect visualization of blood vessels In other words, besidesstabilization of fracture fragments, some splints havecompression effect in the fractured faces offering the chances

of fast healing and early function rehabilitation

1.3.3.2 Osteosynthesis using locking plates

Locking plate fixation was first described in 1995 and usedinitially for humeral shaft and then for humeral head Twotypes of locking plate fixation exist, namely one withconventional incision such as screw and plates and the otherwith minimal incision Locking plate has anatomical structureappropriate for humeral head and  the screw headthreads are fixed to the plate with a specific angle Lockingplate behaves like an external fixator when placed in asupracutaneous fashion

1.3.3.3  Intramedullary osteosynthesis of humerus 

Methods of locking intramedullary nails for humeralsurgical neck fractures include Ender nail, locking screws,locked intramedullary nailing, closed reductionwith Schanz screws for two- and three- part fractures, closedpercutaneous Kirschner wire fixation with the Kapandjitechnique, open reduction and internal fixation of three- andfour-part proximal humeral fractures by intrafocal distraction

1.3.3.4 Shoulder replacement surgery

Arthroplasty replacement is indicated for the surgicaltreatment of proximal humeral fractures with complexfracture patter Nevertheless, its complications consist ofloosening implant, malunion, ectopic ossification, deep woundinfection, injury to nerves and blood vessels

1.4 OSTEOSYNTHESIS WITH METAZEAU

1.4.1 Biomechanical properties of Metaizeau tip

- Properties of Metaizeau

+ Material: Metaizeau nails were more stable than stainlesssteel nails Metaizeaus of 4-mm diameter were used Titaniumhas elastic characteristics

+ Shape: Generally, Metaizeaus have a conical-shapedpoint on one end and a curved tip on the other A goodunderstanding of this feature is required The curved tip isintended for cortical orientation opposite the entry hole,

facilitating advancement of the nail withinthe medullary canal Radius of curvature of nails can beslightly reduced or increased to match the anatomy of thepatient The length of the curved tip should not exceed thelength of the orthogonal projection of the isthmus of themedullary canal, otherwise the nail will get stuck in the bone

- Advantage of Metaizeau

Metaizeau nails have a bow shape with the nail tip in theform of C-shaped manner The projected length of the curvedtip is about 2.2 times greater than the diameter of the nail.Sharp nail tip can penetrate through the opposite corticalbone whereas too long the curved tip may distract fractureduring nail insertion

Benefits of nail tip: Allows easy nail insertion and slidingalong the medullary canal; allows a central orientation inrelation to the medullary canal; good reduction of fracturefragments; stabilize the nail in the metaphyseal part toprevent rotation and displacement

1.4.2 Biomechanical principle of Metaizeau

According to Piere Lascombes, goal of fixation withMetaizeau was originally similar to rigid fixation, namely restorelimb function Nonetheless, the major differences betweenelastic fixation and rigid fixation include:

- For elastic fixation, a rapid recovery of limb function isattributed to faster healing through maximum growth ofperipheral ossification whereas in rigid fixation, fracturefixation devices are determinants for fast restoration ofextremity function For elastic internal fixation, fracturefragment mobility enhances formation of peripheralossification which provides the strongestmechanical fixation during callus formation

- Solid fixation is an important contributor to primary bonehealing without the production of callus but peripheralcalcification growth is not possible

+ The second goal of fixation with Metaizeau: To reducerisks of deep wound infection, osteomyelitis, prosthetic jointinfection, mini-invasive incision, blood transfusion; tominimize excessive growth of bone after a fracture; to restorequickly limb function; no requirement for additional fixationand short healing time

1.4.3 The biomechanical principle of fracture fixation with Metaizeau

Osteosynthesis with Metaizeau is based on the principle ofthree-point fixation and a balanced force produced byinsertion of two opposite nails into the metaphysis andspreading of these two tips over a wide range inthe horizontal plane when stabilized in the metaphysis.Insertion of single nail may generate a force causing angulardisplacement but slightly at the fracture site thanks tocontraction of muscles The placement of the second nailoffering three contacts into the bone opposite to the first nailproduces a perfectly balanced construct and symmetricalbracing action of two elastic nails These two nails holdfracture fragments stable, of which shear force disappears butcompression and traction force remain at the fracturedsegments The former occurs on the concave side and thelatter on convex side of the bone Both forces work together

at fracture site to stimulate healing process

The principle of 3-point fixation has created a solidfixation system, preserving the axial alignment, preventingdisplacement and rotation

1.5 RESEARCHES AND APPLICATION OF ELASTIC NAILS 1.5.1 Foreign studies

There have been numerous studies published on theapplication of elastic nails in fracture fixation

1.5.2 Domestic studies

Surgical treatment of humerus surgical closed neckfracture with TEN has been employed since 2003 in somemajor hospitals in Ha Noi, Ho Chi Minh and provincial citieswith satisfactory results

CHAPTER 2: SUBJECTS AND METHODOLOGY

2.1 RESEARCH SUBJECTS

The study enrolled the medical records of 55 patients withdisplaced humeral surgical neck fractures aged 19-79 yearswho were operatively treated with Metaizeaus withoutopening the fracture site under C-arm image intensifiercontrol between April, 2015 to December, 2018 atOrthopedics and Trauma Department, Saint PaulHospital, Hanoi

* Selection criteria

- Patients with displaced humeral surgical neck fracturesreceived no previous treatment or underwent unsuccessful

conservative treatment

- Patients were eligible for surgery

- Time from trauma to operation did not exceed 14 days

- Fracture morphology: According to Neer classification,Neer III, Neer IV fracture and three-part fracture was selected

* Exclusion criteria

- None of the fractures was pathological including bonecysts, bone tumors, osteogenesis imperfecta; There were noassociated neurovascular injuries in the arms; Bone marrowdue to congenital anomalies or previous fractured humerus;The injured arm with prior sequeal affecting the shoulder andelbow joints Patients refused to participate in the study

2.2 METHODOLOGY

2.2.1 Study design

This is a prospective, cross-sectional descriptive and controlled study The study made a reference to literaturereview on establishment of surgical procedure for proximalhumeral fractures by foreign and domestic authors such asthe technique of reduction, nail insertion, number of nails,exercise following surgery Patients with Neer III, IV fractureand three-part fracture were administered for osteosynthesiswith Metaizeau nail without opening the fracture site underthe guidance of C-arm

+ Neer classification for proximal humeral fractures;Indications for surgery; Selection of reduction and fixationtechnique; Proper choice of surgical timing; Measurement ofdiameter of canal isthmus using three-dimensional computedtomography (CT) images at middle and lower third humerus

to facilitate the selection of the most suitable Metaizeau.When two or three nails are used, they should have thediameter about 1 mm smaller than the diameter of theisthmus in order to allow the nail to slide along the medullarycanal smoothly without getting stuck Patients were explainedabout benefits of TENs, complication and accidents that mightarise intra-and/or post-operation There should be acollaboration between physicians and patient’s familybefore, during, and after surgery

+ Monitoring and evaluation of surgical outcome;postoperative care Post-operative radiographs were taken toevaluate the results of reduction and fixation technique;results of bone healing, rehabilitation and complications Datawere processed using SPSS.20.0 software.

2.2.3 Selection of convenience sampling

Selection of non-probability sampling involvingconvenience sampling, corresponding to medical records of

79 patients aged 19-79 years who were operatively treatedwith Metaizeau nail without opening the fracture site Thesepatients were categorized into groups of Neer III, IV and three-part fracture and selected from study time until adequatesampling size

2.2.4 Materials and medical instruments

Surgical arm tables The C-arm machine is used duringreduction and fixation of fractures Metaizeau nails weremade from titanium alloy raw materials with dimensions of3mm and 3.5mm in diameter; and 440mm - 450mm in length byGPC Medical Ltd - TENing System manufacturingcompany from India TEN Instruments Set: Bone Awl (3-4mm);Locking Pliers; Cutter for Nail; Hammer Fiber Handle, pince; DrillBit Plane 3-4m

2.3 PROCEDURE FOR RESEARCH

2.3.1 Indications for fracture fixation using Metaizeau nail

Displaced humeral surgical neck fractures according tothe Neer classification (Neer III, IV fracture and three-partfracture)

2.3.2 Surgical procedure for humeral surgical neck fractures with Metaizeau nail

* Step 1: Patient selection by age (19-79 years of age);

location of fractured bone (humeral surgical neck fractures);fracture type (Neer III, IV fracture and three-part fracture)

* Step 2: Instrument preparation: Surgical arm tables.

The C-arm machine is used during reduction and fixation offractures Metaizeau nails had diameter of 3mm and 3.5mmand its length ranged from 440mm – 450mm Selection of themost suitable Metaizeau nail was based on the diameter ofthe canal; Surgical lead apron

* Step 3: Surgical technique: Tiến hành phẫu thuật:

Patients were performed endotracheal anesthesia or brachialplexus anesthesia; Closed reduction and Metaizeau nailingwas done under Under C-arm image intensifier control

according to the well-established procedure

- Patient positioning: The patient was place in the supineposition with supporting pad on the lateral shoulder of theinjured arm

- The image intensifier was placed on the injured side forconvenient access by the surgeons

- The patient lies in the supine position The surgeon, theassistant stands to the side of the fractured arm It isimportant to check for angulation prior to initiating operation

Fracture fixation technique consists 5 stages

- Stage 1: Reduction

Perform a trial reduction of the humerus prior tosterilization and final reduction as well as fracture fixationafter sterilization Apply traction along the long axis of thelimb to correct the overlapping of fracture ends and thenreduce angular displacement such that the proximal fragment

is pushed backward while the proximal fragment is raised onthe image intensifier in the anteroposterior and lateralprojections After completion of reduction, disinfect the limb

up to the shoulder and drape in such a way as to leave theupper arm and elbow joint exposed

Surgical field disinfection before surgery using iodine-alcohol; Cover patient with a sterile surgical drapes;Perform the surgery

povidone Stage 2: Skin incision

Determine the proper location of the incision: Using theimage intensifier and awl to make the shortest incision of 1-1.5 cm This incision allows good access to entry hole intocortical bone or Metaizeau nailing made with an awl or a drill.Normally, skin incision should be 1-1.5 cm away from the entryportal The entry hole is usually situated superiorly 1-1.5 cm atthe medial – lateral condyle or posteriorly at the olecranonfossa 

Use retractor to split the fascia from the bone cortex ofmedial and lateral epicondyle or right above the cubital fossa(positioned below the C-arm)

- Stage 3: Bone tunnel

Aims: A bony tunnel is created wide enough using a 3-4

mm cannulated drill bit to allow 3.0 or 3.5 mm TENing into theintramedulary canal An osteotomy site is selected Theosteotomy needs to be so large (3-4 mm) that the nail cancontrol it The osteotomy is done in an obliquemanner towards the axis of medullary canal at the angle of 45

degree from which nail that can be inserted This contributes

to avoiding secondary fracture Location of bony tunnelshould be soft tissue so that nail tips can be covered andavoids protrusion

Cortical osteotomy at the distal of humerus

+ Split or retraction of triceps brachii muscle after thirdposterior incision above the olecranon fossa; split bilateraltendon of medial and lateral epicondyle for lateral incision.Use a regular retractor for spliting so that one end of retractorcan split the muscle tendons and the other touches bonecortex to allow a drill into bone cortex using the awl or drillbit

+ Humeral shaft is marked with sharp 3-4 mm awl Thislandmark is identified under the image intensifier Lateralview of the C-arm image shows medial and lateral epicondyle

or posteriorly above the olecranon fossa, which is 1.5-2 cmaway from posterior wall of humerus

+ Drilling for wall osteotomy: Use a sharp awl for drillingamong the elderly patients (over 61 years of age) and a drillwith diameter of 3-4 mm among the adults (25 – 40 years old)due to hard bony wall The awl or drill was made at correctlocation of wall osteotomy with an inclination of 45 degreeover canal axis to create the passage into the medullarycanal

Stage 4: Nailing

At this stage, fractures must be adequately aligned andinsertion of two or three Metaizeau into medullary canal tocreate a well-balanced elastic fixation construct are required

- Insert first nail: From the lateral epicondyle, place thecurved tip perpendicular to the bony wall at the newly-awledhole

Rotate the nail 1800 to aim its tip towards the medullarycanal Use nail plier to rotate the nail as described and pushforward the nail in the canal During nail insertion into thecanal, use nail pliers to rotate nail so that the sharp end doesnot engage and anchor in the cortex; nail passes through thefracture site

* Fracture reduction and fixation

Stabilize and realign bone fractures along the long axis ofthe bone After crossing the fracture site, nails were putforward to the proximal bone (humeral head), nail tips aimedtoward outer wall of proximal bone at planned distance of 1.5-2cm from the endpoint of nail tip After nail trimming, nail

kept being pushed forward the desired position Fracturefixation was inspected under C-arm control.

- Insert second nail: Repeat steps as the first nail Startingfrom the medial epicondyle, nail tip was positionedperpendicular to bone entrance hole and was then rotated anangle of 1800 so that it was directed toward the medullarycanal Continue to realign the fractured site under C-arm for theanteroposterior-lateral view The second nail crossed thefractured site toward the centre of humeral head Turning thenail tip toward inner bone opposite to the first nail ensuringsymmetrical bracing action of two elastic nails to obtain a goodmechanical balance of reduction and stabilizing forces. 

In case where the medullary canal is wide and two elasticnails are insufficient for alignment of axial and angulardisplacement, posterior wall osteotomy is performed Theentry point was established at 1.5-2cm above the olecranonfossa and then the third nail reached the medullary canal sothat it was placed between the first and second nail Stepswere repeated like the first two nails When nails advancedproximally to fracture site, fractured site continued to be reduced

in the anteroposterior-lateral planes under C-arm images Afterthe desired fracture reduction was achieved, nailing through thefracture site into the central head and rotating it in the oppositedirection toward the other two tips so that an anti-rotationtriangle was established

There were two remarkable differences compared to theinsertion of first nail: First, insertion of second and third nailwas technically challenging due to narrower medullary canal,nail was rotated so that it could slide smoothly avoidingtorsion of the 2nd and 3rd nail around the 1st nail Second, thatfracture fragment was reduced and stabilized by first nailfacilitated the insertion of two remaining nails A particularattention is paid to nailing the second and third to the desiredpositions: Their tips should be 1.5-2 cm from the end-pointand their bending in the opposite direction to the initial nail sothat their tips anchor into two and three opposite bone wallsfor better fixation, anti-rotation and well-balanced constructaccording to the principle requiring two-three curved titaniumnails to be inserted retrograde bilaterally

Stage 5 Nailing trimming

When two and three nail tips were positioned 1.5-2 cmbelow fracture site, Metaizeau was left bent at an angle of 30-

400 at insertion site. 

Nail tips were trimmed proximally to skin and furthertapped each down to the correct position (2-3mm from jointspace) At this point, nail tips at stab incision were placedclose to bone cortex without protrusion and soft tissue injuryduring extremity movement

Skin closure of surgical wounds was achieved with one ortwo layers of suture Injured arm was examined to ensuregood fixation in the AP and lateral image intensifier views

As compared to the nailing technique in the literature, wemade a reference and utilized two techniques ofintramedullary nailing

- Technique 1: From the lateral epicondyle, the first nailwas introduced up to 1cm from the fracture site; Achieveanatomical reduction and advance the nail manually up tothe fracture site; stabilize the top of the nail into the humeralhead; The second and third nail are advanced from the medialepicondyle and posteriorly olecranon fossa across thefragment and then rotate their tips toward fixed position inthe humeral head in three different directions This technique

is widely accepted for Neer III fractures and fragments easy toreduce

- Technique 2: Two-three nails are introducedsimultaneously, roughly 1 cm from the fracture site; nail tips inthe medullary cavity are placed 1 cm apart to make it easier todistinguish the medial and lateral nails Nails behind olecranonfossa have their tips rotated in the opposite direction to themedial and lateral nails The surgeon assistant holds the fracturesite in a reduced position while using three separate pins as alever for reduction of distal fragment from the proximalfragment The first nail crosses the fragment into humeral head,followed by advancing the second and third nail up to humeralhead region according to two-three different directions for Neer

+ If displacement had angulation more than150in both APand lateral view and the medilluray canal is wide, its outcome

is unsatisfactory, thereby requiring the third nail to beadvanced opposite the angulation.

+ Nail tips are fixed into humeral head region at point fixation, which meets the technical requirement

three-+ Surgical time is caculated from skin incision to woundclosure and measured in minutes

+ The number of radiation exposure is caculated as thetotal number of C-arm scans required (from initial reduction ofthe fracture (AP and lateral) until check-up of the correctposition of the nails and the quality of reduction in all stages:reduction, drilling, nailing and final check up

* Step 4: Post-operative treatment

+ For pure surgical neck fracture, administration ofantibiotic therapy includes prophylactic antibiotics pre-and-postoperation in combination analgesic drug and edemamedications Additional 3-5 day treatment was done in cases

of multiple lesions

+ Anteroposterior (AP) and lateral radiographs of adistal humerus fracture was required to check the quality offixation

+ On postoperative day (POD) 1, patients were instructed

to perform muscle-setting exercise and static stretchin.Patients were encouraged to perform gentle range-of-motionexercises of the shoulder, elbow, wrist, and hand in theimmediate postoperative period

+ On POD 2, patients were provided physical therapy athospital bed and continued to maintain movement in theshould and elbow joint with gradual increase inthe amplitude of the movement

+ On POD 3, patients discharged from hospital and made

a regular follow-up appointments. 

- Anesthesia methods: Endotracheal anesthesia andbrachial plexus anesthesia

- Outcome of closed reduction without opening thefracture site: axial alignment, minimal displacement less than

150 and severe displacement greater than 150

- Technique of nailing from medial - lateral epicondyle andposterior olecranon fossa 

- Complications: Nail breakage, jamming, twist, brokenbone cortex, neurovascular injury

- Technique of two – three nail insertion; a nail diameter of 3.0and 3.5 mm

- Rehabilitation: Time of immobilization, performance ofactive and passive ROM exercises

- Emerging issues of surgical procedure and experience drawnfrom these issues

2.4.2 Assessment of treatment outcome

+ Fracture fixation outcome: Radiograph of adistal humerus fracture was taken on POD2 to assess thequality of reduction According to Neer et al, fracture fixationhas satisfactory result when fracture achieves axialalignment in the anteroposterior and latero-oblique planesand unsatisfactory result when in such similar plane, varus orvalgus malpositioning less than 15 degree and 1/3 of shaftwidth and varus or valgus malpositioning greater than 15degree and > 1/3 shaft width Reduction of the fracture meetsthe requirement for aligning fragments and fails to satisfy forrotation malalignment greater than 50 degree

+ Nail positioning: Does nail tip protruding soft tissueaffect the movement of elbow joint? Intraoperative accidents:Neurovascular injury, broken bone cortex, jammed nail, nailbreakage, twisted nail Postoperative early complication:anemia, hematoma and cutaneous ulceration at nail end.Surgical time: is caculated from skin incision until completion

of incisional suture and is measured in minutes The number

of radiation exposure is caculated as the total number of arm scans required (from initial reduction of the fracture (AP

C-and lateral) until check-up of the correct position of the nailsand the quality of reduction The intensity of the incident X-ray beam; Assessment of failure, accidents and complications.

2.4.2.2 Long-term outcome

Follow-up period of at least 12 months

Long-term outcome (assessed based on the followingcriteria - a 100-point scale) Grades were considered excellent

at 90-100, good at 80-89, fair at 70-79, and poor below 70points

Overall outcome

Based on Neer criteria, long-term outcome wascategorized into 4 grades as follows:

+ Excellent: (> 89 points): No pain in your shoulders and

elbows ; no complications, normal range of shoulder motion:Rotation: 3600; Abduction: 1800; adduction: 450; normal range

of elbow motion: Flexion1300; extension: 00 Axial alignmentand no rotation malalignment found in the current study

+ Good (80-89 points): No pain in your shoulders and

elbows; no complications; range of shoulder motion: Rotation:

3600; Abduction: 170-1800; adduction: 30-450; range of elbow

motion: Flexion120-1300; extension: 0 - 50 Minimally displacedfracture (< 150); no rotation malalignment was found

+ Fair (70-79 points): No pain in your shoulders and

elbows; Inflammation at nail ends; Range of shoulder motion:Rotation: < 3600; Abduction: < 1500; adduction: 10- < 450

(limited range of motion); range of elbow motion: Flexion: <

1300; extension: 5-100; angulation ≥ 150 (moderatelydisplaced); rotaion alignment < 50

+ Poor (below 70 points): Delayed healing and rotation

malalignment > 50 or osteomyelitis or non healing; pain infragments and knee joints; Osteomyelitis Range of shouldermotion: Rotation: < 1800; Abduction: < 900; adduction: < 100;range of elbow motion: Flexion: < 900; extension: >100;angulation > 150 (severely displaced); rotaion alignment

2.5 DATA PROCESSING

Data were collected and then processed usingthe statistical analysis and SPSS 20.0 software

2.6 ETHICS IN THE STUDY

This research has put surgical procedure of humerussurgical closed neck fracture with Metaizeau nail withoutopening fragments into application This technique has beenwidely accepted across the countries in the world and brought