Antegrade interlocking nailing of humeral shaft fractures

The results of 39 humeral shaft fractures (37 patients) treated with antegrade locked nailing using a Russell–Taylor nail were reviewed. There were 30 acute fractures, 6 fractures malaligned in a hanging cast or brace, and 3 pathological fractures. Patient age ranged from 26 to 80 years (average, 59.7 years) and average follow-up was 25.7 months (range, 6–48 months). Fracture union was achieved in 92.3% of our cases, while shoulder function was excellent or good in 87.2% of cases. Antegrade locked nailing offers a dependable solution for the treatment of humeral shaft fractures, especially in polytrauma patients and cases of segmental or pathological fractures. Far less satisfactory results were obtained in comminuted fractures of the proximal third in the humerus, especially in osteoporotic patients, and we therefore advocate caution with the use of intramedullary nailing in this type of fracture. Certain technical aspects such as avoiding nailing the fracture in distraction, properly countersinking the tip of the nail, and achieving adequate fixation stability have been found to be of paramount importance to reduce the incidence of delayed union/non-union rate and to obtain better functional results from the shoulder joint.     

A new modular nail for the diaphyseal fractures of the humerus

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape - with concave sides - and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the ‘Garnavos’ nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.     

Five years' clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures

With the development of interlocking nail systems especially designed for the upper arm, standards for the operative treatment of humeral shaft fractures have appeared to change. The trumpet-like shape of the medullary cavity does not allow stable splinting with a nail alone, and therefore the bone--nail complex is commonly stabilized with interlocking bolts. Between June 1996 and June 2001, 51 fractures of the humeral shaft were treated operatively at the BG Unfallklinik Ludwigshafen with the unreamed humeral nail (UHN; Synthes). All nails were inserted by the retrograde technique. Ninety-five percent of the patients showed excellent or good shoulder function at follow-up examinations. For elbow function, 91.4% of the patients showed excellent or good results. Three out of four patients with poor elbow function had suffered from an additional injury to the brachial plexus; one patient developed heterotopic ossification. Intraoperative complications were: one iatrogenic lesion of the radial nerve, two intraoperative shaft fractures, one split at the insertion point, and one supracondylar fracture. As implants we used 7.5 mm nails in 36 cases and 6.7 mm nails in 15 cases. Among the 47 patients undergoing follow-up examinations, we found two cases of non-union. All patients were pain-free. Thirty-seven patients were very satisfied, six satisfied and four dissatisfied with the therapy. Decisive criteria for the use of a new implant are a high safety standard and simple reproducibility; these appear to be fulfilled by retrograde nailing of humeral fractures with the UHN. Interlocking nailing with the UHN enriches the range of therapeutic options for humeral shaft fractures.     

Bundle nailing for treatment of humeral fractures

Surgical Principles Bundle nailing is based on the principle of elastic intramedullary tight fixation. This can only be achieved by a correct technique and by meeting the four essential provisions:

1. “Fensterschnürung”, by which Hackethal described the jamming of the nail ends in the small cortical window, through which the nails are inserted.
2. “Taillenschnürung”, this means the jamming of nails in the isthmus of the shaft.
3. “Spongiosanagelung” describes the impaction of the proximal nail tips into the metaphyseal bone.
4. “Verkeilungsnägel” (short nails) are used to fill the proximal metaphyseal cavity.

Bundle nailing can be performed from proximal or distal, either way three to five nails should pass the fracture site.     

髓内髓外固定治疗肱骨干骨折的疗效

目的评估髓内髓外固定治疗肱骨干骨折的肩关节功能和术后并发症。方法对35例肱骨干骨折患者分别应用闭合复位髓内钉技术(髓内钉组,16例)和切开复位钢板螺钉固定(钢板组,19例)治疗。比较两组术后关节功能和并发症。结果患者均获随访,时间24～40(32.7±5)个月。骨折愈合时间8～32(11.9±4)周。出血量:髓内钉组40～80(60±20)ml,钢板组140～240(200±22)ml。钢板组发生伤口浅表感染1例;髓内钉组发生桡神经损伤2例,骨不连1例,再次骨折1例。肩关节功能:术后2～4周钢板组明显优于髓内钉组(P<0.05),术后6周两组间差异无统计学意义(P>0.05)。结论闭合复位髓内钉治疗肱骨干骨折创伤小、出血少,但容易造成肩袖和关节囊的损伤,近期肩关节活动不如切开复位钢板螺钉固定。     

肱骨自锁髓内钉逆行插钉技术治疗肱骨骨折

目的探讨自锁髓内钉逆行插钉技术治疗肱骨干骨折的临床应用效果。方法采用逆行插钉技术髓内钉固定治疗14例肱骨干骨折。根据术后肩关节活动范围进行效果评价。结果随访12例,时间3~20个月,平均8·7个月,骨折均愈合。肩关节功能评价:优11例,良1例。结论采用肱骨自锁髓内钉逆行插钉技术治疗肱骨骨折在术后肩关节功能恢复上比顺行插钉技术具有优势。     

The impact of antegrade intramedullary nailing start site using the SIGN nail in proximal femoral fractures: A prospective cohort study

IntroductionIn many low and middle-income countries (LMICs) SIGN nail is commonly used for antegrade femoral intramedullary (IM) nailing, using a start site either at the tip of the greater trochanter or piriformis fossa. While a correct start site is considered an essential technical step; few studies have evaluated the impact of using an erroneous start site. This is particularly relevant in settings with limited access to fluoroscopy to aid in creating a nail entry point. The purpose of this study was to evaluate the impact of antegrade SIGN IM nailing start site on radiographic alignment and health-related quality of life.MethodsIn this prospective cohort study, adult patients with proximal femur fractures (OTA 32, subtrochanteric zone) treated with antegrade IM SIGN nail at Muhimbili Orthopaedic Institute (MOI), Dar es Salaam, Tanzania were enrolled. Start site was determined on the immediate postoperative X-ray and was graded on a continuous scale based on distance of the IM nail center from the greater trochanteric tip. The primary outcome measurement was coronal alignment on the post-operative x-ray. The secondary outcomes were reoperation rates, RUST scores and EQ5D scores at one year follow-up.ResultsSeventy-nine patients were enrolled. 50 of them (63.3%) had complete data at 1 year and were included in the final data analysis. Of the fifty patients, nine (18%) had IM nails placed laterally, 26 (52%) medially and 15 (30%) directly over the tip of the greater trochanter. Compared to a start site at the tip or medial to the greater trochanter, a lateral start site was 9 times more likely to result in a varus malalignment (95% CI: 1.42–57.70, p = 0.021).ConclusionsLateral start site was associated with varus malalignment. Although lateral start site was not significantly associated with reoperation, varus deformity was associated with higher reoperation rates. Surgeons should consider avoiding a start site lateral to the tip of the greater trochanter or allow the nail to rotate to avoid malalignment when using the SIGN nail for proximal femur fractures.     

交锁髓内钉治疗肱骨骨折的临床疗效

目的探讨交锁髓内钉在肱骨骨折治疗中的临床疗效。方法回顾性分析在我院进行治疗的肱骨骨折患者46例的临床资料。其中20例患者采用交锁髓内钉内固定治疗为治疗1组,26例患者采用钢板内固定治疗为治疗2组。比较两组的临床疗效。结果治疗1组优良率显著优于治疗2组（P〈0.05）。与治疗2组比较,治疗1组手术时间短、术中出血量少、骨折愈合时间早、住院时间短（P〈0.01）。结论交锁髓内钉治疗肱骨骨折具有较好的临床疗效,并且恢复快、并发症少,值得临床推广。     

Intramedullary nailing in humeral shaft fractures

The aim of this in vitro study was to compare the mechanical behavior of fixation by the Russell-Taylor nail with the more recent Polarus nail. Fixation with an experimental nail made from polyacetal polymer was also included in the study. Thirty humeri were fractured and randomized to receive one of the three nail types. A four-point nondestructive bending test was performed, as well as torsional testing to failure. The torsional test was designed to record the amount of ‘play’ (uncontrolled rotation) in the bone/implant construct. The Polarus nail gave higher rigidity of the nail/bone construct than the two other types. The Russell-Taylor nailing exhibited a high degree of ‘play’ (uncontrolled rotation). The polyacetal nails allowed a large elastic deformation before failure. Received: 5 December 2000     

Functional bracing of humeral shaft fractures. A review of clinical studies

Functional bracing has been widely accepted as the gold standard for treating humeral shaft fractures conservatively. We conducted a literature review to verify the efficacy of this treatment method. Sixteen case series and two comparative studies fulfilled the criteria set. Analysis of these clinical studies showed that humeral shaft fractures when treated with functional bracing heal in an average of 10.7 weeks. Union rate is high (94.5%). Statistical analysis showed that proximal third fractures and AO type A fractures have a higher non-union rate although this is not statistical significant. Residual deformity and joint stiffness are considered the main drawbacks of conservative treatment. Angulation - usually varus - rarely exceeded 10°, while full shoulder and elbow motion was achieved in 80% and 85% of the patients, respectively. Nevertheless, in the few studies that subjective parameters such as functional scores, pain and quality of life were assessed results were not so promising.     

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures

Background:

We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures.

Materials and Methods:

One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union.

Results:

The follow-up period averaged 15 months (range, 6–26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury.

Conclusion:

Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.     

旋入式自锁髓内钉在肱骨骨折治疗中的应用

2002～2005年,我科对36例不同类型的肱骨骨折应用旋入式自锁髓内钉进行固定,效果良好：     

改进型逆行旋入钉治疗肱骨骨折

目的根据肱骨的解剖特点及临床应用,改进原有的肱骨逆行旋入式自锁髓内钉(逆行旋入钉),探讨改进型逆行旋入钉对肱骨骨折的临床价值。方法 2006年3月-2010年3月,共收治146例肱骨骨折患者。将患者随机分为2组,每组73例,分别采用原型及改进型逆行旋入钉治疗。原型组:男40例,女33例;平均年龄41岁;骨折类型为横形41例,斜形18例,螺旋形8例,粉碎形6例;受伤至手术时间3 h～2个月,中位时间11 d。手术以闭合方式固定27例,切开复位固定46例。改进型组:男39例,女34例;平均年龄40岁;骨折类型为横形43例,斜形16例,螺旋形10例,粉碎形4例;受伤至手术时间3 h～3个月,中位时间13 d。手术以闭合方式固定31例,切开复位固定42例。两组患者性别、年龄、骨折类型、病程等一般资料比较差异均无统计学意义(P>0.05),有可比性。术后比较两组骨折愈合情况及患肢功能恢复情况。结果改进型组手术时间和术中出血量均少于原型组,差异有统计学意义(P<0.05)。原型组术中出现3例医源性肱骨髁上骨折;改进型组无医源性肱骨髁上骨折发生。两组切口均Ⅰ期愈合,术后未发生感染、内固定物松动和断裂等并发症。两组共116例获12个月以上随访,每组58例。骨折愈合时间:改进型组新鲜骨折(15±3)周,陈旧骨折和骨不连(30±12)周;原型组新鲜骨折(16±4)周,陈旧骨折(35±14)周;两组骨折愈合时间比较差异均有统计学意义(P<0.05)。术后3个月患肢功能评价:原型组Neer肩关节评分优65例、良8例,Aitken和Rorabeck肘关节功能评分优61例、良12例,两种评分优良率均为100%;改进型组Neer肩关节评分优67例、良6例,Aitken和Rorabeck肘关节功能评分优63例、良10例,两种评分优良率均为100%。结论改进型逆行旋入钉手术操作简便、并发症少,是一种有效可靠的内固定器。     

分叉交锁髓内钉治疗肱骨干骨折

目的探讨分叉交锁髓内钉(BILN)治疗肱骨干骨折的临床效果.方法应用BILN治疗28例肱骨干骨折,根据术后肩肘关节活动范围对其功能进行评价.结果所有患者获平均9个月的随访,骨折均愈合.肩肘关节功能评价:优16例,良9例,差3例.术后没有继发性桡神经损伤,无切口感染,无骨不连.结论BILN治疗肱骨干骨折是一种固定可靠、并发症少、骨折愈合率高、功能恢复良好的方法.     

可膨胀髓内钉系统治疗骨质疏松性肱骨干骨折的临床评价

目的 探讨可膨胀髓内钉系统治疗骨质疏松性肱骨干骨折的疗效。方法采用可膨胀髓内钉治疗骨质疏松性肱骨干骨折32例,记录并发症、骨折愈合时间和肩关节功能。结果32例均获随访,时间12～24个月,骨折均愈合,时间12—32周。根据Neer肩关节功能评定标准：优23例,良6例,可3例,优良率90．63％。无感染及神经损伤等并发症,有2例术中发生了骨折线的扩大,3例术后出现肩峰撞击综合征。结论可膨胀髓内钉无需锁钉,而是通过膨胀稳定骨折端,固定牢靠,对骨折端血运影响小,是治疗骨质疏松性肱骨干骨折较理想方法。     

Comparison of dynamic versus static fixation of intramedullary nailing in tibial diaphyseal fractures: A systematic review and meta-analysis

IntroductionTibial fractures are common long bone injuries, often surgically fixed with intramedullary nails. Modern intramedullary tibial nails allow for two different fixation modes, namely static and dynamic modes. While studies have demonstrated benefits of using either fixation modes, there has been no consensus as to which fixation mode would produce better outcomes and less complications. This systematic review and meta-analysis aims to compare the efficacy and safety of dynamic versus static fixation of intramedullary nails in the operative fixation of tibial diaphyseal fractures.MethodsA meta-analysis was conducted with a multi-database search (PubMed, OVID, EMBASE, Medline) according to PRISMA guidelines on April 15, 2021. Data from all published literature meeting inclusion criteria were extracted and analysed with fixed- and random-effects models.Findings/results: A total of 478 statically fixed and 234 dynamically fixed patients were included in this meta-analysis. Dynamically fixed patients had a significantly shorter mean time to union (mean difference, MD = 5.18 weeks, 95%CI: 1.95–8.41 weeks, p = 0.002) and reoperation rates (OR = 0.21, 95%CI: 0.10–0.47, p < 0.001) than statically fixed patients. No significant difference was found between both groups in terms of malrotation (OR = 0.57, 95% CI: 0.07–4.41, p = 0.59), non-union (OR = 1.10, 95% CI: 0.24–5.05, p = 0.91), delayed union (OR = 1.15, 95%CI: 0.19–7.17, p = 0.88) and malunion (OR = 2.73, 95% CI: 0.29–25.26, p = 0.38).ConclusionWhile acknowledging that there is widespread surgeon preference to dyanamise or statically fix intramedullary nails in certain tibial fracture configurations, primary dynamic fixation of intramedullary tibial nails demonstrated significantly shorter times to bony union and less complications than static nailing in our meta-analysis. Further research on identifying patient factors and fracture patterns that would best benefit from dynamic fixation is required.     

闭合复位或有限切开复位交锁髓内钉治疗肱骨干骨折

目的探讨交锁髓内钉治疗肱骨干骨折的疗效。方法采用闭合复位或有限切开复位交锁髓内钉治疗肱骨干骨折43例。结果43例均获随访,时间8-18个月。40例骨折愈合;3例延迟愈合,行锁钉动力化后骨折愈合。骨折愈合时间10-32周。疗效参照Neer评分标准进行评价：优27例,良12例,可4例,优良率90.7%。结论交锁髓内钉固定牢靠,对骨折端血运影响小,是治疗肱骨干骨折较为理想的方法。     

Modified use of a proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures

BackgroundSurgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of surgical approach and position of implant. The aim of this study is to evaluate the clinical and radiological outcomes of a modified application of the proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures.Materials and methodsA total of 23 patients with extra-articular distal humerus fractures were treated using either open plating or the minimally invasive plate osteosynthesis (MIPO) technique with upside down application of the PHILOS plate. Fracture configuration, number of screws in the distal fragment, and time to union were analysed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up.ResultsFracture union was obtained in all patients at a mean postoperative time of 20.8 ± 2.9 weeks. The mean shortest and longest cortical lengths were 50.7 ± 14.0 mm and 85.2 ± 12.4 mm, respectively. The average number of screws in the distal humeral fragment was 5.6 ± 0.7. No statistically significant correlation was observed between the shortest cortical length and number of screws in the distal fragment (p = 0.224) or between the longest cortical length and the number of screws in the distal humeral fragment (p = 0.956). The average MEPS was 97.6 (range, 75–100). No postoperative complications that required reoperation were occured.ConclusionA modified anterior application of the PHILOS plate in extra-articular distal-third diaphyseal humeral fracture showed satisfactory outcomes, so it is an alternative when considering the ability to increase plate-screw density with locking screw fixation in a distal humeral fragment.Level of evidenceTherapeutic level IV, case series.     

Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures

Intramedullary nailing is one of the most commonly used surgical treatments for humeral diaphyseal fractures. Once an intramedullary fixation technique has been selected, the choice between antegrade or retrograde approach remains controversial. Forty patients with humeral diaphyseal fracture treated with Seidel antegrade intramedullary nailing through an "danterior deltoid incision" (ADI) were evaluated after an average period of 62 months. Clinical and functional evaluation of the shoulder was performed using the Constant Score. Results were excellent in 33 patients, good in 5 and acceptable in 2. Radiological assessment was performed using antero-posterior (AP) and latero-lateral (LL) radiographs of the humerus and AP and Neer radiographs of the shoulder. Radiographic findings demonstrated good consolidation of all fractures; nail and locking proximal screw malpositioning were detected in 2 cases (2 patients with acceptable results). The positive results obtained for shoulder function correlate with patient age and demonstrate that antegrade intramedullary nailing is a valid option for the treatment of humeral diaphyseal fractures, as long as it is performed through ADI access and with the appropriate surgical technique. Surgical technical errors will lead to functional problems of the shoulder, which in some cases will not be completely eliminated even after nail removal.