Distal locking in intramedullary nailing of humeral fractures: a narrative review
Abstract
Objective. This narrative review analyzes distal locking in antegrade intramedullary nailing (IMN) for humeral shaft fractures, a common injury with both conservative and surgical treatment options.
Methods. IMN has gained popularity due to its minimally-invasive nature, preservation of fracture hematoma, and favorable biomechanical properties. However, distal locking remains a debated aspect of the technique. Traditional locking methods provide stability but are associated with risks such as radial nerve injury, increased operative time, and radiation exposure. Alternative systems and nail designs have been developed to reduce these complications, though some compromise rotational stability.
Results. Recent evidence suggests that distal locking may not always be necessary, particularly in non-distal fractures with adequate intrinsic stability, since similar union rates and functional outcomes can be achieved without it while reducing surgical time and complications. The number of distal screws also remains controversial, with single-screw fixation often sufficient except in osteoporotic bone or complex fractures.
Conclusions. Distal locking is still recommended when compression techniques, such as back-slapping, are required or in fractures of the distal third. Overall, IMN is a reliable treatment, but the indication and configuration of distal locking should be individualized based on fracture characteristics and patient factors.
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Copyright
© © Ortopedici Traumatologi Ospedalieri d’Italia (O.T.O.D.i.) , 2026
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