Management of Fracture Shaft of Humerus

8/9/2019 Management of Fracture Shaft of Humerus

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34 Pb Journal of Orthopaedics Vol-XII, No.1, 2011

Original Article

Management of fracture shaft of humerus -

open versus closed antegrade nailing

A S Sidhu*, H S Mann**, Gursukhman D S Sidhu***, A Banga****, A Bassi****, M Gupta *****

* Professor and Head, ** Assistant Professor, *** PG Research Fellow, **** PG Student,

Department of Orthopaedics,

Government Medical College, Patiala.

ABSTRACT

Fractures of the shaft of humerus are difficult to treat. Nonunion, stiffness and inconvenience after conservative

treatment of shaft of humerus are very common. So, under present conditions and advancements in surgical

skills, techniques and good quality implants, ORIF has become gold standard for treatment of fracture shaft

of humerus. 20 cases were treated with open antegrade nailing while 20 with closed antegrade nailing of

humerus (with C arm). Fractures were classified according to AO fracture classification. Patients wereassessed clinically and radiologically. Constant scoring system and Mayo Elbow Performance Score were

used to assess the function of the shoulder and elbow. Results were analysed prospectively. Outcome in

Closed Antegrade nailing group was observed to be excellent in 35% cases, good in 50% cases, satisfactory

in 10% cases and poor in 5% cases. Out come in Open Antegrade nailing group was observed to be excellent

in 15% of cases, good in 45% of cases, satisfactory in 30% cases and poor in 2% cases. In our study of 40

cases, radiological union occurred in all cases. Complications like nail protrusion, superficial infection,

delayed union, gap at fracture site, shoulder and elbow pain were encountered. Finally there was no

significant difference in duration of operation, union time and shoulder and elbow function in two groups.

We feel that there is a long learning curve for closed antegrade interlock nailing of humerus and most of the

complications can be avoided and results improved, if correct technique is followed.

Keywords: Humeral Shaft Fractures, Antegrade Nailing, Nonunion

Corresponding Author :

Dr A S Sidhu

Professor and Head, Department of Orthopaedics ,

Government Medical College, Patiala

E mai l: [email protected]

INTRODUCTION

Fractures of the humerus have challenged medical practitioners

since the beginning of recorded medical history1. Fracture shaft

of humerus is very common representing 3–5 % of all fractures.

The comprehensive AO classification is preferred in studies of

humeral fractures2, 3.

Humeral shaft fractures can be treated nonoperatively,

which includes hanging arm cast, velpeau dressing, coaptation

splint or U slab, shoulder spica cast, functional brace and rarely

skeletal traction4-9. However, non-operative treatment requires

a long period of immobilization, which carries a high risk of

shoulder stiffness and causes great inconvenience to the

patient10. Furthermore, nonunion after conservative treatment

of shaft of humerus is common and treatment of non-union of

any bone is a cumbersome procedure7, 11, 12.

So, under present conditions and advancements in surgical

skills, techniques and good quality implants, open reduction

and internal fixation has become gold standard for treatment of

fracture shaft of humerus. This helps us in allowing early

mobilization and decreasing morbidity to the patient13.

Kuntscher originally described a locking nail; it was until the

late 1970’s when Klemm and Schellmann and later Grosse and

Kempf improved this technique14, 15. Together with improved

fluoroscopy techniques, these new implants made locking

intramedullary nailing very popular, being minimally invasive

method to treat long bone fractures15.

Despite technical improvements of humeral intramedullary

nails, results after Seidel’s initial good results regarding union

rate and shoulder joint function have been and still are very

controversial8, 16, 17. Humeral nailing is associated with brief

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Sidhu et al

Early operative complications occurred in 4 cases of closedantegrade nailing group. 1 case (5%) had more than 5mm

proximal nail protrusion of nail. Also in 2 cases (10%) early

superficial infection occurred while in another 1 case (5%) there

was more than 2mm gap at the fracture site. In open ante grade

nailing group only 10% cases had superficial infection as early

operative complication.

In late operative complications 10 cases were of closed

antegrade nailing and 8 cases were of open antegrade

nailing group. 6 cases (30%) of closed antegrade nailing

had shoulder pain while 2 cases (10%) had elbow pain. 1 (5%)

case each of delayed union and shoulder impairment was also

observed. The cases with elbow pain also had ipsilateral fore

arm plating done. While in open antegrade nailing group

25% had shoulder pain 1 had elbow pain and 2 had delayed

union. In closed antegrade nailing group, union occurred in all

cases although 1 case required secondary bone grafting for

attaining union. In open antegrade nailing group union

occurred in all cases although 2 cases required secondary bone

grafting.

In closed antegrade nailing group 80% cases had excellent

constant score (>90 points) corresponding to excellent shoulder

function, 4 (20%) cases had score between 75-89 corresponding

to good score . In Open Antegrade nailing group, 60% of cases

had excellent constant score21 (>90 points) corresponding to

excellent shoulder function, 30% of cases had score between75-89 corresponding to good score and 2 (10%) cases had

score between 60-74 corresponding to fair score.

In closed antegrade nailing group, 75% cases had excellent

Mayo’s score22 (>90 points) corresponding to excellent elbow

function, 20% of cases had score between 75-89 corresponding

to good score and rest 1 case had score between 60-74corresponding to fair score. In open antegrade nailing

group, 85% of cases had excellent (>90 points) corresponding

to excellent elbow function and 10% of cases had score

between 75-89 corresponding to good elbow function while 1

case had score between 60-74 corresponding to fair elbow

function.

According to inference, outcome in Closed Antegrade

nailing group was observed to be excellent in 35% cases, good

in 50% cases, satisfactory in 10% cases and poor in 5% cases.

Out come in Open Antegrade nailing group was observed to

be excellent in 15% of cases, good in 45% of cases, satisfactory

in 30% cases and poor in 2% cases.

DISCUSSION

The indications for surgical management and internal fixation

of fractures of the shaft of the humerus are very clear. Interlock

nailing is emerging as the gold standard for operative treatment,

with high rates of fracture healing and consolidation and good

outcome with no adverse effect of immediate full weight-bearing

on fracture union or alignment. The advocates of Intramedullary

fixation have highlighted various disadvantages of open

reduction and internal fixation with other methods of

osteosynthesis which requires extensive open surgery with

stripping of soft tissues from bone, a longer operative time and

less secure fixation, especially in the elderly with osteoporotic bone and if crutch walking is required in multiple injuries

patients. The Intramedullary fixation is reported to involve a

simpler technique with minimal exposure and shorter operative

time with less blood loss. The preservation of fracture

hematoma, soft tissue and periosteum around the fracture that

occurs with closed unreamed nailing has been proposed for

Figure 1: Results of open antegrade Nailing at 6 months. Figure 2: Results of closed antegrade nailing at 6 months.


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high rates of union and good results, with no risk of iatrogenic

radial nerve palsy. Locked nailing is said to provide a rotationally

stable fixation and avoid the tendency of various unlocked

nails to back out. Most of the studies support our observations

that A type of fracture pattern is most common of AO fracture

classification pattern seen23, 24, 25. It is documented that humerus

responds poorly to distraction and rate of delayed / non-union

is significantly increased in these cases26. Similar finding was

seen in our study; one of the case that had significant

distraction at fracture site went into delayed union and second

procedure in form of bone grafting was required to achieve

union. Flinkkila et al27, in their study concluded that shoulder

joint range of motion and strength does not recover to normal

after humeral shaft fracture, and antegrade Intramedullary

nailing if performed properly is not responsible for shoulder

joint impairment.

CONCLUSION

In conclusion, it can be derived that there is no significant

difference in duration of operation, union time and shoulder

and elbow function in two groups. There is a long learning

curve for closed Antegrade interlock nailing of humerus and

most of the complications can be avoided and results improved,

if correct technique is followed. A larger randomized trial or

may be a multi-center trial can further improve the interpretation

of the results.

REFERENCES

1. Stig Brorson. Management of Fractures of the Humerus in Ancient

Egypt, Greece, and Rome: An Historical Review. Clin Orthop Relat

Res. 2009 July; 467(7): 1907–14.

2. McQueen M, Court-Brown CM & Ulrich C. Humeral diaphyseal

fractures: their classification and epidemiology. In: Flatow E &

Ulrich C (Eds) Humerus. Butterworth- Heinemann. 1996; 121–27.

3. Müller ME, Nazarian S & Koch P. The Comprehensive Classification

of Fractures of Long Bones. Springer, New York. 1990.

4. Bohler L. Conservative treatment of fresh closed fractures of the

shaft of the humerus. J Trauma 5. 1965; 464–68.

5. Charnley J. The closed treatment of common fractures. Churchill

Livingstone. 1974; 3rd ed. Edinburgh-London-New York.

6. Gregory PR. Fractures of the shaft of the humerus. In: Buchholz

RW & Hecker JD Rockwood & Green’s Fractures in adults.

Lippincott Williams & Wilkins, Philadelphia. 2001; 973– 96.

7. Jupiter JB & van Deck M. Ununited humeral diaphyses. J Shoulder Elbow Surg. 1998; 7: 644-53.

8. Sarmiento A, Waddell JP & Latta LL. Diaphyseal humeral fractures:

treatment options. J Bone Joint Surg. 2001; 83A: 1566–79.

9. Watson-Jones R. Fractures and joint injuries. Livingston, Edinburgh.

1955.

10. Ulrich C. Non-operative management and selection of treatment

method for humeral diaphyseal fractures. In: Flatow E & Ulrich C

(Eds) Humerus. Butterworth-Heinemann. 1996b; 144–55.

11 . Foulk DA & Szabo RM. Diaphyseal humeral fractures: natural history

and occurrence of nonunion. Orthopedics. 1995; 18: 333–35.12 . Healy WL, White GM & Mick CA. Nonunion of the humeral shaft.

Clin Orthop. 1987; 219: 206–13.

13. Heim D, Herkert F, Hess P & Regazzoni P. Surgical treatment of

humeral shaft fractures - the Basel experience. J Trauma. 1993; 35:

226–32

14 . Lindholm RV. The bone-nailing surgeon G.B. G Küntscher and the

Finns. A historica l review of wartime collaboration and its

consequences 1942–1981. Acta Universitatis Ouluensis Series B

Humaniora No 10, Historica no 5, 1982.

15 . Street D. The evolution of intramedullary nailing. In: Browner BD

(ed) The science & practice of intramedullary nailing. Williams &

Wilkins, Baltimore. 1996; 1–26.

16 . Seidel H: Humeral locking nail. A preliminary report. Orthopedics

1989; 12: 219–26.17. Ulrich C. Surgical treatment of humeral diaphyseal fractures. In:

Flatow E & Ulrich C (Eds) Humerus. Butterworth-Heinemann. 1996a;

128–43.

18 . Blum J, Rommens PM & Janzig H. The unreamed humeral nail - a

biological osteosynthesi s of the upper arm. Acta Chir Belg. 1997;

184– 89.

19. Redmond BJ, Biermann JS & Blasier RB. Interlocking nailing of

pathological fractures of the shaf t of the humerus. J Bone Join t

Surg. 1996; 78A: 891–96.

20 . Rommens PM, Verbruggen J & Broos PL. Retrograde locked nailing

of humeral shaft fractures. A review of 39 patients. J Bone Joint

Surg. 1995; 77B: 84–89

21. Constant CR. Constant Scoring Technique for Shoulder Function.

1991. SECEC information.22 . Morrey BF, An KN, Chao EYS : Functional evaluation of the elbow.

In The Elbow and Its Disorders, edited by B. F. Morrey. Ed. 2, pp.

86-89. Philadelphia, W. B. Saunders, 1993.

23 . Kesemenli CC, Subasi M, Arslan H, Necmioglu S & Kapukaya A.

Comparison between the results of intramedullary nailing and

compression plate fixation in the treatment of humerus fractures.

Acta Orthopaedica Traumatol Turcica. 2003; 37:120-25.

24. Raghavendra S & Bhalodiya HP. Internal fixation of fracture of

shaft of humerus by dynamic compression plating or intramedullary

nailing: A prospective study, Indian J of orthopaedics. 2007; 41(3):

214-18.

25 . Tytherleigh-Strong G, Wallis N & McQueen MM. The epidemiology

of humeral shaft fractures. J Bone Joint Surg. 1998; 80B: 249–53.

26. Lin J, Hou SM & Hang YS. Treatment of humeral shaft delayedunions and nonunions with humeral locked nails. J Trauma. 2000;

48: 695–703.

27 . Flinkkila T, Hyvonen P, Siira P & Hamalainen. Recovery of shoulder

joint func tion after humeral shaft frac ture: a comparative study

between antegrade intramedullary nailing and plate fixation. Archives

of orthopaedic and trauma surgery. 2004; 124(8): 537-41.

Fracture shaft humerus - open vs closed antegrade nailing

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Management of Fracture Shaft of Humerus