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Treatment of humeral shaft fractures using antegrade nailing: functional outcome in the shoulder
J Shoulder Elbow Surg (2015) -, 1-5
www.elsevier.com/locate/ymse
Treatment of humeral shaft fractures using antegrade nailing: functional outcome in the shoulder Juan Martin Patino, MD* Departamento de Ortopedia y Traumatologia, Servicio de cirugıa de miembro superior, Hospital Militar Central ‘‘Cosme Argerich’’, Buenos Aires, Argentina Background: The purpose of this study was to evaluate shoulder outcomes and function after humeral shaft fractures treated with antegrade nailing. Materials and methods: Thirty patients with acute humeral shaft fractures who underwent antegrade locked intramedullary nailing were retrospectively studied. Range of motion (ROM) of the affected shoulder was evaluated, comparing it with the nonaffected shoulder, radiologic position of the nails, complications, and need for a second surgery. Results: The study enrolled 20 men and 10 women (average age, 41.9 years). The average follow-up was 35.8 months. The average shoulder elevation averaged 157 , internal rotation was variable (reaching the sacroiliac joint to T7), and external rotation averaged 75 . Elbow flexion-extension ROM averaged 133 (115 -145 ). According to the Rodriguez-Merchan criteria, 12 patients achieved excellent results (40%), 7 good (20%), and 6 fair (23.3%); poor results were found in 5 cases (16.6%). Twelve patients achieved full mobility of the shoulder, whereas 18 had some loss of motion, with significant differences between the affected and nonaffected shoulders (P ¼ .001). Conclusion: Decreased shoulder ROM is common after antegrade nailing of humeral shaft fractures. Avoidance of nail impingement can improve final outcomes. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Shoulder; shoulder function; humeral shaft fractures; fracture fixation; antegrade nailing
Treatment of humeral shaft fractures continues to be controversial. Nonoperative functional treatment has been considered the ‘‘gold standard’’ by numerous authors. This approach is based on publications such as that by Sarmiento et al.24 Various absolute and relative surgical indications Institutional Review Board approval was obtained by, Comite de etica, Hospital Militar Central, No: HGRL 601-HMC. *Reprint requests: Juan Martin Patino, MD, Av. Juan de Garay 2235 1er piso B., 1256, Buenos Aires, Argentina. E-mail address: [email protected]
have been published although not always well described. Examples of relative indications for surgery are intolerance to immobilization and inability to maintain an adequate reduction of the fracture. The most accepted surgical techniques to treat humeral shaft fractures include internal fixation with plates and screws, antegrade or retrograde locked intramedullary (IM) nailing, and placement of an external fixator.15,16,25 The main controversy discussed by different authors has been between open reduction and internal fixation (ORIF) and locked IM nailing.4,7,19
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.009
2 The objections to the use of IM nailing include a higher incidence of loss of shoulder function and range of motion (ROM), shoulder pain, the complex technique involved, and the greater need for further surgery.5,10 Numerous studies have been published reporting shoulder functional outcome after IM nailing of humeral shaft fractures. Most of the results were rated excellent or good, but shoulder ROM outcomes were not always described. The objective of this study was to assess shoulder ROM in patients treated with antegrade IM nailing for humeral shaft fractures. How other factors affected the functional outcome, such as position of the nail, gender, associated injuries, and complications, was also evaluated.
Materials and methods The study identified 45 patients who were treated with IM nailing for acute humeral shaft fractures from January 2005 to January 2011. After exclusion of patients with <2 years, since surgery, the number was reduced to 37 individuals. Of these patients, 5 did not respond to requests for follow-up, 1 had died, and 1 had sustained a severe brachial plexus injury with no rehabilitation potential and was excluded, leaving 30 patients in the final study (Table I). The surgical indications were open fractures, multiple trauma, inability to maintain adequate reduction of the fracture, and lack of cooperation with noninvasive treatment. Preoperative and postoperative radiographic studies were reviewed. A new radiographic evaluation was performed at the time of the enrollment. The fractures were classified according to the AO standard (Arbeitsgemeinschaft f€ur Osteosynthesefragen).17 The radiologic position of the nail in the subacromial space, fracture healing status, and ROM of the shoulder, including flexion, external rotation, and internal rotation in both shoulders, were evaluated. The patients were also evaluated by the RodriguezMerchan criteria,22 which simultaneously evaluate shoulder and elbow function using the ROM of the elbow and mobility of the shoulder. Subjective data, such as pain, were also considered on a graded scale: none, occasional, pain with activity, and variable pain. General subjective disability was rated as none, minimal, moderate, and severe. The final scores were qualified as excellent, good, fair, and poor, using the lowest score for the final result. Shoulder flexion and external rotation were measured with a manual goniometer. Internal rotation was measured by the highest vertebral level reached, graded as follows: T7, excellent; T12, good; L5, fair; and
Statistical analysis ROM comparison between the affected and nonaffected shoulders was evaluated by a c2 test. The cases with functional deficits were
J.M. Patino analyzed by looking at age (arbitrarily divided at 50 years), gender, presence of subacromial nail protrusion seen radiographically, and other complications. A logistic regression model was designed to determine if these factors could be considered predictors of loss of shoulder elevation. Statistical significance was set at P < .05. The software used was R Core Team (2013), a language and environment for statistical computing (R Foundation for Statistical Computing, Vienna, Austria; http://Rproject.org/).
Results The median age was 41.9 years, with 20 men and 10 women. Average follow-up was 35.8 months (24-60). According to the AO classification,17 6 fractures were A1 (20%), 7 fractures were A2 (23.3%), 9 fractures were A3 (30%), 4 fractures were B1 (13.33%), 3 fractures were B2 (10%) and 1 fracture was C1 (3.33%). In 12 cases (40%), shoulder ROM was full. Average (mean) shoulder elevation was 157 (90 -180 ); external rotation averaged 75 (40 -90 ); and internal rotation was variable, ranging from full (T7) to poor (S1). ROM in the shoulder that was operated on was significantly different (P ¼ .001) from that in the contralateral shoulder. Average elbow flexion-extension was 133 (115 -145 ), with an average extension deficit of 3 (15 to 0 ), and average flexion was 137 (125 -145 ). Pain outcomes showed that 5 patients still had pain complaints, 3 with activity and 2 with only occasional pain. Functional limitations were observed in 4 patients, 2 with minimal deficits and 2 with moderate deficits. According to the grading system used, the results were excellent in 12 cases (40%), good in 7 (20%), fair in 6 (23.3%), and poor in 5 (16.6%) (Fig. 1; Table II). In 8 cases (26%), postoperative radiographs revealed subacromial nail protrusion of 1 to 2 mm. Complete fracture healing was noted in 28 cases (92%). Complications included 1 case of granuloma at the distal screw level, 1 case of postoperative radial nerve neurapraxia with spontaneous resolution, 1 tuberosity fracture that healed with no further treatment, and 2 cases of nonunion. Eleven subjects required a second surgery: 7 for nail removal, 1 for distal screw removal, and 1 for a nail exchange due to unacceptable subacromial protrusion. In the 2 patients with nonunions, the nail was removed and the nonunions were treated with ORIF with plates, screws, and bone graft. In comparing those patients with full ROM and those with decreased motion, no significant correlation was noted in regard to associated injuries (P ¼ .93), postoperative subacromial nail protrusion (P ¼ .06), complications (P ¼ .82), age older or younger than 50 years (P ¼ .48), and gender (P ¼ .23).
Shoulder outcome after antegrade nailing
3
Table I
Demographics and characteristics of patients, including AO classification, associated injuries, and length of follow-up
Patient
Gender
Age (years)
Limb
Fracture type (AO)
Associated injuries
Follow-up (months)
1 2 3 4 5 6 7
Female Male Male Male Male Male Male
77 72 27 54 22 21 19
Left Left Left Right Right Right Left
A1 A1 B1 A3 A2 B2 B2
36 24 54 60 24 36 54
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Male Male Male Male Male Female Female Male Male Female Female Female Female Male Male Female Male Female Male Female Male Male Male
26 28 48 22 30 75 55 49 46 36 36 40 28 58 55 60 24 51 35 59 51 29 25
Right Left Right Left Right Right Left Right Left Right Left Right Left Right Left Right Left Right Left Left Right Right Left
B2 A3 A3 A2 A3 B1 A2 A2 C1 A1 A3 A1 A2 A3 A1 B1 A3 A3 A2 A1 B1 A3 A2
None Femur fracture Cubitus fracture Traumatic brain injury, pneumothorax Ulna and proximal radius fracture None Gustilo-Anderson type 1, radial nerve neurapraxia, finger fracture None Radial nerve neurapraxia None Traumatic brain injury, distal radius fracture None None None Pelvis fracture None None None None None None None None None None None None None None None
Table II Functional results, complications, and second surgeries after operative treatment of humeral shaft fractures No. of patients Shoulder full ROM Pain Results of rating Excellent Good Fair Poor Subacromial impingement Other complications Second surgeries
12 5 12 7 6 5 8 6 11
Discussion Several papers have been published in reference to the functional outcome after diaphyseal humeral shaft fractures treated with IM nails, but these studies did not always evaluate shoulder ROM. It is not clear in the medical literature if any shoulder ROM deficits were related to the
24 48 36 48 30 60 24 24 36 60 60 24 24 24 24 42 24 24 30 36 30 24 30
surgical approach or the consequence of a technical error, such as subacromial nail protrusion. Because of the scarcity of information on this topic, this study was designed to evaluate shoulder ROM and to correlate it with any possible complications. This study’s limitations include its retrospective nature, the small number of cases in patients of various ages, and the presence of different types of fractures. The positive aspects of this study include a minimum of 2 years of follow-up, the analysis of shoulder ROM and its relation to complications, and the causes of the deficits. With the rating system used, an excellent score was given to subjects with full shoulder ROM, and a good score was given when ROM was within 10% of the maximum ROM. The series had 60% good and excellent scores, with 40% obtaining full shoulder ROM. Loss of shoulder ROM was found to be common, but it is difficult to compare these data with findings from other studies, in which an excellent rating is often given to subjects with 150 to 180 of shoulder elevation.4,8,9,11,23 Subacromial nail impingement has been reported by numerous authors.1-3 Pain, loss of shoulder motion, and the need for a second surgery appeared to be related to surgical complications, but most prior studies have not
4
J.M. Patino
Figure 1
Patient no. 2: 72 years old. (A) Healed fracture. (B) Patient anterior elevation. (C, D) Patient elbow flexion-extension arc.
correlated these findings with functional outcomes and final ratings.6,12,13,20,21 In a systematic review12,14 comparing open reduction and IM nailing, no significant differences were detected between the 2 methods using the American Shoulder and Elbow Surgeons score.11 There were significant differences in the incidence of impingement using nail placement and in hardware removal surgeries. However, the authors concluded that no evidence in functional differences could be demonstrated. In the present study, subacromial nail impingement was found in 8 cases (26%). Poorer outcomes had a strong correlation with this complication (P ¼ .06) but were not statistically significant, although the small number of cases did not have sufficient power to completely rule this out. However, if those patients with subacromial nail impingement are analyzed, 7 of 8 cases had loss of shoulder ROM. In evaluating the cases with low final ratings, of 8 individuals with a fair final score, 7 had subacromial nail impingement, whereas the 2 cases with nonunion and the 1 case with a radial nerve neurapraxia rated poor. The incidence of subacromial nail protrusion and nonunion was similar to that reported in other studies. One study of 105 patients with antegrade placement reported 52 individuals (47%) with intraoperative complications and 40 subjects (36%) with postoperative complications, and in 36 cases a reoperation was needed.3 Some studies, such as that by Ajmal et al,1 had a higher percentage of complications. In a group of 33 patients, 18
(56%) reported pain in the shoulder or at the fracture site; 13 cases (41%) had poor shoulder functional scores, 14 (42%) needed surgical revision, and only 17 (51%) reported a satisfactory outcome. Poor results were attributed to nail impingement and screw protrusion, but the authors did not specify the number of these complications. In 2003, Kesemenli et al13 compared 33 cases treated with antegrade nailing with 27 cases that underwent ORIF with plates and screws. In the first group, 3 patients developed nail impingement. The study also reported 3 subjects with IM nail placement who had >20 deficit in shoulder mobility, but it is not clear if the ROM deficit corresponded to subjects with nail impingement. One of the objections to the use of antegrade nailing is related to trauma to the supraspinatus tendon during the procedure, although ultrasound studies using this technique have shown no functional alterations.26 It is difficult to evaluate how the pre morbid functional status and shoulder pathologies affect the final results.18 But the significant difference in functional abilities in the affected side compared with the other side could be an indicator of the previous mobility.
Conclusions Decreased shoulder ROM was frequently observed after antegrade IM nailing for humeral shaft fractures, but factors such as gender, associated injuries, and other
Shoulder outcome after antegrade nailing complications did not correlate with final outcomes. However, postoperative subacromial nail impingement tends to decrease shoulder motion, and avoiding this can improve final outcomes.
Disclaimer The author, his immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Ajmal M, O’Sullivan M, McCabe J, Curtin W. Antegrade locked intramedullary nailing in humeral shaft fractures. Injury 2001;32:6924. http://dx.doi.org/10.1016/S0020-1383(01)00076-6 2. Anglen JO, Archdeacon MT, Cannada LK, Herscovici D Jr, Ostrum RF. Avoiding complications in the treatment of humeral fractures. J Bone Joint Surg Am 2008;90:1580-9. 3. Baltov A, Mihail R, Dian E. Complications after interlocking intramedullary nailing of humeral shaft fractures. Injury 2014;45(Suppl 1): S9-15. http://dx.doi.org/10.1016/j.injury.2013.10.044 4. Benegas E, Ferreira Neto AA, Conforto Gracitelli ME, Angeli Malavolta E, Assunc¸~ao JH, De Santis Prada F, et al. Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis. J Shoulder Elbow Surg 2014; 23:767-74. http://dx.doi.org/10.1016/j.jse.2014.02.010 5. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fracturesda meta-analysis. Acta Orthop 2006;77:279-84. http://dx. doi.org/10.1080/17453670610046037 6. Blum J, Janzing H, Gahr R, Langendorff HS, Rommens PM. Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion. J Orthop Trauma 2001;15:342-9. 7. Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomized controlled study. Int Orthop 2007;31:391-5. http://dx.doi.org/10.1007/ s00264-006-0200-1 8. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma 2008;65:94-102. http://dx.doi.org/10.1097/TA. 0b013e31812eed7f 9. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.
5 10. Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res 1998;350:40-50. 11. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am 1986;68:1136-44. 12. Iacobellis C, Agro T, Aldegheri R. Locked antegrade intramedullary nailing of humeral shaft fractures. Musculoskelet Surg 2012;96:67-73. http://dx.doi.org/10.1007/s12306-011-0166-z 13. Kesemenli CC, Subas¸i 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 Orthop Traumatol Turc 2003;37:120-5. 14. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev 2011;6:CD005959. http://dx.doi. org/10.1002/14651858.CD005959.pub2 15. Lin J, Hou SM. Locked nailing of severely comminuted or segmental humeral fractures. Clin Orthop 2003;406:195-204. http://dx.doi.org/ 10.1097/01.blo.0000038052.29678.ec 16. 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 Br 2000;82:336-9. 17. M€uller ME, Perren SM, Allg€ower M. Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer-Verlag; 1995. 18. O’Donnell TMP, McKenna JV, Kenny P, Keogh P, O’Flanagan SJ. Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus. J Bone Joint Surg Br 2008; 90:61-5. http://dx.doi.org/10.1302/0301-620X.90B1.19215 19. Ouyang H, Xiong J, Xiang Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg 2013;22:387-95. http:// dx.doi.org/10.1016/j.jse.2012.06.007 20. Riemer BL, Foglesong ME, Burke CJ 3rd, Butterfield SL. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopaedics 1994;17:19-29. 21. Robinson CM, Bell KM, Curt Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br 1992;74:558-62. 22. Rodriguez-Merchan EC. Compression plating versus Hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma 1995;9:194-7. 23. Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J. Humeral nailing revisited. Injury 2008;39:1319-28. http://dx.doi.org/ 10.1016/j.injury.2008.01.014 24. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;59:596-601. 25. Verbruggen JP, Sternstein W, Blum J, Rommens P, Stapert J. Compression-locked nailing of the humerus. A mechanical analysis. Acta Orthop 2007;78:143-50. http://dx.doi.org/10.1080/17453670610 013556 26. Verdano MA, Pellegrini A, Schiavi P, Somenzi L, Concari G, Ceccarelli F. Humeral shaft fractures treated with antegrade intramedullary nailing: what are the consequences for the rotator cuff? Int Orthop 2013;37:2001-7. http://dx.doi.org/10.1007/s00264-013-2007-1
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Treatment of humeral shaft fractures using antegrade nailing: functional outcome in the shoulder Juan Martin Patino, MD* Departamento de Ortopedia y Traumatologia, Servicio de cirugıa de miembro superior, Hospital Militar Central ‘‘Cosme Argerich’’, Buenos Aires, Argentina Background: The purpose of this study was to evaluate shoulder outcomes and function after humeral shaft fractures treated with antegrade nailing. Materials and methods: Thirty patients with acute humeral shaft fractures who underwent antegrade locked intramedullary nailing were retrospectively studied. Range of motion (ROM) of the affected shoulder was evaluated, comparing it with the nonaffected shoulder, radiologic position of the nails, complications, and need for a second surgery. Results: The study enrolled 20 men and 10 women (average age, 41.9 years). The average follow-up was 35.8 months. The average shoulder elevation averaged 157 , internal rotation was variable (reaching the sacroiliac joint to T7), and external rotation averaged 75 . Elbow flexion-extension ROM averaged 133 (115 -145 ). According to the Rodriguez-Merchan criteria, 12 patients achieved excellent results (40%), 7 good (20%), and 6 fair (23.3%); poor results were found in 5 cases (16.6%). Twelve patients achieved full mobility of the shoulder, whereas 18 had some loss of motion, with significant differences between the affected and nonaffected shoulders (P ¼ .001). Conclusion: Decreased shoulder ROM is common after antegrade nailing of humeral shaft fractures. Avoidance of nail impingement can improve final outcomes. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Shoulder; shoulder function; humeral shaft fractures; fracture fixation; antegrade nailing
Treatment of humeral shaft fractures continues to be controversial. Nonoperative functional treatment has been considered the ‘‘gold standard’’ by numerous authors. This approach is based on publications such as that by Sarmiento et al.24 Various absolute and relative surgical indications Institutional Review Board approval was obtained by, Comite de etica, Hospital Militar Central, No: HGRL 601-HMC. *Reprint requests: Juan Martin Patino, MD, Av. Juan de Garay 2235 1er piso B., 1256, Buenos Aires, Argentina. E-mail address: [email protected]
have been published although not always well described. Examples of relative indications for surgery are intolerance to immobilization and inability to maintain an adequate reduction of the fracture. The most accepted surgical techniques to treat humeral shaft fractures include internal fixation with plates and screws, antegrade or retrograde locked intramedullary (IM) nailing, and placement of an external fixator.15,16,25 The main controversy discussed by different authors has been between open reduction and internal fixation (ORIF) and locked IM nailing.4,7,19
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.01.009
2 The objections to the use of IM nailing include a higher incidence of loss of shoulder function and range of motion (ROM), shoulder pain, the complex technique involved, and the greater need for further surgery.5,10 Numerous studies have been published reporting shoulder functional outcome after IM nailing of humeral shaft fractures. Most of the results were rated excellent or good, but shoulder ROM outcomes were not always described. The objective of this study was to assess shoulder ROM in patients treated with antegrade IM nailing for humeral shaft fractures. How other factors affected the functional outcome, such as position of the nail, gender, associated injuries, and complications, was also evaluated.
Materials and methods The study identified 45 patients who were treated with IM nailing for acute humeral shaft fractures from January 2005 to January 2011. After exclusion of patients with <2 years, since surgery, the number was reduced to 37 individuals. Of these patients, 5 did not respond to requests for follow-up, 1 had died, and 1 had sustained a severe brachial plexus injury with no rehabilitation potential and was excluded, leaving 30 patients in the final study (Table I). The surgical indications were open fractures, multiple trauma, inability to maintain adequate reduction of the fracture, and lack of cooperation with noninvasive treatment. Preoperative and postoperative radiographic studies were reviewed. A new radiographic evaluation was performed at the time of the enrollment. The fractures were classified according to the AO standard (Arbeitsgemeinschaft f€ur Osteosynthesefragen).17 The radiologic position of the nail in the subacromial space, fracture healing status, and ROM of the shoulder, including flexion, external rotation, and internal rotation in both shoulders, were evaluated. The patients were also evaluated by the RodriguezMerchan criteria,22 which simultaneously evaluate shoulder and elbow function using the ROM of the elbow and mobility of the shoulder. Subjective data, such as pain, were also considered on a graded scale: none, occasional, pain with activity, and variable pain. General subjective disability was rated as none, minimal, moderate, and severe. The final scores were qualified as excellent, good, fair, and poor, using the lowest score for the final result. Shoulder flexion and external rotation were measured with a manual goniometer. Internal rotation was measured by the highest vertebral level reached, graded as follows: T7, excellent; T12, good; L5, fair; and
Statistical analysis ROM comparison between the affected and nonaffected shoulders was evaluated by a c2 test. The cases with functional deficits were
J.M. Patino analyzed by looking at age (arbitrarily divided at 50 years), gender, presence of subacromial nail protrusion seen radiographically, and other complications. A logistic regression model was designed to determine if these factors could be considered predictors of loss of shoulder elevation. Statistical significance was set at P < .05. The software used was R Core Team (2013), a language and environment for statistical computing (R Foundation for Statistical Computing, Vienna, Austria; http://Rproject.org/).
Results The median age was 41.9 years, with 20 men and 10 women. Average follow-up was 35.8 months (24-60). According to the AO classification,17 6 fractures were A1 (20%), 7 fractures were A2 (23.3%), 9 fractures were A3 (30%), 4 fractures were B1 (13.33%), 3 fractures were B2 (10%) and 1 fracture was C1 (3.33%). In 12 cases (40%), shoulder ROM was full. Average (mean) shoulder elevation was 157 (90 -180 ); external rotation averaged 75 (40 -90 ); and internal rotation was variable, ranging from full (T7) to poor (S1). ROM in the shoulder that was operated on was significantly different (P ¼ .001) from that in the contralateral shoulder. Average elbow flexion-extension was 133 (115 -145 ), with an average extension deficit of 3 (15 to 0 ), and average flexion was 137 (125 -145 ). Pain outcomes showed that 5 patients still had pain complaints, 3 with activity and 2 with only occasional pain. Functional limitations were observed in 4 patients, 2 with minimal deficits and 2 with moderate deficits. According to the grading system used, the results were excellent in 12 cases (40%), good in 7 (20%), fair in 6 (23.3%), and poor in 5 (16.6%) (Fig. 1; Table II). In 8 cases (26%), postoperative radiographs revealed subacromial nail protrusion of 1 to 2 mm. Complete fracture healing was noted in 28 cases (92%). Complications included 1 case of granuloma at the distal screw level, 1 case of postoperative radial nerve neurapraxia with spontaneous resolution, 1 tuberosity fracture that healed with no further treatment, and 2 cases of nonunion. Eleven subjects required a second surgery: 7 for nail removal, 1 for distal screw removal, and 1 for a nail exchange due to unacceptable subacromial protrusion. In the 2 patients with nonunions, the nail was removed and the nonunions were treated with ORIF with plates, screws, and bone graft. In comparing those patients with full ROM and those with decreased motion, no significant correlation was noted in regard to associated injuries (P ¼ .93), postoperative subacromial nail protrusion (P ¼ .06), complications (P ¼ .82), age older or younger than 50 years (P ¼ .48), and gender (P ¼ .23).
Shoulder outcome after antegrade nailing
3
Table I
Demographics and characteristics of patients, including AO classification, associated injuries, and length of follow-up
Patient
Gender
Age (years)
Limb
Fracture type (AO)
Associated injuries
Follow-up (months)
1 2 3 4 5 6 7
Female Male Male Male Male Male Male
77 72 27 54 22 21 19
Left Left Left Right Right Right Left
A1 A1 B1 A3 A2 B2 B2
36 24 54 60 24 36 54
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Male Male Male Male Male Female Female Male Male Female Female Female Female Male Male Female Male Female Male Female Male Male Male
26 28 48 22 30 75 55 49 46 36 36 40 28 58 55 60 24 51 35 59 51 29 25
Right Left Right Left Right Right Left Right Left Right Left Right Left Right Left Right Left Right Left Left Right Right Left
B2 A3 A3 A2 A3 B1 A2 A2 C1 A1 A3 A1 A2 A3 A1 B1 A3 A3 A2 A1 B1 A3 A2
None Femur fracture Cubitus fracture Traumatic brain injury, pneumothorax Ulna and proximal radius fracture None Gustilo-Anderson type 1, radial nerve neurapraxia, finger fracture None Radial nerve neurapraxia None Traumatic brain injury, distal radius fracture None None None Pelvis fracture None None None None None None None None None None None None None None None
Table II Functional results, complications, and second surgeries after operative treatment of humeral shaft fractures No. of patients Shoulder full ROM Pain Results of rating Excellent Good Fair Poor Subacromial impingement Other complications Second surgeries
12 5 12 7 6 5 8 6 11
Discussion Several papers have been published in reference to the functional outcome after diaphyseal humeral shaft fractures treated with IM nails, but these studies did not always evaluate shoulder ROM. It is not clear in the medical literature if any shoulder ROM deficits were related to the
24 48 36 48 30 60 24 24 36 60 60 24 24 24 24 42 24 24 30 36 30 24 30
surgical approach or the consequence of a technical error, such as subacromial nail protrusion. Because of the scarcity of information on this topic, this study was designed to evaluate shoulder ROM and to correlate it with any possible complications. This study’s limitations include its retrospective nature, the small number of cases in patients of various ages, and the presence of different types of fractures. The positive aspects of this study include a minimum of 2 years of follow-up, the analysis of shoulder ROM and its relation to complications, and the causes of the deficits. With the rating system used, an excellent score was given to subjects with full shoulder ROM, and a good score was given when ROM was within 10% of the maximum ROM. The series had 60% good and excellent scores, with 40% obtaining full shoulder ROM. Loss of shoulder ROM was found to be common, but it is difficult to compare these data with findings from other studies, in which an excellent rating is often given to subjects with 150 to 180 of shoulder elevation.4,8,9,11,23 Subacromial nail impingement has been reported by numerous authors.1-3 Pain, loss of shoulder motion, and the need for a second surgery appeared to be related to surgical complications, but most prior studies have not
4
J.M. Patino
Figure 1
Patient no. 2: 72 years old. (A) Healed fracture. (B) Patient anterior elevation. (C, D) Patient elbow flexion-extension arc.
correlated these findings with functional outcomes and final ratings.6,12,13,20,21 In a systematic review12,14 comparing open reduction and IM nailing, no significant differences were detected between the 2 methods using the American Shoulder and Elbow Surgeons score.11 There were significant differences in the incidence of impingement using nail placement and in hardware removal surgeries. However, the authors concluded that no evidence in functional differences could be demonstrated. In the present study, subacromial nail impingement was found in 8 cases (26%). Poorer outcomes had a strong correlation with this complication (P ¼ .06) but were not statistically significant, although the small number of cases did not have sufficient power to completely rule this out. However, if those patients with subacromial nail impingement are analyzed, 7 of 8 cases had loss of shoulder ROM. In evaluating the cases with low final ratings, of 8 individuals with a fair final score, 7 had subacromial nail impingement, whereas the 2 cases with nonunion and the 1 case with a radial nerve neurapraxia rated poor. The incidence of subacromial nail protrusion and nonunion was similar to that reported in other studies. One study of 105 patients with antegrade placement reported 52 individuals (47%) with intraoperative complications and 40 subjects (36%) with postoperative complications, and in 36 cases a reoperation was needed.3 Some studies, such as that by Ajmal et al,1 had a higher percentage of complications. In a group of 33 patients, 18
(56%) reported pain in the shoulder or at the fracture site; 13 cases (41%) had poor shoulder functional scores, 14 (42%) needed surgical revision, and only 17 (51%) reported a satisfactory outcome. Poor results were attributed to nail impingement and screw protrusion, but the authors did not specify the number of these complications. In 2003, Kesemenli et al13 compared 33 cases treated with antegrade nailing with 27 cases that underwent ORIF with plates and screws. In the first group, 3 patients developed nail impingement. The study also reported 3 subjects with IM nail placement who had >20 deficit in shoulder mobility, but it is not clear if the ROM deficit corresponded to subjects with nail impingement. One of the objections to the use of antegrade nailing is related to trauma to the supraspinatus tendon during the procedure, although ultrasound studies using this technique have shown no functional alterations.26 It is difficult to evaluate how the pre morbid functional status and shoulder pathologies affect the final results.18 But the significant difference in functional abilities in the affected side compared with the other side could be an indicator of the previous mobility.
Conclusions Decreased shoulder ROM was frequently observed after antegrade IM nailing for humeral shaft fractures, but factors such as gender, associated injuries, and other
Shoulder outcome after antegrade nailing complications did not correlate with final outcomes. However, postoperative subacromial nail impingement tends to decrease shoulder motion, and avoiding this can improve final outcomes.
Disclaimer The author, his immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Ajmal M, O’Sullivan M, McCabe J, Curtin W. Antegrade locked intramedullary nailing in humeral shaft fractures. Injury 2001;32:6924. http://dx.doi.org/10.1016/S0020-1383(01)00076-6 2. Anglen JO, Archdeacon MT, Cannada LK, Herscovici D Jr, Ostrum RF. Avoiding complications in the treatment of humeral fractures. J Bone Joint Surg Am 2008;90:1580-9. 3. Baltov A, Mihail R, Dian E. Complications after interlocking intramedullary nailing of humeral shaft fractures. Injury 2014;45(Suppl 1): S9-15. http://dx.doi.org/10.1016/j.injury.2013.10.044 4. Benegas E, Ferreira Neto AA, Conforto Gracitelli ME, Angeli Malavolta E, Assunc¸~ao JH, De Santis Prada F, et al. Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis. J Shoulder Elbow Surg 2014; 23:767-74. http://dx.doi.org/10.1016/j.jse.2014.02.010 5. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fracturesda meta-analysis. Acta Orthop 2006;77:279-84. http://dx. doi.org/10.1080/17453670610046037 6. Blum J, Janzing H, Gahr R, Langendorff HS, Rommens PM. Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion. J Orthop Trauma 2001;15:342-9. 7. Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomized controlled study. Int Orthop 2007;31:391-5. http://dx.doi.org/10.1007/ s00264-006-0200-1 8. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma 2008;65:94-102. http://dx.doi.org/10.1097/TA. 0b013e31812eed7f 9. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.
5 10. Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res 1998;350:40-50. 11. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am 1986;68:1136-44. 12. Iacobellis C, Agro T, Aldegheri R. Locked antegrade intramedullary nailing of humeral shaft fractures. Musculoskelet Surg 2012;96:67-73. http://dx.doi.org/10.1007/s12306-011-0166-z 13. Kesemenli CC, Subas¸i 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 Orthop Traumatol Turc 2003;37:120-5. 14. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev 2011;6:CD005959. http://dx.doi. org/10.1002/14651858.CD005959.pub2 15. Lin J, Hou SM. Locked nailing of severely comminuted or segmental humeral fractures. Clin Orthop 2003;406:195-204. http://dx.doi.org/ 10.1097/01.blo.0000038052.29678.ec 16. 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 Br 2000;82:336-9. 17. M€uller ME, Perren SM, Allg€ower M. Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer-Verlag; 1995. 18. O’Donnell TMP, McKenna JV, Kenny P, Keogh P, O’Flanagan SJ. Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus. J Bone Joint Surg Br 2008; 90:61-5. http://dx.doi.org/10.1302/0301-620X.90B1.19215 19. Ouyang H, Xiong J, Xiang Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg 2013;22:387-95. http:// dx.doi.org/10.1016/j.jse.2012.06.007 20. Riemer BL, Foglesong ME, Burke CJ 3rd, Butterfield SL. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopaedics 1994;17:19-29. 21. Robinson CM, Bell KM, Curt Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br 1992;74:558-62. 22. Rodriguez-Merchan EC. Compression plating versus Hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma 1995;9:194-7. 23. Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J. Humeral nailing revisited. Injury 2008;39:1319-28. http://dx.doi.org/ 10.1016/j.injury.2008.01.014 24. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977;59:596-601. 25. Verbruggen JP, Sternstein W, Blum J, Rommens P, Stapert J. Compression-locked nailing of the humerus. A mechanical analysis. Acta Orthop 2007;78:143-50. http://dx.doi.org/10.1080/17453670610 013556 26. Verdano MA, Pellegrini A, Schiavi P, Somenzi L, Concari G, Ceccarelli F. Humeral shaft fractures treated with antegrade intramedullary nailing: what are the consequences for the rotator cuff? Int Orthop 2013;37:2001-7. http://dx.doi.org/10.1007/s00264-013-2007-1