Fracture of the shaft of the humerus represents 3 to 5 % of all fractures (1). Current research in this area focuses on defining the incidence and health care resources needed to treat these fractures, refining the indications for surgical intervention, decreasing the surgical failure rate through new implants and techniques, and minimizing the duration and magnitude of disability post injury.
The successful treatment does not end with bony union but the current emphasis is on a holistic approach of patient care. The treatment of the humeral shaft fractures demands a knowledge of anatomy, surgical indications ,techniques and implants, and patient function and expectations.
The treatment methods for fracture shaft of humerus includes
1.Conservative treatment like
A. Coaptation splint:
It is indicated for acute humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns.
The disadvantages are irritation of the patient's axilla and splint slippage.
B. Velpeau bandage (Thoracobrachial immobilization)(2):
It is indicated for minimally displaced or non displaced fractures that do not require reduction.
It may be exchanged for functional bracing 1 to 2 weeks after injury.
C. Hanging arm cast :
Indications include
Displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns.
The patient must remain upright of semiupright at all times with the cast in a dependent position for effectiveness.
D. Functional bracing :
This utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints.
It is typically applied 1 to 2 weeks after the fracture is treated with hanging arm cast or coaptation splint.
2. Surgical treatment
Plate osteosynthesis
Intramedullary nailing
External fixation
Mckee divided the indications for operative treatment into 3 categories
1.Fracture indications
• Failure to obtain and maintain adequate closed reduction
Shortening >3 cm
Rotation >30 degrees
Angulation >20 degrees
• Segmental fractures
• Pathologic fractures
• Intra-articular extension
Shoulder joint
Elbow joint
2. Associated injuries
Open wound
Vascular injury
Brachial plexus injury
Ipsilateral forearm fractures
Ipsilateral shoulder or elbow fractures
Lower extremity fractures requiring upper extremity weight bearing
Burns
High-velocity gun shot injury
Chronic associated joint stiffness
3.Patient indications
Multiple injuries-polytrauma
Head injury Glasgow Coma Scale ≤8
Chest trauma
Poor patient tolerance, compliance
Unfavorable body habitus
Morbid obesity
Large breast
The goal of operative treatment of humeral shaft fractures is to re-establish length, alignment and rotation with stable fixation that allows early motion and ideally early weight bearing on the fractured extremity.
The plate osteosynthesis remains the gold standard of fixation of humeral shaft fractures against which other methods can be compared.Although it has high union rate ,it involves extensive dissection and soft tissue stripping,chance of injury to radial nerve and infection is present.
The intramedullary interlocking nailing has the advantage of minimal surgical exposure and soft tissue dissection ,with stable fixation and rotational control.It can be done antegrade or retrograde manner.
AIM OF THE STUDY
The aim of this study is to compare the Radiological and Functional outcome in patients with fracture shaft of the humerus treated with Dynamic Compression plating and those treated with Intramedullary Interlocking nailing.
REVIEW OF LITERATURE
Heineman et al (3) have done a meta analysis of patients with fracture of humeral shaft treated with plate fixation and those treated with intramedullary nail fixation and found that there is no significant difference between the two groups.
Bhandari et al. (4) have done another meta analysis comparing compression plating and intramedullary nail fixation for fracture shaft of humerus and concluded that Plate fixation may reduce the risk of reoperation and shoulder impingement.
Chapman JR et al (5) in a randomized control study of 84 patients compared plate osteosynthesis and locked intramedullary nail fixation for diaphyseal fracture of humerus concluded that both provide predictable methods for achiving fracture stabilization and ultimate healing.
McCormack RG et al (6) have done a randomized trial in 44 patients comparing fixation of fracture shaft of humerus with dynamic compression plate and with intramedullary nail and concluded that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus and fixation by a IMN nail may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.
Flinkkila T et al (7) studied about the recovery of shoulder joint function after humeral shaft fracture comparing between Plate osteosynthesis and antegrade IM nailing and concluded that shoulder joint ROM and strength does not recover to normal after humeral shaft fracture and antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.
Huerta Lazcarro J et al (8) in their study compared the prevalence of radial nerve lesion after fixation of humeral shaft fractures with dynamic compression plate and intramedullary nailing and concluded that the surgical technique with DCP represents a higher incidence of radial nerve lesion propably due to the exposure and proximity to the radial nerve during surgery.
S Raghavendra et al (9) in their study on internal fixation of the shaft of the humerus by dynamic compression plating or intramedullary nail have concluded that though there was no significant difference between plating or nailing in terms of union , compression plating is the preferred method with better preservation of joint function and lesser need for secondary bone grafting for union.
Amit B Putti et al (10) in their study of comparison between Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures showed that complication rates were higher in Intramedullary nailing group whereas functional outcome were good in both modalities.
Rodriguez - Merchan EC (11) showed in their study of comparing compression plating versus Hackethal nailing in closed humeral shaft fractures showed better functional outcome in compression plating group and need for second surgical procedure was more in nailing group.
Gamal Hosny Abdel Maksod,Md(12) et al in their study compared both procedures and concluded that dynamic compression plating of humeral shaft fractures resulted in a higher rate of union in a shorter duration of time with less complications than antegrade intrmedullary interlocking nailing.
Kiran Singisetti and M.Ambedkar(13) in their prospective comparative study on Nailing versus Plating in humerus shaft fractures concluded that higher rate of excellent and good results were seen in Plating group.
M. Changulani et al(14) in their study inferred that complications like infection were found to be higher with Plating as compared to shortening of the arm and restriction of shoulder movements due to impingement were higher in the Interlocking group.
Lin, Jinn MD(15) in his article on treatment of Humeral Shaft Fractures with Locked Nail and comparison with Plate Fixation showed that Humeral locked nailing offered a less invasive surgical technique and more favorable treatment results than did plate fixation.
Stern PJ et al(16) in their study about intramedullary fixation of humeral shaft fractures found that complications developed in 67% of cases and 64% required at least one additional operative procedure.
ANATOMY
The humerus is a long bone which has a cylindrical central part called the shaft and enlarged upper and lower ends.The anterior aspect of the upper end shows a prominent vertical groove called the intertubercular sulcus.
The head is rounded and has a smooth articular surface. It is directed medially and also backwards and upwards.The upper end also shows two prominences called the greater and lesser tubercles(or tuberosities).These two tubercles are separated by intertubercular sulcus (or the bicipital groove).
There are two distinct regions of the upper end of the humerus that are referred to as the neck.The junction of the head with the rest of the upper end is called the anatomical neck,while the junction of the upper end with the shaft is called the surgical neck.
Humeral shaft is one in which main fragment is distal to the surgical neck of the proximal humerus and proximal to the supracondylar ridge distally. Proximally the humerus is roughly cylindrical in cross section tapering to triangular shape distally.
The shaft of the humerus has three borders(13): anterior, medial and lateral.These are readily identified in the lower part of the bone.
The anterior border becomes continuous with the anterior margin of the greater tubercle.
The medial border can be traced to the lower end of the lesser tubercle.
The lower part of the lateral border can be seen from the front and its upper part runs upwards on the posterior aspect of the bone.
The three borders divide the shaft into three surfaces. The anterolateral surface lies between the anterior and lateral borders.the anteromedial surface lies between the anterior and medial borders.The posterior surface lies between the medial and lateral borders.
The anterolateral surface has a V shaped rough area called the deltoid tuberosity which is present near the middle of this surface.From behind the upper part of the shaft is crossed by a broad and shallow radial groove which runs downwards and laterally across the posterior and anterolateral surfaces.
The anteromedial surface is bounded by the anterior and medial borders. Distal to the intertuberous sulcus a small area of the anteromedial surface is devoid of muscular attachment, but its lower half is occupied by the medial part of brachialis. Coracobrachialis is attached to a roughened strip on the middle of the medial border. The humeral head of pronator teres is attached to a narrow area close to the lowest part of the medial supracondylar ridge, and the ridge itself gives attachment to the medial intermuscular septum of the arm.
The posterior surface lies between the medial and lateral borders. A ridge descends obliquely and laterally across its proximal third, and gives attachment to the lateral head of triceps. Above triceps, the axillary nerve and the posterior circumflex humeral vessels wind round this aspect of the bone under cover of deltoid. Below and medial to the attachment of the lateral head of triceps, a shallow groove which contains the radial nerve and the profunda brachii vessels, runs downwards and laterally to gain the anterolateral surface of the shaft.
The lower end of the humerus is irregular in shape and is also called the condyle. The lowest parts of the medial and lateral borders of the humerus form sharp ridges that are called the medial and lateral supracondylar ridges respectively.Their lower ends terminate in two prominences called the medial and lateral epicondyles.The lateral part is rounded and is called the capitulum.It articulates with the head of the radius.The medial part of the articular surface is shaped like a pulley and is called the trochlea.It articulates with the upper end (trochlear notch) of the ulna.
The anterior aspect of the lower end of the humerus shows two depressions. The depression above the capitulum is called the radial fossa and that above the trochlea is called the Coronoid fossa. Another depression is seen above the trochlea on the posterior aspect of the lower end.This depression is called the Olecranon fossa.
The muscles covering the humerus are coracobrachialis, brachialis and biceps brachii in the anterior compartment and triceps in the posterior compartment.
The Radial nerve and the Profunda brachii vessels lie in the radial groove between the attachments of the lateral and medial heads of the triceps.
Blood supply of the Humerus
The normal blood supply of a long bone is best considered in terms of vascular systems (Rhinelander, 1972; 1974) according to its function (14)
• Afferent vascular system
The afferent vascular system comprises of arteries and arterioles carrying nutrients to bone.These include the principal nutrient artery, the metaphyseal arteries, the epiphyseal artery and the periosteal arterioles.
The vascular supply of the humeral diaphysis arises from perforating branches of the brachial artery.One or two main diaphyseal nutrient arteries enter the shaft obliquely through one or two nutrient foramina leading to nutrient canals.Their site of entry and angulation are almost constant and characteristically directed away from the epiphysis they divide into ascending and descending branches in the medullary cavity.
It is now well established that there are numerous musculo-periosteal vessels entering the bone at multiple points over its entire surface.
After maturity the three sources of blood supply to the diaphysis are
1. Nutrient artery
2. Metaphyseal arteries
These arteries enter on all sides at ligamentous attachments.
3. Periosteal arterioles
These arterioles enter at fascial attachments to supply the external third of the cortex locally.
Efferent vascular system
This system comprises of the veins and venules carrying the waste products away from the bone.These include
1. Metaphyseal veins
2. Cortical venous channels from deep cortex to periosteal venules
3. Venae comitantes accompanying the nutrient artery
4. Large emissary veins which completely traverse the cortex
Intermediate vascular system
The principal nutrient artery and the metaphyseal arteries carry blood from the circulation almost exclusively into the medulla. The intravascular pressure in the medulla is higher than in the periosteal area. This pressure gradient is the chief factor maintaining the blood flow in bone centrifugally (Brookes, 1971)(15) .
The medullary arterial supply provides circulation to the inner two-thirds of the cortex leaving the periosteal arterial supply to provide circulation to the remaining outer third of the cortex.
Applied Anatomy
Fracture Healing:
Periosteal circulation plays a very important role in healing of fractures. Soft tissue stripping, while performing an internal fixation of a fractured bone must be kept to a minimum to encourage the participation of periosteum and its circulation in fracture healing.
AO CLASSIFICATION (1)
A1 Simple fracture, spiral
.1 proximal zone
.2 middle zone
.3 distal zone
A2 Simple fracture, oblique(> or = 30°)
.1 proximal zone
.2 middle zone
.3 distal zone
A3 Simple fracture, transverse (< 30°:)
.1 proximal zone
.2 middle zone
.3 distal zone
B1 Wedge fracture, spiral wedge
.1 proximal zone
.2 middle zone
.3 distal zone
B2 Wedge fracture, bending wedge
.1 proximal zone
.2 middle zone
.3 distal zone
B3 Wedge fracture, fragmented wedge
.1 proximal zone
.2 middle zone
.3 distal zone
C1 Complex fracture, spiral
.1 with two intermediate fragments
.2 with three intermediate fragments
.3 with more than three intermediate fragments
C2 Complex fracture, segmental
.1 with one intermediate segmental fragment
.2 with one intermediate segmental and additional wedge fragment(s)
.3 with two intermediate segmental fragments
C3 Complex fracture, irregular
.1 with two or three intermediate fragments
.2 with limited shattering (< 4 cm)
.3 with extensive shattering (> or = 4 cm)
Evolution of Intramedullary nails
In the beginning of the 20th century, Ernest Hey Groves (England) already used specially designed three- or four-edged intramedullary nails for the fixation of diaphyseal long bone fractures.
Smith - Petersen introduced a nail in 1920's to fix subcapital femoral fractures
In 1940, Lambrinudi suggested the placement of strong wires and thin metal sticks through the medullary canal. This method was later upgraded by the Rush brothers.
In 1950's ,two important techniques were developed. In 1942,Fischer reported the use of intramedullary reamers to increase the contact area between the nail and the host bone. Kuntscher(16) introduced the flexible reamers and they believed that reaming along with larger diameter nail would enhance the stability of fractures by increasing the contact area. He also felt that although intramedullary vascular supply was obliterated by this the periosteum and surrounding tissues would promote adequate bone formation for healing. In 1960's cephallomedullary nails were introduced highlighted by the development of the Zickel nail which contained a hole in the proximal portion of the nail for head and neck.
In the 1990s, the major advancements came with the expansion of indications for unreamed and reamed intramedullary nailing.
EFFECTS OF REAMING
Reaming has a significant biologic and mechanical impact on the physiology of fracture healing. Intramedullary reaming causes destruction of the contents of the marrow Cavity (Blood vessels and marrow). The medullary canal is irregular in both longitudinal and cross sections. For a stable intramedullary fixation a firm fit is needed.
The process of reaming is for centralizing the nail and also produces a larger contact area between the nail and bone thereby increases the stability of fixation(17). Reaming allows insertion of larger diameter , stronger nail and reaming can stimulate fracture healing by providing a source of autologous bone graft from the reamed particles at the fracture site.
Outcome studies consistently show that reaming potentiates the healing response with intramedullary fixation of long-bone fractures. Recent laboratory studies implicate alterations in cortical blood flow patterns and the osteogenic potential of reaming debris as critical components of this process.
COMPLICATIONS
Thermal necrosis is a rare (18) but commonly referenced complication of reaming. The risks of heat-induced cortical damage can be minimized by sequential reaming with sharp instruments and by reaming with instruments that are sized appropriately to fit the intramedullary canal. Reaming results in increased intramedullary pressure and secondary embolization of marrow elements to the pulmonary system.
Points to reduce the complication while reaming
1. Avoid reamers with blunt flutes.
2. Always start with the end cutting reamer
3. Reamers should be with deep flutes to facilitate passage of medullary
contents
4. Advancement of the reamer must be slow with reamer rotating at full speed.
5. Distal vent can be used to lower the medullary pressure.
BIOMECHANICS OF IM NAILING
The intramedullary nail or rod is commonly used for long-bone fracture fixation particularly diaphyseal and selected metaphyseal fractures. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints (19) that allow for secondary fracture healing, A nail is subject to fatigue and can eventually break if bone healing does not occur.
The basic principle of Intramedullary nailing is "Dynamic Osteosynthesis"(20)
Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter.
Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics.
Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.
Evolution of Plates (20)
Metal fixation for internal fixation of fractures have been used for more than 100 years.Lane first introduced a metal plate in 1895 for internal fixation which was eventually abandoned owing to problems with corrosion.
Lambotte in 1902 and Sherman in 1912 introduced their versions of plates which had improvements in metallurgical formulation which increased corrosive resistance but both were eventually abandoned as a result of their insufficient strength.
Lambotte plate
The next important development in fracture plate design was initiated by Eggers in 1948 with two long slots which allowed screw heads to slide.The use of this plate was limited by its structural weakness and the resultant instability of its fixation.
Danis in 1949 recognized the need for compression between the fracture fragments and introduced a plate he called the coapteur, which suppressed the interfragmentary motion and increased the stability.
Danis plate
In 1958 Bagby and Janes designed a plate with oval holes which allowed interfragmentary compression while tightening the screws.
Muller et al. permitted interfragmentary compression by using a tensioner that was temporarily anchored to the bone and the plate.
Tensioner device
Dynamic Compression Plate (DCP) has specially designed oval holes similar to Bagby and Janes invention to compress bony fragments during screw tightening.
Dynamic Compression Plate
Advantages:
1. Low incidence of malunion
2. Stable internal fixation
3. No need for external immobilization
4. Early mobilization of neighbouring joints
The Swiss group developed a plate design to reduce the plate's interference with cortical perfusion and decrease cortical porosis which is called as Limited Contact - Dynamic Compression Plate (LC-DCP).
The concept of biological osteosynthesis led to the development of the Point- contact fixator (PC-FIX),which abandoned interfragmentary compression and bicortical fixation.
CLASSIFICATION OF PLATES
A bone plate has two mechanical functions(21).
1. Transmits forces from one end of the bone to the other, bypassing and thus protecting the area of fractures.
2. Holds the fractures ends maintaining the proper alignment throughout the healing process.
Regardless of their length, thickness, geometry and configuration, all plates are classified into
1. Neutralization plate
2. Compression plate
3. Butress plate
4. Condylar plate
1. Neutralization Plate:
A Neutralization plate acts as a "bridge". Its main function is to act as a mechanical link between the healthy segments of bone above and below the fracture.It does not produce any compression at the fracture site.
The most common clinical application of this plate is to protect the screw fixation of a short oblique fracture or butterfly fragment or for the fixation of a segmental bone defect in combination with bone grafting.
2. Compression Plate:
A compression plate produces a locking force across a fracture site to which it is applied.The effect occurs according to Newton's third law.The direction of the force is parallel to the plate.
Compression can be Static or Dynamic.A plate applied under tension produces static compression at a fracture site.This compression is constant when the limb is at rest or is functioning. Dynamic compression is a phenomenon by which the plate can transfer or modify functional physiological forces into compressive forces at the fracture site.When functional activity begins the physiological forces which are normally destabilizing for the fracture are converted to a stabilizing and active force by the same plate which now acts as a tension band.
3. Buttress Plate:
The mechanical function of this plate is to strengthen (buttress) the weakened area of the cortex.It prevents the bone from collapsing during the healing process. This plate applies a force to the bone which is perpendicular to the flat surface of the plate.It is mainly used to maintain the bone length or to support the depressed fracture fragments.It is commonly used in fixing epiphyseal and metaphyseal fractures.
4. Condylar Plate:
Its main application has been in the treatment of intra-articular distal femoral fractures.It has two mechanical functions.
1. It maintains the reduction of the major intra-articular fragments thus restoring the anatomy of the joint surface.
2. Rigidly fixes the metaphyseal components to the diaphyseal shaft.
PRINCIPLE OF ABSOLUTE STABILITY USING PLATES
Absolute stability of plated fractures requires anatomical reduction and interfragmentary compression,which can be established by lag screws,axial compression by plate or both.Static compression between two fragments is maintained over several weeks and does not enhance bone resorption or necrosis.Fracture fragment interdigitation and compression reduces interfragmentary motion to nearly zero and allows for direct bony remodelling of the fracture (primary bone healing without callus).
Compression must sufficiently neutralize all forces (bending, tension,shear, and rotation) along the whole cross section of a fracture to achieve absolute stability.
There are four ways of achieving interfragmentary compression with a plate : (22)
1. compression with the dynamic compression unit in a plate
2. compression by contouring (overbending) the plate
3. compression by additional lag screws through plate holes
4. compression with the articulated tension device
GENERAL PRINCIPLES OF PLATE FIXATION
Successful use of a bone plate depends on the properties of the plate,the screws,the bone and on the correct application of biomechanical principles.
Plate related factors
The strength of a plate depends on
the thickness of the plate and
the stiffness of the material which should be close to the bone
Screw related factors
The effectiveness of the screw depends on the
Design of the thread
Screw head
A minimum of 6 cortices on each side of the fracture is necessary for a rigid fixation in humerus
Strength of the plate fixation depends on the holding power of the screws.
Bone related factors:
The health of the bone is an important factor as the holding power of the screw is dependent on the elastic force provided by the bone.
Construct related factors
The strength of the construct will depend on the direction of the load and the position of the plate. The plate applied on the tension side of the bone is a strong construct. It becomes strongest when two plates are applied at right angles to each other.
The strength of the reconstructed bone depends on :
Strength of the plate and screw - design,dimension and material and purchase
Configuration of the fracture - comminution and placement of plate
Properties of the plate-bone construct - working length and load sharing
SURGICAL APPROACHES
ANTEROLATERAL APPROACH (23)
Position of the patient
The patient is placed supine on the operating table with the arm lying on an armboard and abducted about 60°.
Incision
A curved longitudinal incision over the lateral border of the biceps starting about 10 cms proximal to the flexion crease of the elbow.
Dissection
There is no internervous plane.Superficially, the biceps is retracted medially to reveal the brachialis and the brachioradialis and an intermuscular plane is developed between them.Radial nerve is identified between the muscles at the level of the elbow joint.It is retracted medially and the deep dissection is done by incising the lateral border of the brachialis and by lifting it off by subperiosteal dissection.
POSTERIOR APPROACH
Position of the patient
The patient is placed either in lateral position with the affected side uppermost or in prone position with the arm 90° and the elbow allowed to bend and the forearm to hang over the side of the table.
Incision
A longitudinal incision in the midline of the posterior aspect of the arm, from 8 cms below the acromion to the olecranon fossa.
Dissection
There is no true internervous plane. Superficially to identify the gap between the lateral and long head of triceps,above the level where they fuse to form a common tendon . Proximally continue blunt dissection between the two heads and distally it needs sharp dissection along the line of incision.Deeply, the medial head of triceps is incised in the midline, down to the periosteum and strip the muscle by epi-periosteal dissection.
MATERIALS AND METHODS
This is a prospective comparative study of 22 patients with humeral shaft fractures treated with Intramedullary interlocking nailing and Plate osteosynthesis done in the Department of Orthopaedics, Government Kilpauk Medical College Hospital from April 2009 to May 2010.
INCLUSION CRITERIA
Acute fractures of humeral shaft
Patients aged above 18 years
Fractures 2cm below surgical neck and 3 cm above olecranon fossa
Multiple injuries
Neurovascular involvement
Osteoporotic bone
Angulation more than 15 degrees
Non compliance in conservative treatment
Exclusion criteria
Open physis
Age less than 18 years
Fractures involving proximal 2 cms and distal 3 cms of the humeral diaphysis
MANAGEMENT
All cases are initially assessed for head injury and other associated injuries and resuscitated .Initial management was done with U - slab till the patient is fit for surgery.
Pre operative protocol for IL Nailing
Nail length:
The nail size is measured with the full length x-ray from tip of greater tuberosity to 3cms above the proximal tip of olecranon fossa.Clinically it is measured by subtracting 5 cms from the tip of acromian to the lateral epicondyle of humerus. The best method is by a scanogram where the nail of appropriate length is tied to the patient and x-ray is taken. It is a must to have all nail sizes and appropriate instrumentation .It is mandatory to have the C- arm image intensifier and a good technician. The nail used in our study is Sharma nail. Bone Graft was done in 1 patient where fracture was reduced by open method.
SURGICAL TECHNIQUE OF IM NAILING
ANTEGRADE HUMERUS NAILING BY CLOSED METHOD(24)
POSITION OF THE PATIENT
The patient is positioned supine on a fracture table with a sand bag under the shoulder and the whole upper limb is prepared and drapped to keep the limb free.
ANAESTHESIA
General anaesthesia or Regional block
APPROACH
Through Lateral Deltoid Splitting approach with the image intensifier the entry point is made just medial to the greater tuberosity and in the area at junction between the articular surface of the head and greater tuberosity with a k-wire and passed into the medullary canal.
After splitting the deltoid , the Rotator cuff is exposed and split at the tendon of the supraspinatus. The entry point reamer is used over the k-wire and is enlarged.45 cms guide wire is introduced through the entry point and is passed into the distal fragment after reducing the fracture closed and under
the guidance of C-arm image intensifier.Progressive reaming was done over the guide wire upto 1 mm more than the desired nail size.
Nail Insertion
The appropriate nail is mounted on the zig and inserted through the guide wire. The nail size should be carefully selected because over size nail may end up splintering the distal fragment.The nail is pushed to a level where the nail is not protruding out through the articular surface of the proximal humerus.
Distal Locking
The size of nail are the 7mm cannulated nails.The distal locking for the 7mm cannulated nail was 4.5 mm self tapping locking screws for which 3.00mm drillbits were used. The distal locking are antero-posterior locking. Under image guidance a stab incision is made at the anterior aspect of forearm , the bicep and brachialis is split to expose the surface of the bone. Under image guidance appropriate drill bit is used and the distal screws are inserted.
Proximal Locking
This is done using the proximal jig that is mounted with the nail. Care must be used to avoid the axillary nerve. The proximal locking are in the medio-lateral plane.
OPEN REDUCTION OF FRACTURES
This technique was used for fixing old fractures . Fracture site is exposed by anterolateral approach. Skin incision is made in the groove between the prominences of biceps brachii and deltoid. Cephalic vein is identified and ligated. Plane is created between the muscle bulk of biceps and deltoid. Brachialis is split in the middle to expose the fracture site. Fracture site is exposed and freshened. Bone grafting may be placed to promote fracture union.
Post - operative protocol:
Immediately after surgery the limb is supported with an arm sling.
Wound inspection was done on 2nd post operative day
Suture removal on 12th post op day
In cases of nailing ,active elbow and shoulder excercises started on 3rd day under the supervision of the physiotherapist.
SURGICAL TECHNIQUE OF PLATE OSTEOSYNTHESIS
Implants used
The most commonly used plate for fixation of humeral shaft fractures is the broad, 4.5-mm dynamic compression plate, occasionally, a narrow, 4.5-mm, DCP is used for smaller bones. For spiral or oblique fractures, the ideal construct consists of a lag screw with a neutralization plate, whereas transverse fractures are ideally suited for a compression plating technique. Bone Graft was done in 3 cases.
Procedure (25)
Anaesthesia :
General or Regional Block
Position of the Patient:
Lateral position with elbow flexed over a pillow and forearm hanging by the side.
Approach
Posterior approach
Through posterior approach incision was made in midline upto the tip of olecranon in line with the humerus.The dissection is carried down to the triceps fascia and the fascia is incised. The radial nerve is identified and freed proximally and distally to allow for mobilization.The triceps is incised off the periosteum and the fracture site is exposed.After the fracture ends are freshened, the fragments are reduced and held with bone clamps or with a lag screw.
Then it is fixed with 4.5mm broad or narrow DCP in neutralization or compression mode.
Post - Operative Protocol:
Wound inspection done on 2nd post op day. Suture removal done on 12th day In cases of Plating , active shoulder and elbow started on 5th to 6th day once the pain level decreases under physiotherapist guidance and tolerability of the patient.
CASE 1
Name : ESTHER
Age/Sex : 45/F
Mode of Injury : Fall
Extremity : Right
Associated Injury : None
Type of Fracture ( AO) : A
Time Interval between Injury : 18 days
and surgery
Nail size : 7Ã-240 mm
Reduction : Closed
Post-op period : Uneventful
Mobilisation started : 3rd day
Time of union : 20 weeks
Range of Movements : Full
Complications : Nil
Rodriguez-Merchan Criteria : Excellent
CASE 2
Name : Srinivasan
Age/Sex : 65/M
Mode of Injury : Fall
Side Involved : Left
Associated Injury : Radial Nerve Injury
Fracture Type (AO) : A
Time Interval between Injury : 15 days
and surgery
Nail size : 7Ã-200 mm
Reduction : Closed
Post-op period : Uneventful
Mobilisation started : 3rd day
Time of union : 16 weeks
Range of Movements : Full
Complications : Nil
Rodriguez-Merchan Criteria : Excellent
CASE 1
Name : VijayaKumar
Age/Sex : 23/M
Mode of Injury : RTA
Side Involved : Right
Associated Injury : None
Fracture Type : A
Time Interval between Injury : 7 days
and surgery
Plate Used : 10 holed Broad Dcp
Bone Graft Used : No
Post-op period : Uneventful
Mobilisation started : 5th day
Time of union : 14 weeks
Range of Movements : Full
Complications : Nil
Rodriguez-Merchan Criteria : Excellent
CASE 2
Name : Vinoth Kumar
Age/Sex : 21/M
Mode of Injury : RTA
Side Involved : Right
Associated Injury : None
Fracture Type : B
Time Interval between Injury : 6 days
and surgery
Plate Used : 8 Holed Narrow DCP
Bone Graft : No
Post-op period : Uneventful
Mobilisation started : 5th day
Time of union : 16 weeks
Range of Movements : Full
Complications : Nil
Rodriguez-Merchan Criteria : Excellent
CASE 3
Name : Thirugnanam
Age/Sex : 45/M
Mode of Injury : Fall
Side Involved : Right
Associated Injury : None
Fracture Type : B
Time Interval between Injury : 24 days
and surgery
Plate Used : 10 Holed Broad DCP
Bone Graft : Yes
Post-op period : Uneventful
Mobilisation started : 7th day
Time of union : 18 weeks
Range of Movements : Full
Complications : Nil
Rodriguez-Merchan Criteria : Excellent
OBSERVATION AND RESULTS
AGE DISTRIBUTION
AGE
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
21-40 YEARS
6
8
41-60 YEARS
3
1
61 - 80 YEARS
1
3
Majority of the patients taken for the study both in the Interlocking nailing group and in the Plating group are in the age group of 21 to 40 years (60 - 70%)
SEX DISTRIBUTION
SEX
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
MALE
7
10
FEMALE
3
2
Majority of the patients in the study who sustained fracture shaft of humerus are males both in the interlocking nailing and in the plating group.
MODE OF INJURY
MODE OF INJURY
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
RTA
7
8
FALL
2
4
ASSAULT
1
-
The mode of injury in most of the cases in both the groups are due to Road Traffic Accidents (70% in IL nailing group and 67% in Plating group).The remaining are due to fall and due to assault.
SIDE OF INJURY
SIDE INVOLVED
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
RIGHT
6
8
LEFT
4
4
50 - 60 % of the patients in the study have involvement of the dominant side in both groups.
FRACTURE TYPE
AO TYPE
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
TYPE A
5
7
TYPE B
5
5
TYPE C
-
-
The most common type of fracture in our study in both the groups according to AO classification is Type A.The next type in frequency is Type B.
ASSOCIATED INJURIES
ASSOCIATED INJURIES
NO. OF CASES
FRACTURE BOTH BONES FOREARM ON CONTRALATERAL SIDE
1
FRACTURE BOTH BONES LEG
1
FRACTURE DISTAL RADIUS
1
RADIAL NERVE INJURY
1
Comparison between plate osteosynthesis and interlocking nailing was done for
1. Time taken for Union
2. Percentage of Union
3. Functional outcome
4. Complications
1. TIME TAKEN FOR UNION
S.NO
SURGICAL PROCEDURE
TIME TAKEN FOR UNION
AVERAGE
MINIMUM
MAXIMUM
1.
INTERLOCKING NAILING
16 WEEKS
28 WEEKS
22 WEEKS
2.
PLATE OSTEOSYNTHESIS
16 WEEKS
24 WEEKS
20 WEEKS
The minimum time taken for union in the group treated with Interlocking nailing is 16 weeks and the maximum time is 28 weeks with an average of 22 weeks.one case went in for non - union.
The minimum time for union in the group treated with Plate Osteosynthesis is 16 weeks and the maximum time is 24 weeks with average of 20 weeks. All cases united within this period in this group.
2. PERCENTAGE OF UNION
METHODS
TOTAL NO. OF CASES
UNITED FRACTURES
PERCENTAGE OF UNION
INTRAMEDULLARY NAILING
10
9
90%
PLATE OSTEOSYNTHESIS
12
12
100%
The Percentage of fractures in the Interlocking Nailing group which went in for union without need for a secondary procedure is 90%. One case which is not united is due to distraction at the fracture site which was planned for exchange nailing .
3. FUNCTIONAL OUTCOME
RODRIGUEZ MERCHAN CRITERIA (26)
RATING
ELBOW ROM
SHOULDER ROM
PAIN
DISABILITY
EXCELLENT
EXTENSION 5
FLEXION 130
FULL ROM
NONE
NONE
GOOD
EXTENSION 15
FLEXION 120
< 10% LOSS OF TOTAL ROM
OCCASIONAL
MINIMUM
FAIR
EXTENSION 30
FLEXION 110
10% TO 30% LOSS
WITH ACTIVITY
MODERATE
POOR
EXTESION 40
FLEXION 90
> 30 % LOSS
VARIABLE
SEVERE
FOR INTERLOCKING NAILING GROUP
SHOULDER ROM
RATING
PERCENTAGE
EXCELLENT
70% ( 7 )
GOOD
20% ( 2 )
FAIR
10% ( 1 )
POOR
-
The functional Range of Movements in shoulder joint after Nailing is excellent and good in 90% of patients and fair in 1 patient (10% ). The decrease in movement in 1 patient is due to the impingement of nail.
ELBOW ROM
RATING
PERCENTAGE
EXCELLENT
90% ( 9 )
GOOD
10% ( 1 )
FAIR
-
POOR
-
The elbow function recovered in almost all patients with 90% excellent result and 10 % has good recovery.
FOR PLATE OSTEOSYNTHESIS GROUP
SHOULDER ROM
RATING
PERCENTAGE
EXCELLENT
75% ( 9 )
GOOD
25% ( 3 )
FAIR
-
POOR
-
In this study 92% of cases have excellent and good results in shoulder function and 1 case had fair result.
ELBOW ROM
RATING
PERCENTAGE
EXCELLENT
75% ( 9 )
GOOD
25% ( 3 )
FAIR
-
POOR
-
All patients treated with Plate Osteosynthesis had excellent to good functional outcome in elbow.
COMPLICATIONS
COMPLICATIONS
INTERLOCKING NAILING
PLATE OSTEOSYNTHESIS
NON UNION
1 (10%)
-
SHOULDER IMPINGEMENT
1 (10%)
-
INFECTION
1 (10%)
2 (16%)
1. NON UNION:
In the group of patients treated with interlocking nailing 1 case went in for non union. It is mainly due to the distraction at the fracture site that occurred while nail insertion.
In the group treated with Plate Osteosynthesis all cases united with an average period of 20 weeks.
2. SHOULDER IMPINGEMENT AND PAIN :
In Interlocking Nailing group, 1 patient had shoulder impingement due to protrusion of nail due to prominence of the nail at the proximal end.
In Plate Osteosynthesis group, no cases had shoulder impingement or stiffness or pain.
3. INFECTION :
In patients treated with Interlocking Nailing, 1 patient in whom the fracture reduction was done by open reduction had superficial infection which settled with parentral antibiotics.
In patients who were treated by Plate Osteosynthesis, 2 patients developed superficial infection which settled with parentral antibiotics and all fractures went in for union.
DISCUSSION
Fractures of the humeral shaft approximates 3 % to 5 % of all fractures. The treatment options ranges from conservative treatment like Coaptation Splint, Velpeau bandage, Hanging arm cast,functional brace etc. to surgical treatment like Plate Osteosynthesis, Interlocking Nailing and External Fixation.
The indications for Primary operative management of these fractures are
Non compliant patients,
Patient with neuro vascular deficits,
Alignment cannot be maintained by closed methods,
Holstein Lewis type of fracture with Radial nerve palsy,
Bilateral fractures,
Polytrauma patients,
Pathological fractures,
Floating elbow etc.
Although there have been many studies about the fixation methods of humeral shaft fractures, it is still controversial about the definitive method to be adopted for these fractures to get maximal outcome.
This study is mainly to compare the union rate of the fractures and functional outcome between the patients treated with Plate Osteosynthesis and those treated with Interlocking Nailing for fracture shaft of humerus.
In this study, the age group of the patients in both the groups ranges from 20 to 70 years with a mean age of 45 years.
Majority of the patients sustained this fracture are males and the most common mode of injury is due to Road Traffic Accident (around 70%) in both groups.
This study shows no significant difference between the time of union with an average of 22 weeks in the Interlocking Nailing group and an average of 20 weeks in the Plating group. Raghavendra S et al (9) in their study of 31 patients compared the time of union between the patients treated with Plating and with Interlocking Nailing concluded that there is no significant difference between the two groups.
In this study one patient in the Interlocking Nailing group went in for non-union (10%) which required secondary procedure . In a study by AB Putti et al (10), showed a non union rate of 8 % in patients treated with Interlocking Nailing .
The anatomical configuration of the shaft of the humerus makes it prone for residual fracture site distraction. In our study the fracture site distraction occurred in 1 patient (10%) .In a study by Shyamasunder Bhat et al (27), they showed distraction at the fracture site during nailing in about 8.1% of cases.
In this study shoulder pain occurred in 1 out of 10 patients due to impingement of nail (10%) .This is comparable to the study by James P. Stannard et al (28) where they showed an occurrence of mild to moderate shoulder pain in about 20% of the patients and also in a study made by Chapman et al. there is significant reduction in shoulder movement in the Nailing group.
CONCLUSION
In our study, there is no significant difference in the period of union of fractures after both the methods .
The chance of infection is more in the Plating group than in patients treated with Closed reduction and Interlocking Nailing patients.
The Restriction of shoulder movements are seen in patients in the Nailing group possible due to Prominent nail tip at the entry site and also due to violation of the Rotator Cuff .
Non union can occur due to distraction of the fracture site while Nailing.
The Advantages of Interlocking Nailing are
1. No need for open reduction of fractures as it is done under C-arm Image Intensifier.
2. Minimal soft tissue dissection.
3. Rehabilitation can started early than in case of patients in the Nailing Group.
The Disadvantages are :
1. Inadequate compression at the fracture site.
2. Distraction at the fracture site due to improper nail length causes impingement due to protrusion of nail at the site of entry.
3. Exposure to Radiation
The Advantages found in the Plating are
1. Adequate compression at the fracture site.
2. No need for secondary procedure.
3. Less incidence of Non union.
The Disadvantages are
1. Needs more soft tissue Dissection.
2. Careful isolation of Radial nerve has to be done.
3. Chances of infection is more.
4. Delayed start of Rehabilitation due to pain at the operated site.
5. Post op immobilization may be necessary in few cases.
