Minimally invasive plate osteosynthesis for metastatic pathologic humeral fractures

Because patients with metastatic bone disease may survive only 3 to 12 months, the goal of surgery for pathologic fractures is to attain rigid and durable internal fixation and immediate postoperative use of the upper extremity. Surgical options such as intramedullary nailing, plating, and insertion of prosthesis usually reinforced with bone cement have been proposed for pathological humeral fractures. We describe a 42-year-old man with a pathologic distal humeral fracture. The fracture location and lack of distal bone stock precluded the use of intramedullary nails. We performed minimally invasive plating by using a locking plate for bridging and stabilization of fracture. Minimally invasive plate osteosynthesis of the humeral shaft was developed to allow anterior plate and screw stabilization involving less soft tissue disruption and to theoretically improve healing rates and reduce complications, such as infection and iatrogenic radial nerve palsy. Plain radiographs showed stable consolidation of the fracture without screw loosening at the 7-month follow-up. Elbow range of motion was 120°, and the arm was stable without pain. Minimally invasive plate using a locking plate can provide stable fixation and allow early arm mobilization without protection and decrease the risk of operation-related complications, making it a useful surgical alternative in the treatment of pathologic humeral fractures.     

Operative treatment of humeral shaft fractures. Comparison of plating and intramedullary nailing

Plate and screw fixation (PSF) has always been the more common surgical treatment of humeral shaft fractures. However, intramedullary nailing (IMN) of the humerus has gained in popularity over the last two decades. The purpose of this retrospective study was to evaluate the clinical outcome of plate fixation versus intramedullary nailing of midshaft humeral fractures. The study included 91 patients treated at the department of Trauma Surgery of the University hospital of Leuven; 42 fractures had been treated by plate fixation and 49 by IM nailing. Union, functional outcome, possible complications and the need for additional surgery were compared between the IMN and PSF group. No significant difference in terms of fracture union and functional recovery was noted between the two groups. There were four cases of postoperative radial nerve palsy in the PSF group, versus two in the IMN group (non significant difference). A significantly larger number of patients with restrictive pain and/or functional hindrance in the shoulder or elbow was noted in the IMN group (p = 0.0053). Problems with osteosynthesis material occurred as often in the PSF group as in the IMN group. One patient developed wound infection at the shoulder after antegrade nailing. A significantly larger number of complications was seen in the IMN group than in the PSF group (p = 0.05). A reoperation was necessary in 143% of the PSF patients and 163% of the IMN patients (non significant difference). In this retrospective study, IMN did not achieve better results than PSF of humeral midshaft fractures and was associated with more postoperative complications. Based on these findings, we suggest that plating of humeral shaft fractures should be considered as the primary treatment for all surgical indications, except for some open fractures requiring temporary external fixation, pathological fractures, humeral shaft fractures in morbidly obese and osteopenic patients, and large segmental fractures of the humerus.     

Compression Plating Versus Intramedullary Fixation of Humeral Shaft Fractures

Most humeral shaft fractures do not require surgery. When operative stabilization is indicated, the surgeon can choose between compression plating and intramedullary fixation. The results after compression plating have been shown to be predictable with respect to healing, alignment, and range of motion of the shoulder and elbow joints. Although complications are unusual with plate fixation, the procedure can require extensive dissection and operative time. Intramedullary fixation offers an alternative to plate fixation, with the principal advantage being a limited surgical dissection. This benefit must be balanced against the reportedly high rate of postoperative shoulder problems seen with antegrade nail placement. Unfortunately, few direct comparative studies have been done to evaluate the various techniques. The authors attempt to clarify and resolve these issues.     

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)     

不同方法治疗胫骨干骨折疗效分析

目的 探讨适合胫骨干骨折的手术治疗方法及并发症的预防措施。方法 回顾性分析手术治疗胫骨干骨折患者67例，根据选择手术方式不同，将患者分为交锁髓内钉、加压钢板组和外固定支架3组，临床观察结合x线片评价骨折愈合、延迟愈合、不愈合作为判断临床疗效标准。结果 髓内钉组的骨折愈合率明显高于加压钢板组和外固定支架组，外固定组的骨折延迟愈合率高于其他两组；并发症包括骨不连、关节僵硬及畸形愈合，发生率为22.4％，其中骨不连发生率为13.4％。结论 髓内钉内固定治疗胫骨干骨折的临床疗效优于加压钢板和外固定支架；骨不连为胫骨骨折常见并发症，应严格掌握手术适应证、规范手术操作。     

Dorsal plate osteosynthesis of the tibial shaft. Results of a collective study of the German section of the International AO (Study Group for Osteosynthesis Problems)

This collective study was conducted by the German section of AO International to work out the indications for fixation of the tibial shaft by means of dorsal plating. Primary dorsal plating was done in 70 cases. Most of the patients had second- or third-degree open fractures with severe ventral soft tissue injuries or closed fractures that could not be reduced and fixed conservatively. In 72 patients, secondary dorsal plate fixation was performed. The main reason for the dorsally positioned plate was persistent instability or axial malalignment after previous external or internal fixation, but failed conservative treatment constituted a further reason. Most of these patients had such severe damage following fractures that dorsal plating was the last chance of avoiding amputation. The high rate of complications (12 infections and 7 non-unions and breakages of implants after primary dorsal plating; 20 infections and 11 non-unions and breakages of implants after secondary dorsal plating) has to be considered in the light of the extraordinary indications for the dorsal plating of the tibial shaft in especially severe fractures or disastrous sequelae. In cases with extremely severe conditions before fixation, dorsal plating of the tibial shaft for secondary operative treatment yields adequate results.     

Indications, dangers and results of surgical treatment of humeral shaft fractures

A series of 78 fractures of the humeral shaft is presented that were treated operatively between 1978 and 1987. Open fractures, fractures with primary palsy of the radial nerve, distal fractures with an intraarticular component, fractures in polytraumatized patients and non-unions were absolute indications for operative stabilization in this series. In 71 fractures, internal stabilization was performed and in 7 fractures external fixation. In 16 fractures (20.6%), primary palsy of the radial nerve was present. In 10 patients (12.8%), radial nerve palsy appeared postoperatively. Nonunions and deep infections did not occur. In two cases, a second osteosynthesis was necessary after loosening of the implants. The humeral shaft fracture shows normal bony consolidation after conservative treatment as well as appropriate plate osteosynthesis. Nine of the 16 patients with primary radial nerve palsy (56.2%) and 6 of the 10 patients with secondary radial nerve palsy (60%) had total functional recovery. In our series, intraoperative palsy of the radial nerve was the most frequent complication after dissection of spiroid fractures in the middle or lower third of the humeral shaft. In this fracture form, a more unstable osteosynthesis, such as intramedullary pinning in accordance to Hackethal, should be chosen.     

Plating of humeral shaft fractures--has the pendulum swung back?

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.     

顺行旋入式髓内钉治疗肱骨干骨折疗效观察

目的总结顺行旋入式髓内钉治疗肱骨干骨折的临床疗效。方法24例肱骨干骨折患者采用顺行旋入式自锁髓内钉固定。结果24例均获随访,平均18．6个月,所有患者骨折均愈合,平均愈合时间23．0（21．4—24．7）周。肩关节Constant评分平均82．7（76．9—88．6）分;肘关节Mayo评分平均91．3（89．6—93．1）分;Neer评分：优19例,良5例。结论顺行旋入式髓内钓。固定手术操作简单、时间短、损伤小、术中并发症少、骨折愈合快,适合稳定性骨折和断端非缺损性粉碎性骨折,尤其适用于开放性肱骨干骨折手术。     

Nonunion of humeral shaft fractures following flexible nailing fixation

The treatment of humeral shaft fractures ranges from conservative modalities to operative fixation, including plate osteosynthesis and intramedullary fixation. Nonunion is a complication of conservative and operative interventions but is more often associated with elastic nailing. This article discusses elucidates the successful outcomes achieved with flexible nailing of humeral shaft fractures.     

顺行旋入式髓内钉与锁定钢板治疗肱骨干骨折疗效比较

目的比较顺行旋入式髓内钉和锁定钢板系统治疗肱骨干骨折的临床疗效。方法对38例肱骨干骨折患者,采用顺行旋入式自锁髓内钉固定21例,锁定钢板系统内固定17例。结果 38例均获随访,平均18.6个月。旋入式自锁髓内钉组平均手术时间(47.90±4.98)min,桡神经损伤1例,骨折平均愈合时间(23.04±1.62)周,肩关节Constant评分平均(77.71±5.84)分,肘关节Mayo评分(91.33±1.73)分;锁定钢板系统组平均手术时间(62.64±4.71)min,桡神经损伤2例,骨折平均愈合时间(27.88±1.57)周,肩关节Constant评分(86.14±2.27)分,肘关节Mayo评分(92.44±2.29)分。治愈率均为100%。旋入式髓内钉组在手术时间、骨折愈合时间上短于锁定钢板组(P0.01),但Con-stant肩关节评分较低(P0.01),其他指标无统计学差异(P0.05)。结论旋入式自锁髓内钉手术操作简单、时间短、损伤小、术中并发症少、骨折愈合快,适合稳定性骨折、非缺损性粉碎性骨折,但抗旋转及抗短缩方面不及锁定钢板系统,对非稳定性骨折、断端缺损性粉碎性骨折宜选择锁定钢板系统。     

Radial nerve transposition with humeral fracture fixation: preliminary results

Humeral shaft fractures traditionally have been managed with closed treatment. In patients with polytrauma, open fractures, and patients at risk for nonunion, open reduction and internal fixation and intramedullary nailing have been advocated. The current study describes a technique used in humeral shaft fractures that reduces the risk of iatrogenic radial nerve injury during plate osteosynthesis in fracture patterns at high risk of nonunion (highly comminuted, transverse fractures). Ten patients who had radial nerve transposition were reviewed retrospectively using the electronic records database at the authors' institution. The average age of the patients was 27 years and average followup was 25 months. All had humeral shaft fractures, AO class A3.2 in four patients, B3.2 in five patients, and C2.2 in one patient. All fractures were deemed to be at high risk for nonunion. There were no iatrogenic nerve palsies as a result of the transposition, and no infections. Two patients had delayed or nonunion, who achieved healing after a second intervention. Transposition of the radial nerve is a useful adjunct to plating of humeral shaft fractures in patients at high risk for nonunion. The technique is safe, does not cause iatrogenic injury, and protects the radial nerve during all subsequent approaches to the fracture site.     

Comparison of compression plate and flexible intramedullary nail fixation in pediatric femoral shaft fractures

The purpose of this study was to compare the results of compression plating and flexible intramedullary nailing for pediatric femoral shaft fractures. Thirty-eight consecutive patients with 40 femoral shaft fractures were evaluated. Twenty-two femoral segments were treated with a compression plate and 18 femoral segments were treated with flexible intramedullary nailing. The time to healing, operation time and complications were evaluated. The average operation time was statistically significantly shorter in the nailing group (P=0.039). Four implant failures occurred in the compression plate group whereas one non-union was observed in the flexible nailing group. Flexible intramedullary nailing seems to provide a high union rate with a shorter operation time when compared with plate fixation.     

Experience with plate osteosynthesis in femoral shaft fractures]

Today, femoral shaft fractures are often treated by open or closed intramedullary nailing because of a lower rate of complications with this method. Therefore, the practice of plating these fractures is now decreasing. We studied the indications for nailing and for plating, as well as the indications when both methods can be used with the same results. At the University Clinic of Surgery in Graz, 107 femoral shaft fractures were plated between 1983-1986. We could find no higher incidence of complications between plating or nailing femoral fractures described by previous authors compared with our own results.     

Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis

BACKGROUND: The choice of plates or intramedullary nails for operatively treated humeral shaft fractures remains controversial, since randomized controlled trials have lacked sufficient power. A meta-analysis of existing trials would improve inferences regarding the treatment effect. METHODS: We reviewed randomized trials in Medline, Cochrane and SciSearch, along with other sources of published randomized trials from 1969-2000. Of 215 citations identified, only 3 studies were included. RESULTS: The 3 studies (involving 155 patients) were pooled, since they were homogeneous (p > 0.1). Plate fixation gave a lower relative risk of reoperation than intramedullary nailing (RR = 0.26, 95% CI 0.007-0.9, p = 0.03). This translated to a risk reduction of 74% for reoperation when plate fixation was employed. Thus, 1 reoperation could be prevented for every 10 patients treated with plates. Plate fixation also reduced the risk of shoulder problems in comparison to intramedullary nails (RR = 0.10, 95% CI 0.03-0.4, p = 0.002). INTERPRETATION: Plate fixation of humeral shaft fractures may reduce the risk of reoperation and shoulder impingement. The cumulative evidence remains inconclusive, and a larger trial is needed in order to confirm these findings.     

Limited contact dynamic compression in diaphyseal fractures of the humerus: good outcome in 51 patients

We reviewed 51 plate fixations for fracture of the humeral diaphysis managed during the last 3 years. The indications for surgery included non-union, delayed union, polytrauma, neurological involvement and inadequate reduction. All the fractures were stabilized with a Limited Contact Dynamic Compression Plate (LCDC Plate). We found that this plate gave adequate rotational and vertical stability to the fracture. 48 fractures healed after median 2.5 months. Early evidence of callus formation indicated minimal compromise with the vascularity of bone which may be attributed to the undercut design of the plate, causing relatively less cortical ischemia. In addition, the plate fixation was associated with fewer complications, as compared to those reported with intramedullary nailing.     

Limited contact dynamic compression in diaphyseal fractures of the humerus: Good outcome in 51 patients

We reviewed 51 plate fixations for fracture of the humeral diaphysis managed during the last 3 years. The indications for surgery included non-union, delayed union, polytrauma, neurological involvement and inadequate reduction. All the fractures were stabilized with a Limited Contact Dynamic Compression Plate (LCDC Plate). We found that this plate gave adequate rotational and vertical stability to the fracture. 48 fractures healed after median 2.5 months. Early evidence of callus formation indicated minimal compromise with the vascularity of bone which may be attributed to the undercut design of the plate, causing relatively less cortical ischemia. In addition, the plate fixation was associated with fewer complications, as compared to those reported with intramedullary nailing.     

Limited contact dynamic compression in diaphyseal fractures of the humerus: Good outcome in 51 patients

We reviewed 51 plate fixations for fracture of the humeral diaphysis managed during the last 3 years. The indications for surgery included non-union, delayed union, polytrauma, neurological involvement and inadequate reduction. All the fractures were stabilized with a Limited Contact Dynamic Compression Plate (LCDC Plate). We found that this plate gave adequate rotational and vertical stability to the fracture. 48 fractures healed after median 2.5 months. Early evidence of callus formation indicated minimal compromise with the vascularity of bone which may be attributed to the undercut design of the plate, causing relatively less cortical ischemia. In addition, the plate fixation was associated with fewer complications, as compared to those reported with intramedullary nailing.     

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

Abstract There is an increasing interest in intramedullary nailing for humeral fractures. Starting with diaphyseal fractures, now also proximal metaphyseal fractures of the humerus can be nailed with satisfying results. Basic ideas for humeral nailing are less invasive approaches to the humerus, less soft tissue damage, e.g. lower rates of radial nerve palsy, closed reduction and the biomechanical aspects of a central implant with elastic fixation properties. Nailing of diaphyseal humeral shaft fractures is an equivalent alternative to plating; nailing of proximal metaphyseal humeral fractures is still new and needs more reliable scientific data to clear its advantages compared to other fixation techniques. Nailing of distal metaphyseal humeral fractures is no serious option at the moment. Angular stable interlocking systems show better fixation qualities for proximal fractures or fracture components. Although in very osteoporotic bone cutouts are registered. Static interlocking is advisable. High torsional stability of the fracture fixation has to be achieved, since significant torsional load occurs during the usual movement of the upper limbs. As there is an important learning curve, possible complications of intramedullary nailing have to be kept in mind and avoided by a careful operation technique.     

Intraoperative interfragmentary radial nerve compression in a medially plated humeral shaft fracture: a case report

Persistent secondary radial nerve palsy following open reduction and plating of humeral shaft fractures is rare, as the nerve is usually identified and protected throughout surgery. However, it is very difficult to identify and protect the radial nerve during medial and posteromedial approaches and closed intramedullary nailing, thus increasing the risk of damaging it. This case of interfragmentary radial nerve compression at the fracture site occurred during posteromedial plating of a laterally displaced and angulated segmental fracture of the middle and distal thirds of the humeral shaft. Exploration and nerve grafting was later required to regain function. It is important that the radial nerve be identified and protected in fixation of humeral shaft fractures with high-risk fracture configurations.