Plate osteosynthesis in humeral shaft fractures. Indications and results

Non operative management of humeral shaft fractures is well recognized as the standard of care for uncomplicated injuries. Operative treatment of humeral fractures may be performed when limited indications are present as in patients with multiple trauma including ipsilateral forearm injuries, arterial injury or primary radial nerve palsy. 18 patients with humeral shaft fractures underwent open reduction and internal fixation (ORIF) using the AO plating technique at the Kantonsspital Chur from 1980 to 1986. Follow-up was available for 17 patients of whom 16 suffered from multiple injury trauma. The broad DC plate combined with lag screws was used in most cases. Two brachial artery transections were repaired at the time of primary osteosynthesis by the same surgeons with full functional recovery. Concomitant nerve injuries were repaired primarily in one case and postprimarily in 3 more cases. The overall result was excellent in 9 patients, good in 5 patients, fair in 2 patients and poor in one patient with complete brachial plexus injury. Bone healing was uneventful in all 17 patients. No infection and no delayed union or pseudarthrosis has been observed.     

Primary surgical treatment of humeral shaft fractures

Primary internal fixation of acute humeral shaft fractures is only seldom indicated. Following the late results, indication and technique must be very strict. This is shown by the number of 37 cases in seven years and the very low complication rate.     

The surgical treatment of humeral shaft fractures

This is a study of 84 patients with upper arm fractures who were treated by plate osteosynthesis. The indication was mandatory in 9 patients with open fractures, 23 patients with primary radial nerve palsy on admission, 5 patients with radial nerve palsy after the initial treatment, 22 patients with pseudarthrosis and 7 patients who were polytraumatised. The operation was also indicated in 15 patients, because of the form of the fracture, in 3 patients with brachial plexus lesion, in 3 patients because it involved both upper arms and in 3 patients with segmental fractures. The 4.5 DCP was used in all these cases. All the cases of pseudarthrosis progressed to achieve bony union after the operation. There was no incidence of postoperative pseudarthrosis. We did encounter two cases (2.4%) of radial nerve palsy that required exploration. All the preoperative primary and secondary cases of radial nerve palsy recovered postoperatively. After an average follow-up period of 2.4 years (1-10 years) 90% of the patients could be classified as having very good or good results.     

Indications and osteosynthesis procedures in humeral shaft fractures

In the therapy of fractures of the humeral shaft, the individual patient's total condition should be taken into consideration when selecting the adequate method of treatment. Conservative treatment of humeral shaft fractures is still preferred, and Sarmiento's functional therapy has expanded the therapeutic possibilities. The decision for operative treatment is clarified by dividing the indications into the following categories: absolute, relative and recommended indications. In order to reduce complication rates and to ensure stability, we chose among three osteosynthetic procedures: 1. Bundle nailing. 2. Compression plate. 3. Fixateur externe (De Bastiani's mono-fixateur). In simple fractures of the shaft, bundle nailing is an effective and low-risk treatment. Compression plate is indicated in the presence of radial nerve palsy and in very distal shaft fractures. In open fractures and fractures with accompanying blood vessel damage, we favour stabilization with the De Bastiani's unilateral fixateur externe.     

Indications and results of the surgical treatment of distal intra-articular humeral fractures in the elderly

In this paper we review 16 patients with closed intercondylar fractures of the distal end of the humerus that had open reduction and internal fixation. All patients were older than 60 years of age. Using the classification system of Müller et al. 6 fractures were classified as type C2 and 10 fractures as type C3. The surgical procedures and the types of internal fixation of the fractures allowed early postoperative mobilisation (3rd postoperative day). A rating scale modified according to Cassebaum was used for the results. At a mean follow-up of 4.2 years 3 patients were rated as excellent 9 as good and 2 as fair. No severe complications were registered.     

Functional treatment of closed humeral shaft fractures

We treated 93 consecutive patients, average age 53 (16–90) years, with closed humeral shaft fractures applying a functional brace immediately after injury. Seventy-two (77%) fractures healed without problems. There were significantly more consolidation problems in fractures in the proximal third (46% consolidated) compared to those at the middle (81% consolidated) and distal third (86% consolidated) of the shaft. Logistic regression analysis revealed the only predictive factor in respect to successful brace treatment was fracture location. No significant difference was found in respect to healing between different AO-type fractures.

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Résumé Nous avons traité 93 malades consécutifs, dâge moyen 53 ans (16–90), avec une fracture diaphysaire humérale fermée en utilisant une attelle fonctionnelle immédiatement après le traumatisme. Soixante-douze (77%) fractures ont guéri sans problème. Il y avait plus de difficultés de consolidation dans les fractures du tiers proximal (46% ont consolidé) comparé à celles du tiers moyen (81% ont consolidé) et du tiers distal (86% ont consolidé) de la diaphyse. Lanalyse statistique a révélé que le seul facteur prédictif de la réussite du traitement est la localisation de la fracture. Aucune différence significative na été trouvée selon les types de la classification AO.

     

Indications and results of operative treatment of femoral shaft fractures in children.

In the literature a number of risks due to operative treatment of femoral shaft fracture in children have been reported and justification for such treatment has been thrown into doubt. In our patient series 35 out of 191 children (18%) with femoral shaft fracture were treated by operation, 18 by intramedullary nailing, 16 by other means of osteosynthesis and one crushed extremity by primary amputation. No infections occurred. Nineteen patients of these were re-examined 4.5 to 13.9 years later. Eleven of them had no subjective complaints. Weakness of the fractured limb was suffered by 2 in normal life and by an additional 6 patients in hard exercise. Muscle atrophy of the thigh, more than 2 cm in circumference, was found in 9 patients. Mean longitudinal overgrowth of the fractured femur treated by operation was 9.8 mm corresponding to 10.7 mm in 52 patients treated by traction and casting. Overgrowth of 7.2 mm in intramedullary nailed patients was significantly less (P less than 0.001) than 13.5 mm in those treated by other means of osteosynthesis. A rigid fixation of the fracture partly prevented later spontaneous correction of angulation. Based on the results gained by previous author and from this study a list of indications for osteosynthesis of femoral shaft fracture in children is considered.     

Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study

We performed ninety-six internal-fixation procedures for fracture or non-union of the humeral shaft in eighty-four patients, with a mean follow-up of 32.6 months (range, three months to fourteen years). The primary indications for operative intervention included humeral shaft fracture in a patient with multiple trauma, non-union, inadequate reduction of a humeral shaft fracture by closed methods, pathological humeral-shaft fracture, and progressive radial-nerve palsy. Methods of internal fixation included compression plates and screws and intramedullary Küntscher nails or Rush rods. The use of an AO/ASIF compression plate or interfragmentary lag screws with an AO/ASIF neutralization plate in twenty-seven multiply-injured patients resulted in a union rate of 100 per cent and generally good motion of the shoulder and elbow. Five multiply-injured patients also obtained good results through fixation by a modified Hackethal technique using two Rush rods. The use of intramedullary Küntscher nails resulted in a rate of union of 91 per cent in eleven multiply injured patients. Ten patients with non-union of a humeral shaft fracture had an 80 per cent rate of union with the use of an AO/ASIF compression plate. The use of a Küntscher nail in eleven patients with non-union resulted in a rate of union of only 73 per cent and frequently caused subacromial impingement. Fractures of the humeral shaft that had had an inadequate reduction by closed means or were associated with progressive radial-nerve palsy were best managed by a compression plate or the modified Hackethal technique.(ABSTRACT TRUNCATED AT 250 WORDS)     

The operative treatment of diaphyseal humeral shaft fractures

Fractures of the humeral shaft comprise 1% to 3% of all fractures. Incidence rates reveal a bimodal distribution in which there is one small peak during adolescence, followed by a larger spike during the fifth and sixth decades of life. Most humeral diaphysis fractures are simple patterns of the mid-diaphysis. This article emphasizes surgical approaches to humeral fractures, providing a review of the surgical spectrum of treatment inclusive of intramedullary nailing and plating, but also includes a brief discussion of the conservative approach.     

肱骨干下1/3骨折手术治疗进展

肱骨干下1/3骨折多由传导暴力或旋转暴力引起,类型多样,骨折线常累及干骺端,易形成低位肱骨干骨折,且伴发桡神经损伤概率较高.肱骨远端特殊的解剖结构及复杂的应力使得行内固定比较困难.临床手术方法较多,主要有钢板、髓内钉固定,包括钢板内固定的前方入路、后方入路、前外侧入路及联合入路等,髓内钉固定的顺行和逆行方式;外固定支架适合于开放性、广泛骨缺损、粉碎性肱骨干骨折.微创锁定加压钢板固定肱骨干更加可靠,获得了良好的临床疗效.该文就相关解剖基础、生物力学和手术方法的争议等,作一综述.     

Midterm results of surgical treatment of displaced proximal humeral fractures in children

Purpose

To analyse the clinical outcomes of 26 children treated surgically for displaced proximal humerus fracture.

Materials and methods

From January 2008 to December 2012, 26 children/adolescents (14 boys, 12 girls) were treated surgically for displaced fractures at the proximal extremity of the humerus. Ten were grade III and 16 were grade IV according to the Neer–Horowitz classification with a mean age of 12.8 ± 4.2 years. Twenty young patients were surgically treated with a closed reduction and direct percutaneous pinning; six required an open approach. To obtain a proper analysis, we compared the Costant scores with the contralateral shoulder (Δ Costant).

Results

The mean follow-up period was 34 months (range 10–55). Two grade IV patients showed a loss in the reduction after percutaneous treatment. This required open surgery with a plate and screws. On average, the treated fractures healed at 40 days. The mean Δ Costant score was 8.43 (range 2–22). There was a statistically significant improvement in the mean Δ Costant score in grade III patients. In grade IV patients, there was a significant improvement in the mean Δ Costant score in those treated with open surgery versus mini-invasive surgery.

Conclusions

Our study shows excellent results with percutaneous k-wires. This closed surgery had success in these patients, and the excellent outcomes noted here lead us to prefer the mini-invasive surgical approach in NH grade III fractures. In grade IV, the best results were noted in patients treated with open surgery. We suggest an open approach for these patients.

Level of evidence

III.

     

Management of humeral shaft fractures

Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.     

Functional treatment of the distal third humeral shaft fractures

OBJECTIVE: The objective of the present study was to determine the effectiveness of functional treatment for distal third humeral shaft fractures in young adults. PATIENTS AND METHODS: A custom-made prefabricated brace was applied for the functional treatment of 21 isolated, closed, distal third humeral shaft fractures of 21 patients (17 male and 4 female). Their average age was 25 years (range 18-37 years). The mean follow-up period was 39 weeks. RESULTS: All of the fractures united. The average time to union was 12 weeks. The average varus angulation was 7.8 deg in 8 patients, and the average shortening of the fractured limb was 10 mm in 4 patients. Minimal motion restrictions mostly occurred in shoulder abduction and lateral rotation. No patient showed a lack of elbow motion. Angulatory deformities and shortening had no effect on the functional outcome. None of the patients suffered radial nerve palsy during the course of treatment or due to entrapment in the callus of the healed fracture. CONCLUSIONS: Young adults who have isolated, closed, distal third humeral shaft fractures are good candidates for functional bracing.     

双钢板治疗肱骨干骨折的疗效

目的总结双钢板治疗肱骨干骨折的临床疗效。方法采用双钢板治疗28例肱骨干骨折患者。记录手术时间、术中出血量、骨折愈合时间及并发症发生情况,采用Mayo肘关节功能评分、UCLA肩关节功能评分评价肩肘关节功能。结果手术时间57~94 min,术中出血量55~220 ml。患者均获得12个月随访。骨折愈合时间3~5个月。术后12个月,Mayo肘关节功能评分为85~95分,肩关节功能UCLA评分优良率为26/28。2例发生并发症,经治疗后愈合。结论双钢板治疗肱骨干骨折固定牢靠,有利于骨折快速愈合,且术后并发症较少,关节功能恢复良好。