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Plating of humeral shaft fractures—has the pendulum swung back?
Injury, Int. J. Care Injured (2004) 35, 580—586
Plating of humeral shaft fractures–—has the pendulum swung back? D.M. Niall*, J. O’Mahony, J.P. McElwain Department of Orthopaedic Surgery, The Meath and Adelaide Hospital (incorporating the National Children’s Hospital), Tallaght, Dublin 24, Ireland Accepted 27 October 2003
KEYWORDS Humeral shaft fractures; AO classification; Plate fixation
Summary We reviewed 49 patients following plate osteosynthesis of humeral shaft fractures. There were no complications as a result of surgery. Union occurred in 47 patients (96%) at a mean of 9 weeks. Two patients required secondary procedures to achieve union. All patients had full range of motion in the elbow and shoulder joints following union. In the light of the popularisation of intramedullary nailing techniques in the last decade, with recognised complications of iatrogenic radial nerve injury, inadequate rotational stabilisation, non-union and shoulder impingement, we advocate plating of humeral shaft fractures as the surgical treatment of choice. ß 2003 Elsevier Ltd. All rights reserved.
Introduction The ideal management of closed fractures of the humeral shaft continues to be debatable. Non-surgical treatment has recognised morbidity with non union rates of up to 12% and loss of shoulder and elbow movement from prolonged immobilisation.16,17,38 Surgical stabilisation is recognised as the treatment of choice for open, segmental and pathological fractures, the floating elbow, multiple injuries and fractures associated with neurovascular injury. However, management of the isolated two or three part fracture by dynamic compression plating or intramedullary nailing remains controversial. Plating provides satisfactory results but requires extensive dissection with meticulous radial nerve protection and may fail in osteopenic bone.2,7,13 The global tendency towards intrame*Corresponding author. Present address: Newland Lodge, Rathbeggan, Dunboyne Co., Meath, Ireland. Tel.: þ35-3-1-8252572. E-mail address: [email protected] (D.M. Niall).
dullary techniques in recent years has produced a wealth of experience in the use of the humeral nail with mixed results.7,15,18,19,23,29,31 In our unit, all methods of conservative and operative treatment have been used in the past, based on individual factors. The senior author preferentially used nailing techniques in the early 1990s. However, critical review revealed less than optimal outcome.6 In the light of his experience, the preferred fixation method in recent years has been plate osteosynthesis and the purpose of this study was to evaluate our clinical results in a series of patients treated with this method.
Patients and methods Between 1990 and 2000, 52 humeral shaft fractures fitting our inclusion criteria were treated in this trauma unit by open reduction and plate osteosynthesis. The complete records of 49 patients were available for review and these made up the study group. For inclusion, the fracture was required to be
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.021
Plating of humeral shaft fractures
581
Figure 1 Pre-operative anteroposterior radiograph of the left humerus in a 19 y.o. female shows a spiral fracture of the middle and lower third with displacement of the distal fragment.
non-pathological, less than 6 weeks old at time of surgery, and to be located at least 5 cm distal to surgical neck and 5 cm proximal to olecronon fossa. There were 30 males and 19 females with a mean age of 33 years (range 17—72). The mechanism of injury and fracture types (as determined by the AO classification and descriptive classification), are
Table 1
tabulated in Tables 1 and 2, respectively. The right humerus was involved in 10 and the left in 39 cases. Under general anaesthesia, the fracture was plated through an anterolateral approach in nine cases and a posterior approach in 40 cases, at a mean of 3 days post injury (range 0—28 days). A broad 4.5 mm dynamic compression plate (AO) was used in all cases. In those patients with a butterfly fragment, interfragmentary lag screws were also used. The approach, length of the plate and necessity for bone
Mechanism of injury
Road traffic accident Assault Fall ‘‘Traction’’/‘‘dragging’’ injuries Equestrian sport Other sports
21 6 7 6 5 4
Table 2
Fracture classification (AO classification)
Transverse (A3.2) Spiral lower 1/2 (A1.3) Spiral lower 1/2, butterfly fragment (B1.3) Midshaft, comminuted (C1.3)
6 24 18 1
582
grafting were dependent on the fracture pattern and site, and the surgeon’s preference. The anterolateral approach was used for transverse midshaft fractures and long spiral fractures extending proximally. The posterior approach was used for the majority of lower/middle third spiral fractures and those with butterfly fragments. Five patients had supplementary bone grafting. Post-operatively, the arm was held in a broad arm sling for comfort and range of motion physiotherapy was instituted in the elbow and shoulder joints immediately. Those with radial nerve palsy were treated with a wrist splint with dynamic finger extensions. Outcome parameters of time to union, return to normal activities, and shoulder and elbow function were assessed by clinical and radiological records. Union was defined as the presence of bridging callus in both cortices as seen on two perpendicular views
D.M. Niall et al.
in a fully functional arm. Range of motion of shoulder and elbow were measured using a goniometer at the time of union.
Results Thirty-four patients had an isolated humeral shaft fracture. The remainder of the group has multiple injuries with a mean Injury Severity Score of 22. The commonest associated injury was a head injury in seven patients. Twelve patients (24%) had radial nerve neuropraxia on presentation or evolving in the first 24 h. Recovery of radial nerve palsies occurred with two distinct patterns; the majority (eight patients) made rapid recovery in a mean of 6 weeks (range 1—10 weeks). Four patients had a more profound
Figure 2 At 6 weeks following open reduction and fixation with an AO dynamic compression plate, the fracture is healed.
Plating of humeral shaft fractures
injury with prolonged but full recovery at a mean of 10 months. There were no radial nerve palsies as a result of surgery. One patient had a traction injury to his left upper limb sustained by entanglement in farm machinery, resulting in a compound Grade 1V humeral shaft fracture with a brachial plexus injury. The fracture was temporarily stabilised with an external fixator until good aseptic soft tissue cover was achieved. At 4 weeks, the fixator was removed and secondary plating and bone grafting was performed through an anterolateral approach. Solid bony union occurred 14 weeks later. There were four other Gustilo grade 1 puncture wounds. Forty-seven fractures (96%) were radiologically healed by 14 weeks following surgery, with a mean time to union of 9 weeks (Figs. 1 and 2). One patient with a high energy midshaft comminuted fracture had secondary bone grafting for delayed union at 14 weeks and subsequently healed. Another patient was considered to have a non-union at 18 weeks and the fracture was re-explored, re-plated and grafted with successful union achieved. At the time of union, all patients had full range of motion of their shoulder. Elbow extension was minimally restricted in eight patients, all of whom had an anterolateral surgical approach. Full elbow extension was achieved on further follow-up several weeks later. Forty-four patients returned to their former occupation and sporting activities within 4 months from the time of injury. The remaining five had prolonged rehabilitation as a result of their radial nerve and brachial plexus injuries. There were no metalwork failures or removals in the long term.
Discussion Our union rate of 96% at 14 weeks following plate osteosynthesis does not differ from previous experience in the literature.8,13,14,25,28,40 The question remains however, whether conservative methods of treatment or intramedullary nailing give the same or better result. Conservative treatment of humeral shaft fractures is well documented in the literature.27,32,33,38,39,41 Various hanging casts, Uslabs and functional braces are described but difficulties in application, satisfactory fracture reduction and immobilisation are all reported.27,38 Osman described a failure rate of 37.5% using a moulded plaster cast.27 Sarmiento’s early report of 98% union and few complications with functional bracing has been the ‘‘gold standard’’ against which other techniques have been compared.32 Since his classic paper in 1977, other authors support his claim of
583
better fracture stability and early joint motion over other conservative treatments.21,39,41 More recently, Sarmiento published his experience with 620 fractures33 with an overall union rate of 97%. However, he included a significant number of open fractures (25%), gunshot injuries (19%) and comminuted fractures (59%), all relative contraindications to surgical intervention with conventional techniques. It is also noteworthy that the injured extremity (including the elbow) was initially immobilised in a cast or coaptation splint for 9 days before application of the moulded brace. Active elevation and abduction of the shoulder were not permitted during the time to union. Both of these factors probably contribute to some adjacent joint stiffness at follow-up. Only 60 and 76% of patients had full range of shoulder and elbow motion, respectively on discontinuing the brace.33 Other authors report some limitation in shoulder mobility at the time of union.21,39,41 Koch described a union rate of 87% at 10 weeks, with normal shoulder motion in only 58% of patients.21 He noted that transverse fractures were more likely to fail to unite. Whilst our union rate with plating is comparable to the above studies, immediate full active shoulder and elbow motion confers advantage in terms of patient comfort and rehabilitation. The success of intramedullary nailing techniques for lower limb fractures in the 1980s provoked interest in their humeral equivalent. The reported advantages included minimal surgical invasion, avoidance of fracture exposure (preserving vascularity and reducing risk of infection), and reamed autogenous graft material at the fracture site. Early reports were promising.12,35 Habernek reported 100% union and full shoulder function at 2 months using the Seidel nail.12 However, the unique spreading device for distal fixation proved difficult to execute and was not designed to prevent rotation. Hence its popularity rapidly waned.11,29,37 Robinson reported poor shoulder function in over 50% of patients either from nail protrusion proximally or local rotator cuff damage during insertion.29 He described considerable technical problems at surgery, an overall complication rate of 87% and a reoperation rate of 70%. Delayed union, non-union and metalwork removal all had an incidence of 25%. The advent of the Russell—Taylor antegrade nail with a distal locking screw produced conflicting literature reports.1,6,9,15,18,23 Hems and Bhullar found 33% of fresh fractures failed to unite at 8 months and 16% of patients had poor shoulder function.15 Comminution of the fracture on nail insertion was common. Flinkkila described a non-union rate of 22% in 126 fractures, highlighting distraction of the fracture as a significant cause, and shoulder
584 impingement in 37% of the group.9 More recently, experience from our own unit has shown significant rates of non-union (10%) delayed union (10%), poor shoulder function (17%) and shoulder stiffness requiring MUA (8%).6 Dissatisfaction with shoulder function led to the concept of retrograde nailing.31 An early report by Ingman comparing both approaches found improved shoulder function with retrograde nailing.17 Subsequent authors consistently support this finding but report fractures and fissuring at the retrograde insertion site.3,31 Simon recently highlighted supracondylar fracture on nail removal as a frequent late complication.36 The most recent concept of flexible/semi-rigid nails, to avoid the problem of rigid nail introduction into thin supracondylar bone, is associated with non-union and ‘‘back-out’’ at the insertion site.5,42 However, the global interest in intramedullary nailing of humeral fractures is reflected in over 50 clinical papers in the last 10 years. Many discard the technique, recognising technical difficulties, shoulder impingement and significant non-union rates as common issues.1,6,9,29,37 There are several biomechanical and operative considerations which argue against the nail as a suitable construct for the humerus. Mechanical stresses differ from the lower limb. The primary stress in the weight-bearing tibia or femur is a ‘‘bending’’ force which is better withstood with a centrally placed nail than an eccentrically placed plate. In the humerus the primary stress is a ‘‘torsional’’ or rotational force. The intramedullary nail, in particular the slotted design, withstands rotational force poorly.3 Biomechanical studies show rotational ‘‘play’’ of up to 25 degrees with various humeral nail designs, partially due to the larger diameter of the locking holes over the screws.26,34 This is particularly relevant in the transverse or short oblique fracture, where torsional stress may allow movement along the fracture plane. The unreamed solid nail has better torsional stiffness than slotted nails and may provide better union in future clinical studies.3 In contrast, the eccentrically placed AO plate provides good resistance to torsional stress and theoretically provides better biomechanics for the humerus. Stiffness of the construct is proportional to the thickness of the plate and hence the rationale of using a broad 4.5 mm plate. Several operative considerations also must be acknowledged. Reaming of humeral fractures is often hazardous if segmentation or butterfly fragments exist, as rotation of unstable fragments may induce radial nerve injury. Nail insertion into a tight or unreamed canal can also predispose to fracture comminution, distraction and radial nerve neuropraxia.24,29 Fracture distraction in the lower limb
D.M. Niall et al.
can be corrected by distally locking first and ‘‘back slapping’’ the nail for compression before proximal locking. This technique is unsuitable for the humerus where a proud nail proximally will impinge on the rotator cuff. Clinically, the literature supports plate osteosynthesis for humeral shaft fractures with union rates of 93—100%.2,7,8,10,13,14,27,28,40 The incidence of iatrogenic transient radial nerve palsy is cited by most authors to be 0—2%2,7,13,14 but occurred in 8 out of 156 patients (5%) in one recent series, with one suffering long term sequelae.28 Joint stiffness is an infrequent complication and usually follows delayed fixation. Opponents to plate fixation are often concerned about the risk of fixation failure in osteopenic bone. Recently, both Schuhli locking nuts and cement augmented screws have been shown to enhance fixation stability in osteopenic bone and are particularly resistant to torsional loading.20 Schuhli screws have further advantage in avoiding the adverse effects of cement extravasation and thermal necrosis. There are few direct comparative studies in the last 10 years to compare the results of plating and nailing. Several retrospective reports draw conflicting conclusions but often had small heterogenous patient groups and used several different designs of nails.22,25,27,30 The ‘‘best evidence’’ to date is two recent prospective controlled trials.4,24 McCormack compared plating with antegrade and retrograde nailing.24 Non-union occurred in 4% of the plated fractures and 10% of nails. Complications were significantly more frequent with nailing through either approach (62%) than with plating (13%). Shoulder impingement or radial nerve palsy did not occur after plating but had incidences of 31 and 14%, respectively after nailing. Further surgery was required in 33% of the nailed group. Chapman also prospectively compared antegrade nailing with plating.4 Good union rates were achieved with both techniques but healing was significantly faster after plating. He emphasized shoulder impingement in the nailed group as the most prevalent distinguishing feature.4 Both authors conclude that open reduction and compression plating remain the safest surgical treatment for fresh fractures. Our experience with plating contrasted favourably with our previous results with the Russell— Taylor nail.6 Whilst we accept that our study does not provide any new data, it acknowledges plating as an acceptable technique in the light of the recent interest in newer methods. We emphasise the advantage of early rehabilitation of the adjacent joints. Some elbow restriction following the anterolateral approach can be attributed to stiffness of the disturbed biceps to passive stretch. We attribute
Plating of humeral shaft fractures
our lack of radial nerve injury to early surgical intervention, when early callus formation has not obscured the anatomy.
Conclusions The advantage of early mobilisation supports surgical stabilisation of humeral shaft fractures in principle. We believe the literature supports plate osteosynthesis as both the safest and biomechanically superior method of fixation for the acute diaphyseal fracture. The precise role of the intramedullary nail is yet to be defined. Over the past decade, the literature attention almost exclusively addresses new nail designs and their outcome. This trend for ‘‘innovation’’ must be evaluated against the background of traditional methods which have served well in the past. At present, we believe open reduction and compression plating remain the treatment of choice for non-pathological humeral shaft fractures that require operative intervention.
References 1. Ajmal M, O’Sullivan M, McCabe J, Curtin W. Antegrade locked intramedullary nailing in humeral shaft fractures. Injury 2001;32:692—4. 2. Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience. J Bone Joint Surg 1985;67-B(2):293—6. 3. Blum J, Machemer H, Hogner M, Baumgart F, Schlegel U, Wahl D, et al. Biomechanics of interlocked nailing in humeral shaft fractures. Comparison of 2 nail systems and the effect of interfragmentary compression with the unreamed humeral nail. Unfallchirurg 2000;103(3): 183—90. 4. Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma 2000;14(3): 162—3. 5. Chen CM, Chiu FY, Lo WH. Treatment of acute closed humeral shaft fractures with Ender nails. Injury 2000;31(9): 683—5. 6. Cox MA, Dolan M, Synnott K, McElwain JP. Closed interlocking nailing of humeral shaft fractures with the RussellTaylor nail. J Orthop Trauma 2000;14(5):349—53. 7. Dabezies EJ, Banta CJ, Murphy CP, d’Ambrosia RD. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma 1992;6(1): 10—3. 8. Dayez J. Internal screwed plate for recent fractures of the humeral diaphysis in adults. Rev Chir Orthop Reparatrice Appar Mot 1999;85(3):234—44. 9. Flinkkila T, Hyvonen P, Lakovaara M, Linden T, Ristiniemi J, Hamalainen M. Intramedullary nailing of humeral shaft fractures. A retrospective study of 126 cases. Acta Orthop Scand 1999;70(2):133—6.
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10. Foster RJ, Dixon GL, Bach AW, Appleyard RW, Green TM. Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study. J Bone Joint Surg 1985;67-A(6):857—64. 11. Gaullier O, Rebai L, Dunaud JL, Moughabghab M, Benaissa S. Treatment of fresh humeral diaphysis fractures by Seidel intramedullary locking nailing. A study of 23 initial cases after 2.5 years with rotator cuff evaluation. Rev Chir Orthop Reparatrice Appar Mot 1999;85(4):349—61. 12. Habernek H, Orthner E. A locking nail for fractures of the humerus. J Bone Joint Surg (Br) 1991;73(4):651—3. 13. Hee HT, Low BY, See HF. Surgical results of open reduction and plating of humeral shaft fractures. Ann Acad Med Singapore 1998;27(6):772—5. 14. Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures–—the Basel experience. J Trauma 1993;35(2):226—32. 15. Hems TE, Bhullar TP. Interlocking nailing of humeral shaft fractures: the Oxford experience 1991—1994. Injury 1996; 27(7):485—9. 16. Holm CL. Management of humeral shaft fractures. Fundamental nonoperative techniques. Clin Orthop 1970;71: 132—9. 17. Hosner W. Fractures of the shaft of the humerus. An analysis of 100 consecutive cases. Reconstr Surg Traumatol 1974;14: 38—64. 18. Ikpeme JO. Intramedullary interlocked nailing for humeral fractures: experience with the Russell-Taylor humeral nail. Injury 1994;25(7):447—55. 19. Ingman AM, Waters DA. Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique and clinical results. J Bone Joint Surg 1994;76-B(1): 23—9. 20. Jazrawi LM, Bai B, Simon JA, Kummer FJ, Birdzell LT, Koval KJ. A biomechanical comparison of Schuhli nuts or cement augmented screws for plating of humeral fractures. Clin Orthop 2000;377:235—40. 21. Koch PP, Gross DFL, Gerber C. The results of functional (Sarmiento) bracing of humeral shaft fractures. J Shoulder Elbow Surg 2002;11(2):143—50. 22. Lin J. Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation. J Trauma 1998;44(5):859—64. 23. Lin J, Hou SM. Antegrade locked nailing for humeral shaft fractures. Clin Orthop 1999;365:201—10. 24. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg 2000;82-B(3):336—9. 25. Meekers FS, Brooks PL. Operative treatment of humeral shaft fractures. The Leuven experience. Acta Orthop Belg 2002;68(5):462—70. 26. Molster A, Gjerdet NR, Strand RM, Hole RM, Hove LM. Intramedullary nailing in humeral shaft fractures. Mechanical behavior in vitro after osteosynthesis with three different intramedullary nails. Arch Orthop Trauma Surg 2001;121(10):554—6. 27. Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY. Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases. Chir Main 1998;17(3):195—206. 28. Paris H, Tropiano P, Clouet D’orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2000;86(4):346—59.
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29. Robinson CM, Bell KM, Court-Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg 1992; 74-B(4):558—62. 30. Rodriquez-Merchan EC. Compression plating versus hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma 1995;9(3):194—7. 31. Rommens PM, Verbruggen J, Broos PL. Retrograde locked nailing of humeral shaft fractures. A review of 39 patients. J Bone Joint Surg 1995;77-B:84—9. 32. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg 1977;59-A(5):596—601. 33. Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg 2000;82-A:478—86. 34. Schopfer A, Hearn TC, Malisano L, Powell JN, Kellam JF. Comparison of torsional strength of humeral intramedullary nailing: a cadaveric study. J Orthop Trauma 1994;8(5): 414—21. 35. Seidel H. Humeral locking nail: a preliminary report. Orthopaedics 1989;12(2):219—26.
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36. Simon P, Jobard D, Bistour L, Babin SR. Complications of Marchetti locked nailing for humeral shaft fractures. Int Orthop 1999;23(6):320—4. 37. Svend-Hansen H, Skettrup M, Rathcke MW. Complications using the Seidel intramedullary humeral nail: outcome in 31 patients. Acta Orthop Belg 1998;64(3):291—5. 38. Thompson RG, Compere EL, Schnute WJ, Compere CL, Kennahan WT, Keagy RD, et al. The treatment of humeral shaft fractures by the hanging cast method. J Internat Coll Surg 1965;43:52—60. 39. Wallny T, Westermann K, Sagebiel C, Reimer M, Wagner UA. Functional treatment of humeral shaft fractures: indications and results. J Orthop Trauma 1997;11(4):283—7. 40. Winker H, Vosberg W, Cyris A. Results of treatment of humerus shaft fractures. Aktuelle Traumatol 1993; 23(Suppl 1):36—41. 41. Zagorski JB, Latta LL, Zych GA, Finnieston AR. Diaphyseal fractures of the humerus. Treatment with prefabricated braces. J Bone Joint Surg Am 1988;70(4):607—10. 42. Zatti G, Teli M, Ferrario A, Cherubino P. Treatment of closed humeral shaft fractures with intramedullary elastic nails. J Trauma 1998;45(6):1046—50.
Plating of humeral shaft fractures–—has the pendulum swung back? D.M. Niall*, J. O’Mahony, J.P. McElwain Department of Orthopaedic Surgery, The Meath and Adelaide Hospital (incorporating the National Children’s Hospital), Tallaght, Dublin 24, Ireland Accepted 27 October 2003
KEYWORDS Humeral shaft fractures; AO classification; Plate fixation
Summary We reviewed 49 patients following plate osteosynthesis of humeral shaft fractures. There were no complications as a result of surgery. Union occurred in 47 patients (96%) at a mean of 9 weeks. Two patients required secondary procedures to achieve union. All patients had full range of motion in the elbow and shoulder joints following union. In the light of the popularisation of intramedullary nailing techniques in the last decade, with recognised complications of iatrogenic radial nerve injury, inadequate rotational stabilisation, non-union and shoulder impingement, we advocate plating of humeral shaft fractures as the surgical treatment of choice. ß 2003 Elsevier Ltd. All rights reserved.
Introduction The ideal management of closed fractures of the humeral shaft continues to be debatable. Non-surgical treatment has recognised morbidity with non union rates of up to 12% and loss of shoulder and elbow movement from prolonged immobilisation.16,17,38 Surgical stabilisation is recognised as the treatment of choice for open, segmental and pathological fractures, the floating elbow, multiple injuries and fractures associated with neurovascular injury. However, management of the isolated two or three part fracture by dynamic compression plating or intramedullary nailing remains controversial. Plating provides satisfactory results but requires extensive dissection with meticulous radial nerve protection and may fail in osteopenic bone.2,7,13 The global tendency towards intrame*Corresponding author. Present address: Newland Lodge, Rathbeggan, Dunboyne Co., Meath, Ireland. Tel.: þ35-3-1-8252572. E-mail address: [email protected] (D.M. Niall).
dullary techniques in recent years has produced a wealth of experience in the use of the humeral nail with mixed results.7,15,18,19,23,29,31 In our unit, all methods of conservative and operative treatment have been used in the past, based on individual factors. The senior author preferentially used nailing techniques in the early 1990s. However, critical review revealed less than optimal outcome.6 In the light of his experience, the preferred fixation method in recent years has been plate osteosynthesis and the purpose of this study was to evaluate our clinical results in a series of patients treated with this method.
Patients and methods Between 1990 and 2000, 52 humeral shaft fractures fitting our inclusion criteria were treated in this trauma unit by open reduction and plate osteosynthesis. The complete records of 49 patients were available for review and these made up the study group. For inclusion, the fracture was required to be
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.021
Plating of humeral shaft fractures
581
Figure 1 Pre-operative anteroposterior radiograph of the left humerus in a 19 y.o. female shows a spiral fracture of the middle and lower third with displacement of the distal fragment.
non-pathological, less than 6 weeks old at time of surgery, and to be located at least 5 cm distal to surgical neck and 5 cm proximal to olecronon fossa. There were 30 males and 19 females with a mean age of 33 years (range 17—72). The mechanism of injury and fracture types (as determined by the AO classification and descriptive classification), are
Table 1
tabulated in Tables 1 and 2, respectively. The right humerus was involved in 10 and the left in 39 cases. Under general anaesthesia, the fracture was plated through an anterolateral approach in nine cases and a posterior approach in 40 cases, at a mean of 3 days post injury (range 0—28 days). A broad 4.5 mm dynamic compression plate (AO) was used in all cases. In those patients with a butterfly fragment, interfragmentary lag screws were also used. The approach, length of the plate and necessity for bone
Mechanism of injury
Road traffic accident Assault Fall ‘‘Traction’’/‘‘dragging’’ injuries Equestrian sport Other sports
21 6 7 6 5 4
Table 2
Fracture classification (AO classification)
Transverse (A3.2) Spiral lower 1/2 (A1.3) Spiral lower 1/2, butterfly fragment (B1.3) Midshaft, comminuted (C1.3)
6 24 18 1
582
grafting were dependent on the fracture pattern and site, and the surgeon’s preference. The anterolateral approach was used for transverse midshaft fractures and long spiral fractures extending proximally. The posterior approach was used for the majority of lower/middle third spiral fractures and those with butterfly fragments. Five patients had supplementary bone grafting. Post-operatively, the arm was held in a broad arm sling for comfort and range of motion physiotherapy was instituted in the elbow and shoulder joints immediately. Those with radial nerve palsy were treated with a wrist splint with dynamic finger extensions. Outcome parameters of time to union, return to normal activities, and shoulder and elbow function were assessed by clinical and radiological records. Union was defined as the presence of bridging callus in both cortices as seen on two perpendicular views
D.M. Niall et al.
in a fully functional arm. Range of motion of shoulder and elbow were measured using a goniometer at the time of union.
Results Thirty-four patients had an isolated humeral shaft fracture. The remainder of the group has multiple injuries with a mean Injury Severity Score of 22. The commonest associated injury was a head injury in seven patients. Twelve patients (24%) had radial nerve neuropraxia on presentation or evolving in the first 24 h. Recovery of radial nerve palsies occurred with two distinct patterns; the majority (eight patients) made rapid recovery in a mean of 6 weeks (range 1—10 weeks). Four patients had a more profound
Figure 2 At 6 weeks following open reduction and fixation with an AO dynamic compression plate, the fracture is healed.
Plating of humeral shaft fractures
injury with prolonged but full recovery at a mean of 10 months. There were no radial nerve palsies as a result of surgery. One patient had a traction injury to his left upper limb sustained by entanglement in farm machinery, resulting in a compound Grade 1V humeral shaft fracture with a brachial plexus injury. The fracture was temporarily stabilised with an external fixator until good aseptic soft tissue cover was achieved. At 4 weeks, the fixator was removed and secondary plating and bone grafting was performed through an anterolateral approach. Solid bony union occurred 14 weeks later. There were four other Gustilo grade 1 puncture wounds. Forty-seven fractures (96%) were radiologically healed by 14 weeks following surgery, with a mean time to union of 9 weeks (Figs. 1 and 2). One patient with a high energy midshaft comminuted fracture had secondary bone grafting for delayed union at 14 weeks and subsequently healed. Another patient was considered to have a non-union at 18 weeks and the fracture was re-explored, re-plated and grafted with successful union achieved. At the time of union, all patients had full range of motion of their shoulder. Elbow extension was minimally restricted in eight patients, all of whom had an anterolateral surgical approach. Full elbow extension was achieved on further follow-up several weeks later. Forty-four patients returned to their former occupation and sporting activities within 4 months from the time of injury. The remaining five had prolonged rehabilitation as a result of their radial nerve and brachial plexus injuries. There were no metalwork failures or removals in the long term.
Discussion Our union rate of 96% at 14 weeks following plate osteosynthesis does not differ from previous experience in the literature.8,13,14,25,28,40 The question remains however, whether conservative methods of treatment or intramedullary nailing give the same or better result. Conservative treatment of humeral shaft fractures is well documented in the literature.27,32,33,38,39,41 Various hanging casts, Uslabs and functional braces are described but difficulties in application, satisfactory fracture reduction and immobilisation are all reported.27,38 Osman described a failure rate of 37.5% using a moulded plaster cast.27 Sarmiento’s early report of 98% union and few complications with functional bracing has been the ‘‘gold standard’’ against which other techniques have been compared.32 Since his classic paper in 1977, other authors support his claim of
583
better fracture stability and early joint motion over other conservative treatments.21,39,41 More recently, Sarmiento published his experience with 620 fractures33 with an overall union rate of 97%. However, he included a significant number of open fractures (25%), gunshot injuries (19%) and comminuted fractures (59%), all relative contraindications to surgical intervention with conventional techniques. It is also noteworthy that the injured extremity (including the elbow) was initially immobilised in a cast or coaptation splint for 9 days before application of the moulded brace. Active elevation and abduction of the shoulder were not permitted during the time to union. Both of these factors probably contribute to some adjacent joint stiffness at follow-up. Only 60 and 76% of patients had full range of shoulder and elbow motion, respectively on discontinuing the brace.33 Other authors report some limitation in shoulder mobility at the time of union.21,39,41 Koch described a union rate of 87% at 10 weeks, with normal shoulder motion in only 58% of patients.21 He noted that transverse fractures were more likely to fail to unite. Whilst our union rate with plating is comparable to the above studies, immediate full active shoulder and elbow motion confers advantage in terms of patient comfort and rehabilitation. The success of intramedullary nailing techniques for lower limb fractures in the 1980s provoked interest in their humeral equivalent. The reported advantages included minimal surgical invasion, avoidance of fracture exposure (preserving vascularity and reducing risk of infection), and reamed autogenous graft material at the fracture site. Early reports were promising.12,35 Habernek reported 100% union and full shoulder function at 2 months using the Seidel nail.12 However, the unique spreading device for distal fixation proved difficult to execute and was not designed to prevent rotation. Hence its popularity rapidly waned.11,29,37 Robinson reported poor shoulder function in over 50% of patients either from nail protrusion proximally or local rotator cuff damage during insertion.29 He described considerable technical problems at surgery, an overall complication rate of 87% and a reoperation rate of 70%. Delayed union, non-union and metalwork removal all had an incidence of 25%. The advent of the Russell—Taylor antegrade nail with a distal locking screw produced conflicting literature reports.1,6,9,15,18,23 Hems and Bhullar found 33% of fresh fractures failed to unite at 8 months and 16% of patients had poor shoulder function.15 Comminution of the fracture on nail insertion was common. Flinkkila described a non-union rate of 22% in 126 fractures, highlighting distraction of the fracture as a significant cause, and shoulder
584 impingement in 37% of the group.9 More recently, experience from our own unit has shown significant rates of non-union (10%) delayed union (10%), poor shoulder function (17%) and shoulder stiffness requiring MUA (8%).6 Dissatisfaction with shoulder function led to the concept of retrograde nailing.31 An early report by Ingman comparing both approaches found improved shoulder function with retrograde nailing.17 Subsequent authors consistently support this finding but report fractures and fissuring at the retrograde insertion site.3,31 Simon recently highlighted supracondylar fracture on nail removal as a frequent late complication.36 The most recent concept of flexible/semi-rigid nails, to avoid the problem of rigid nail introduction into thin supracondylar bone, is associated with non-union and ‘‘back-out’’ at the insertion site.5,42 However, the global interest in intramedullary nailing of humeral fractures is reflected in over 50 clinical papers in the last 10 years. Many discard the technique, recognising technical difficulties, shoulder impingement and significant non-union rates as common issues.1,6,9,29,37 There are several biomechanical and operative considerations which argue against the nail as a suitable construct for the humerus. Mechanical stresses differ from the lower limb. The primary stress in the weight-bearing tibia or femur is a ‘‘bending’’ force which is better withstood with a centrally placed nail than an eccentrically placed plate. In the humerus the primary stress is a ‘‘torsional’’ or rotational force. The intramedullary nail, in particular the slotted design, withstands rotational force poorly.3 Biomechanical studies show rotational ‘‘play’’ of up to 25 degrees with various humeral nail designs, partially due to the larger diameter of the locking holes over the screws.26,34 This is particularly relevant in the transverse or short oblique fracture, where torsional stress may allow movement along the fracture plane. The unreamed solid nail has better torsional stiffness than slotted nails and may provide better union in future clinical studies.3 In contrast, the eccentrically placed AO plate provides good resistance to torsional stress and theoretically provides better biomechanics for the humerus. Stiffness of the construct is proportional to the thickness of the plate and hence the rationale of using a broad 4.5 mm plate. Several operative considerations also must be acknowledged. Reaming of humeral fractures is often hazardous if segmentation or butterfly fragments exist, as rotation of unstable fragments may induce radial nerve injury. Nail insertion into a tight or unreamed canal can also predispose to fracture comminution, distraction and radial nerve neuropraxia.24,29 Fracture distraction in the lower limb
D.M. Niall et al.
can be corrected by distally locking first and ‘‘back slapping’’ the nail for compression before proximal locking. This technique is unsuitable for the humerus where a proud nail proximally will impinge on the rotator cuff. Clinically, the literature supports plate osteosynthesis for humeral shaft fractures with union rates of 93—100%.2,7,8,10,13,14,27,28,40 The incidence of iatrogenic transient radial nerve palsy is cited by most authors to be 0—2%2,7,13,14 but occurred in 8 out of 156 patients (5%) in one recent series, with one suffering long term sequelae.28 Joint stiffness is an infrequent complication and usually follows delayed fixation. Opponents to plate fixation are often concerned about the risk of fixation failure in osteopenic bone. Recently, both Schuhli locking nuts and cement augmented screws have been shown to enhance fixation stability in osteopenic bone and are particularly resistant to torsional loading.20 Schuhli screws have further advantage in avoiding the adverse effects of cement extravasation and thermal necrosis. There are few direct comparative studies in the last 10 years to compare the results of plating and nailing. Several retrospective reports draw conflicting conclusions but often had small heterogenous patient groups and used several different designs of nails.22,25,27,30 The ‘‘best evidence’’ to date is two recent prospective controlled trials.4,24 McCormack compared plating with antegrade and retrograde nailing.24 Non-union occurred in 4% of the plated fractures and 10% of nails. Complications were significantly more frequent with nailing through either approach (62%) than with plating (13%). Shoulder impingement or radial nerve palsy did not occur after plating but had incidences of 31 and 14%, respectively after nailing. Further surgery was required in 33% of the nailed group. Chapman also prospectively compared antegrade nailing with plating.4 Good union rates were achieved with both techniques but healing was significantly faster after plating. He emphasized shoulder impingement in the nailed group as the most prevalent distinguishing feature.4 Both authors conclude that open reduction and compression plating remain the safest surgical treatment for fresh fractures. Our experience with plating contrasted favourably with our previous results with the Russell— Taylor nail.6 Whilst we accept that our study does not provide any new data, it acknowledges plating as an acceptable technique in the light of the recent interest in newer methods. We emphasise the advantage of early rehabilitation of the adjacent joints. Some elbow restriction following the anterolateral approach can be attributed to stiffness of the disturbed biceps to passive stretch. We attribute
Plating of humeral shaft fractures
our lack of radial nerve injury to early surgical intervention, when early callus formation has not obscured the anatomy.
Conclusions The advantage of early mobilisation supports surgical stabilisation of humeral shaft fractures in principle. We believe the literature supports plate osteosynthesis as both the safest and biomechanically superior method of fixation for the acute diaphyseal fracture. The precise role of the intramedullary nail is yet to be defined. Over the past decade, the literature attention almost exclusively addresses new nail designs and their outcome. This trend for ‘‘innovation’’ must be evaluated against the background of traditional methods which have served well in the past. At present, we believe open reduction and compression plating remain the treatment of choice for non-pathological humeral shaft fractures that require operative intervention.
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