I. Background

Plate fixation and intramedullary nailing are common treatments for proximal and diaphyseal humerus fractures. Currently, no consensus exists on whether plating or nailing is superior. Multiple studies have shown similar outcomes regarding fracture healing and radial nerve palsy rates. However, intramedullary nails have traditionally been associated with higher reoperation rates and worse shoulder function—particularly when using the traditional lateral approach.

Humeral nailing is typically performed in the supine or beach-chair position using a deltoid-splitting lateral approach. This approach may injure the supraspinatus tendon, which could contribute to poorer shoulder function postoperatively. Additionally, the acromion may block access to an ideal medial starting point, forcing the surgeon to choose a more lateral starting point, leading to varus malalignment (which prior studies have linked to worse functional outcomes). Even when a medial starting point is successfully established in the traditional lateral approach, the acromion may push the nail laterally during insertion in osteoporotic bone.

The Neviaser approach—a superior shoulder approach located posterior to the distal clavicle and medial to the acromion—serves as an effective alternative when the traditional lateral approach is not feasible. This approach allows nail insertion through the supraspinatus muscle belly, potentially affecting shoulder function less than injuring the supraspinatus tendon. This study aims to: (1) describe a technique for achieving a medialized starting point for humeral nailing using the lateral decubitus position with an arthroscopic shoulder distractor via the Neviaser approach; and (2) present clinical outcomes from a single institution using this technique.

II. Surgical Technique

Indications for this technique include proximal and mid-diaphyseal humerus fractures (OTA/AO types 11 and 12) that fail nonoperative management, open fractures requiring debridement, and fractures in polytrauma patients requiring early stabilization. Exclusion criteria include inability to tolerate lateral decubitus positioning, open physes, medullary canal too small to accommodate the nail, fractures within 5 cm of the distal metaphysis, or fractures with distal extension compromising distal fixation.

The patient is placed on a radiolucent operating table in the lateral decubitus position, secured with adjustable positioning pads, with the affected extremity facing upward. The contralateral upper extremity is placed on an arm rest anteriorly. All bony prominences are routinely padded, and a rolled towel is placed in the axilla. The patient is secured to the table with a safety strap, allowing table tilt to assist with fluoroscopy. The affected hand is wrapped in two abdominal pads and a cotton roll, then placed into a traction boot. An arthroscopic shoulder distractor is positioned at the foot of the bed anteriorly, with a rope connecting the traction boot to the weights on the distractor's tower. Typically, 10–15 pounds of traction are used to suspend the upper extremity (avoiding excessive fracture distraction), and the traction weight can be adjusted as needed. Standard sterile preparation and draping are then performed, with special attention to exposing the medial shoulder region to allow starting point establishment.

After positioning, the C-arm is brought in from the patient's anterior side. The following projections are typically used: the C-arm is positioned parallel to the floor for Grashey views and perpendicular to the floor for scapular Y views (Figure 1). The C-arm angle and table tilt can be adjusted to obtain clear Grashey and scapular Y views while minimizing overlap from bone or soft tissue.

At this point, gross reduction can be assessed. Traction alone usually achieves basic alignment, but the surgeon can optimize reduction by adjusting the shoulder traction trajectory: raising/lowering the traction tower adjusts coronal alignment, moving it anterior/posterior adjusts sagittal alignment, and rotating the traction boot/device controls axial alignment. The most favorable limb position is often 20–40 degrees of abduction and 15–30 degrees of forward flexion. This position can be achieved by adjusting traction weight and arthroscopic distractor height, but the lowest effective traction is recommended to avoid potential iatrogenic radial nerve injury. These adjustments are performed by an unscrubbed assistant.

For diaphyseal fractures, the nail itself provides reduction, and adjusting the above parameters often achieves final reduction. If reduction is inadequate, further closed reduction techniques may be attempted, such as strategic towel bump placement or manual pressure with a blunt instrument (similar to closed reduction in other long bones). Percutaneous reduction techniques may also be used if anatomy allows. Finally, a limited open approach can be chosen to achieve and maintain reduction using clamps, provisional plates, or cables. Continuous traction intraoperatively helps maintain reduction.

Once satisfactory reduction is achieved, nail insertion proceeds. Our institution uses the Neviaser approach for nail insertion as described in the literature. A key technical point: because the upper extremity is in an abducted position within the traction device, the ideal starting point (which, when using a straight humeral nail, must align with the humeral shaft in both coronal and sagittal planes) is exposed medially with this technique (Figures 2, 3). This gives the medialized Neviaser approach an advantage over the transdeltoid lateral approach and makes it more suitable for straight nails rather than those with a lateral bend. However, the specific approach and nail design should be tailored to individual anatomy.

The ideal starting point (B) is shifted medially through technique adjustments, aligning it with the Neviaser approach and the central axis of the humerus. In contrast, acromiohumeral anatomy may block a medialized starting point, resulting in a more lateral starting point (C). Without using the Neviaser approach with shoulder abduction, the starting point may be excessively medial (A), failing to remain coaxial with the humeral shaft.

These two cases show that when the upper extremity is abducted in the arthroscopic shoulder distractor, the ideal starting point naturally shifts medially, and this starting point is easily achieved via the Neviaser approach.

If difficulty with the Neviaser approach is anticipated in this technique, intraoperative feasibility testing can be performed by placing a K-wire through the approach to simulate guidewire trajectory. Typically, a 2–3 cm longitudinal incision is made at the Neviaser approach point (the soft-tissue triangle posterior to the clavicle and medial to the acromion), with the incision direction aligned with the anatomic axis of the humeral shaft in coronal and sagittal planes. The starting guidewire is placed into the proximal humerus, ensuring it aligns with the proximal humeral shaft axis in both planes (if using a straight nail). An awl is then used to open the proximal humerus, maintaining proper trajectory throughout. A soft-tissue protection sleeve is used in all cases to minimize injury to the supraspinatus muscle belly.

A standard ball-tipped guidewire is advanced down the medullary canal across the fracture, length is measured, reaming is performed to the appropriate size, and the nail is impacted (Figure 4). Proximal locking screws are placed using the targeting jig, taking care to avoid articular surface injury. Distal locking screws are placed from posterior to anterior using the "perfect circle" technique. Lateral decubitus positioning with the arthroscopic shoulder distractor facilitates this: the posterior aspect of the arm is directly visible, traction provides stable support, and flexion/extension can be easily adjusted via the distractor to obtain perfect circle images, greatly reducing C-arm manipulation. After fixation is complete, the shoulder joint and supraspinatus region are thoroughly irrigated, and the incision is closed in layers. Weight-bearing status and range of motion are guided by fracture pattern; early functional exercises are recommended if fixation stability allows.

Before nail insertion, the fracture shows valgus alignment. As the nail contacts the medial cortex of the distal fragment, fine adjustment of fracture alignment is achieved through nail advancement.

III. Summary

Humeral nailing using a medialized starting point via the Neviaser approach with lateral decubitus positioning and an arthroscopic shoulder distractor is a viable option for treating various proximal and diaphyseal humerus fractures. In our series, no patient had radiographic malreduction or nonunion, and the mean operative time was 60 minutes.

Source:Kung, Justin E. MD*; Pumilia, Cyrus A. MD; Desai, Miraj MD; Ferdon, Robert J. MD; Gauthier, Chase MD; Wood, Sam MD; Ventresca, Heidi MD; Cunningham, Daniel J. MD; Murr, Kevin MD; Jones, Thomas M. MD. Lateral decubitus positioning with arthroscopic shoulder distractor for humeral intramedullary nail. *OTA International: The Open Access Journal of Orthopaedic Trauma* 8(4):e446, December 2025. | DOI: 10.1097/OI9.0000000000000446.