AO非扩髓肱骨髓内钉治疗肱骨干骨折

目的：总结运用AO非扩髓肱骨髓内钉(UHN)治疗肱骨干骨折的临床效果。方法：从1999年2月-2002年5月，本科运用髓内固定技术共治疗了46例肱骨干骨折的病人，其中男21例，女25例。平均年龄42岁。根据肩肘关节的活动范围对术后肩肘关节的功能进行评价。结果：肩肘关节功能优秀30例(占65％)，良好13例(占28％)，差3例(占7％)。手术时间平均为60min。术后没有继发性桡神经瘫，无伤口感染。3例患者术后出现肩蜂下撞击综合征，2例患者出现肘关节的疼痛。结论：非扩髓肱骨髓内钉对于肱骨干骨折是一种固定可靠，并发症少，骨愈合率高，功能恢复良好的手术方法。     

Humeral nailing revisited

Unreamed interlocked humeral nailing for stabilisation of acute humeral fractures was introduced a decade ago. Antegrade and retrograde nail insertion are equally popular. The role of nailing as opposed to plating of humeral fractures is the subject of continuous debate. Between 1997 and 2005, 99 acute fractures of the humeral shaft were treated operatively with the unreamed humeral nail (UHN, Synthes) in our Level I Trauma Centre. The mean age of the patients was 63 years. Only eight patients (8.1%) were polytraumatised, nine patients had an open fracture (9.1%), five had a primary radial nerve palsy (5.1%). There were 54 antegrade and 45 retrograde nailings. The procedures were performed by 19 different surgeons, who carefully followed a detailed operation protocol. There were 6 adverse events: 3 secondary radial nerve palsies (3%), 2 fissures at the insertion point (2%) and one false placement of a locking screw (1%). Three patients developed pseudarthrosis (3%). Eight further operation were necessary (8.1%): 3 exploration of the radial nerve, 3 for treatment of pseudarthrosis, one replacement of a locking screw and one wound revision for superficial wound infection. Ninety patients (92 fractures) were evaluated after bone healing. Shoulder function was assessed using the Constant Score, elbow function with the Mayo Elbow Score. 91.3% and 5.4% of patients had an excellent or good shoulder function, 81.5% and 14.1% had an excellent or good elbow function. All patients with a functional deficit of the shoulder joint had antegrade, all patients with a deficit at the elbow joint retrograde nailing. Motor function recovered in all radial nerve palsies. 93.5% of patients had an excellent or good functional end result.Unreamed humeral nailing is a valid therapeutic option for stabilisation of acute humeral shaft fractures. Antegrade and retrograde nailing are associated with specific but different complications. By strictly adhering to the operation technique, the number and severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional outcome is the rule.     

Closed retrograde multiple intramedullary Kirschner wires fixation for humeral shaft fractures with the limb flexed over an articulated support

Objective

To evaluate the results of multiple closed intramedullary Kirschner wiring via a supracondylar entry point for humeral shaft fractures.

Patients and methods

The charts of 37 patients with humeral shaft fractures treated with the Hackethal''s technique between January 2007 and December 2011 were reviewed retrospectively. The operation was performed with the patient lying in supine (n = 22) or lateral (n = 15) position. The elbow was flexed over an articulated support with the arm kept in a vertical position. Thirty-three patients were available for final evaluation with a mean follow-up delay of 14 (range, 6–24) months. We were concerned about fracture union, range of motion of the shoulder and the elbow, and complications. Final evaluation used the criteria by Qidwai.

Results

Bone union rate was 94%. Restriction of ranges of motion of the shoulder more than 20° was noticed in two patients due to protruding wires. Three patients developed limitation of elbow extension owing to backing out of the wires. The overall results were excellent (n = 26; 79%), good (n = 4; 12%), and poor (n = 3; 9%).

Conclusion

Closed Hackethal''s technique using K-wires gives satisfactory results in terms of bone union and elbow and shoulder function in selected humeral shaft fractures. The articulated support precludes the transolecranon traction.     

带锁髓内钉与锁定加压钢板内固定治疗肱骨干骨折的随机对比研究

目的前瞻性对比研究带锁髓内钉和带锁加压钢板(LCP)治疗肱骨干骨折的临床效果。方法随机将49例分成两组(髓内钉28例;LCP组21例)。患者全部为新鲜肱骨干骨折,骨折部位距肱骨外科颈至少3cm,距尺骨鹰嘴大于5cm。临床疗效评价包括手术时间、出血量、骨折愈合情况、桡神经恢复、感染和肘关节、肩关节不适症状,影像学评价包括骨折力线、愈合时间、延长愈合和不愈合的发生率。结果平均随访1.5年。LCP组19例(90.5)骨折在16周后愈合,髓内钉组24例(85.7)在16周后愈合(P=0.70)。肩关节疼痛和肩关节活动受限在髓内钉组发生明显(P<0.05),而LCP组未发现这种情况。LCP组肘关节的活动范围明显减少(P<0.05),尤其是肱骨干远端1/3骨折患者。两组总并发症发生率比较无明显差异。结论对于需要手术治疗的肱骨干骨折,髓内钉和LCP都能使骨折稳定以达到最终愈合。     

Treatment of Pathological Humeral Shaft Fractures with Unreamed Humeral Nail

Purpose The purpose of this study is to analyze the results of intramedullary fixation of pathological humeral shaft fractures using an unreamed humeral nail (UHN). Patients & Methods Twenty-one consecutive patients with 24 humeri fractured secondary to metastatic disease were retrospectively reviewed. The primary tumors included carcinomas of breast (11), kidney (2), multiple myeloma (2), colon (2), prostate (1), thyroid (1), lymphoma (1) and unknown origin (1). All fractures were stabilized with antegrade unreamed humeral nailing. Cemented technique was performed in 5 procedures. The mean age was 64 (range, 40–86), male to female ratio 6:15. Results Blood loss was unremarkable in 19 patients (22 procedures). Two patients who underwent fixation of additional pathological fractures during the same operation were given a total of 3 units of PC perioperatively. Mean postoperative hospitalization period due to one UHN procedure alone was 3 days (range, 2–7 days). Two patients died of their disease within 3 weeks of surgery. The remaining 19 patients returned to nearly normal function within 6 weeks after nailing. One patient developed postoperative local wound cellulitis. Relief of pain was rated as good in all but one patient. Adjuvant therapy was given in 20 procedures. Bony union was achieved in 88% (15/17) of all the cases where the patient had survived a minimum of 3 months. Conclusion Unreamed humeral nailing of the pathological humeral shaft fractures provides immediate stability and pain relief, minimum morbidity and early return of function to the extremity.     

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.     

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.     

髓内钉与干骺端锁定加压钢板治疗肱骨投弹骨折的疗效比较

背景：投弹骨折是部队新训期间常见的训练伤之一,手术治疗可以达到早期功能锻炼的目的,本文对应用髓内钉和锁定加压钢板的疗效进行了比较。 目的：比较闭合复位、AO非扩髓肱骨髓内钉系统（UHN）经皮置钉固定与切开复位干骺端锁定加压钢板（LCP）内固定治疗肱骨投弹骨折的临床疗效。 方法：2007年1月至2010年12月,对32例肱骨干中下段投弹骨折的患者随机分为两组,UHN组（15例）均采用闭合复位、顺行经皮带锁髓内钉内固定技术、LCP组（17例）均采用后路切开复位、干骺端锁定加压钢板内固定技术治疗。通过手术时间、失血量、骨折平均愈合时间、切口并发症、周围神经损伤和肩肘关节Rodriguez-Merchan评分评定疗效。 结果：所有患者均获得随访,时间12-47（31±12．5）个月。UHN组与LCP组在手术时间、出血量、骨折平均愈合时间及切口并发症等方面差异有统计学意义（P〈0．05）,在周围神经损伤、肩肘关节功能评分方面无明显统计学差异。结论：UHN与干骺端LCP治疗肱骨投弹骨折均可获得满意疗效。髓内钉具有创伤小、切口并发症少的优势,但平均愈合时问及手术时间相对较长。     

Minimally invasive plating for complex humeral shaft fractures

INTRODUCTION: The treatment for humeral shaft fracture is still controversial, especially for complex fractures. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating complex humeral shaft fractures by using locking compression plate with minimally invasive technique. MATERIALS AND METHODS: A total of 21 patients with 21 acute complex humeral shaft fractures (AO type C) were included in this study. All were treated with locking compression plate in a minimally invasive way. The average age of the patients was 42.9 years and there were 14 males and 7 females. Plain radiographs of humerus were used to assess bony union. Functional recovery of the shoulder joint was assessed using the Constant and HSS scoring systems. RESULTS: The patients were followed for a mean of 28.7 months (range 19-37). With one operation, nineteen fractures (90.4%) achieved a solid union in an average of 14.3 weeks. At final follow-up, 20 patients (95.2%) had satisfactory alignment, except for one associated with olecranon fracture, all patients had a good to excellent elbow function with a mean HSS score of 91.7 points. Eighteen patients (85.7%) achieved satisfactory shoulder function with a mean Constant score of 83.1 points. One superficial infection (4.8%) and two non-unions (9.6%) were found postoperatively. CONCLUSIONS: It was concluded that use of a minimally invasive plate osteosynthesis with locking compression plate is a safe alternative way to classic surgical methods in the treatment of complex humeral shaft fractures, which had a high union rate with less risk of complications.     

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.     

肱骨干骨折不愈合原因分析与治疗方法的探讨

目的：分析肱骨干骨折不愈合原因,探讨治疗方法。方法：随诊病例23例,了解初次治疗及本次术后1年以上情况。结果：除解剖因素外,均有治疗不当因素。如治疗方式失误,内固定材料欠,外固定与功能练习不正确等。经切开腹位,交锁髓内钉内固定,髂骨取骨植骨治疗这种陈旧骨折,骨折全部愈合,肩关节功能优良率68．3％,肘关节功能优良率72．7％,结论：Russell-Taylor(R-T)肱骨髓内钉用于肱骨干骨折不愈合或延迟愈合效果良好,关节功能恢复与初次治疗成功与否有关。     

Association of hyperglycemia with increased mortality after severe burn injury

OBJECTIVE: To assess results of exchange nailing in nonunion after intramedullary (IM) nailing of humeral shaft fractures. METHODS: This was a retrospective study; 24 patients with nonunion after IM nailing of humeral shaft fractures were reviewed. In 13 cases, nonunion was treated using exchange nailing, and 11 patients were treated nonoperatively. Union was assessed from radiographs. Shoulder joint symptoms and function were assessed after a mean 4.7 years' follow-up using Constant-Murley scoring and self-administered questionnaires devised by L'Insalata et al. RESULTS: Single or repeated exchange nailing resulted in union in 6 of 13 patients. Shoulder joint function was satisfactory (mean Constant-Murley score of 72) for those patients whose fracture eventually united and poor (mean Constant-Murley score of 39) for those left with nonunion. CONCLUSION: Exchange nailing results in a poor union rate in nonunion after IM nailing of humeral shaft fractures. Permanent nonunion of the humeral shaft leaves the patient with severe disability.     

Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation.

Introduction Antegrade intramedullary (IM) nailing of humeral shaft fractures is reported to cause shoulder joint impairment. This retrospective study compared shoulder joint symptoms, range of motion (ROM), and isometric strength after antegrade IM nailing and dynamic compression (DC) plating of humeral shaft fractures.Materials and methods We compared 29 patients with DC plating and 44 with antegrade IM nailing of their humeral shaft fractures. Shoulder pain, LInsalata and Constant scores, shoulder joint ROM and isometric shoulder strengths were measured after mean follow-up of 6.2 (1–15) years (DC plating) and 5.5 (2–10) years (IM nailing).Results Patients had nonsignificantly more shoulder pain after IM nailing than after DC plating. Shoulder scores and isometric strength measurements showed no difference between the groups. Flexion was significantly better after DC plating, but none of the other ROM parameters differed between the groups. The shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups.Conclusions Shoulder joint ROM and strength does not recover to normal after humeral shaft fracture. Antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.     

Dual Locking Plate Osteosynthesis for 3- or 4-Part Proximal Humeral Fractures Combined with Multiple Fractures of the Greater Tuberosity

BackgroundThis retrospective study was conducted to evaluate the efficacy of dual locking plate osteosynthesis for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.MethodsFrom January 2012 to December 2018, 19 skeletally mature patients, who suffered 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity, were treated with open reduction and internal fixation using a dual locking plate technique through a delto-pectoral approach. Indexes for evaluation included fracture healing, quality of reduction, and incidence of complications (infections, screw perforation into the glenohumeral joint, subacromial impingement, hardware failure, avascular necrosis, and loss of reduction). Shoulder function was evaluated using Constant–Murley scoring.ResultsThe patients were assessed at a mean time of 25.3 months after surgery. Union of fractures was radiographically confirmed for all 19 patients. The mean Constant–Murley patient score was 85.2 points, and complications were identified in two patients during follow-up evaluations.ConclusionsThe method of using dual locking plate osteosynthesis through a delto-pectoral approach resulted in a satisfactory union rate, excellent fracture reduction, low complication rate and good shoulder function for patients with complex proximal humeral fractures. The method is effective for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.     

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.     

交锁髓内钉手术治疗肱骨干骨折

目的介绍采用交锁髓内钉手术治疗肱骨干骨折。方法自1999年1月～2003年1月采用交锁髓内钉(远端不交锁)治疗肱骨干骨折36例。男28例，女8例；年龄19～59岁，平均38岁。AO分型，A型24例，B型11例，C型1例，均采用闭合复位、顺行插钉技术，远端不交锁，术后第2天肩肘带保护下开始功能锻炼，不采用其它外固定。结果随访26例，随访时间3～38个月，平均20个月，所有病例伤口Ⅰ／甲愈合，骨折无延迟愈合及不愈合。平均愈合时间9周，术后肩肘关节功能恢复良好。结论交锁髓内钉是治疗肱骨干骨折较好方法，远端可不交锁。     

Treatment of humeral shaft nonunions: nailing versus plating

Introduction The aim of this study was to compare plating and nailing for treating nonunions of the upper two-thirds of the humerus.Materials and methods Fifty nonunions of the upper two-thirds of the humerus were treated by two different methods: 24 of them by unreamed locked nailing and bone graft (group A), and the other 26 by plate fixation and bone grafting (group B).Results All fractures healed in both groups. In group A, the time required for healing was 4.2 months (range 4–6 months), whereas in group B it was 4.7 months (range 4–6 months). This difference was statistically significant (p<0.05). Functional results and the range of motion of the shoulder and elbow were similar with both techniques. In group B there were 3 cases of transient, iatrogenic, radial nerve palsy.Conclusions We feel that both plate fixation and the unreamed humeral locked nail are good alternatives for the treatment of humeral shaft nonunions, although nailing achieves union earlier and has fewer complications.     

Are Outcomes Comparable for Repair of AO/OTA Type 13C1 and Type 13C2 Distal Humeral Fractures Using the Paratricipital Approach?

BackgroundStudies have reported favorable outcomes using the paratricipital approach for fixation of distal humeral intra-articular fractures. However, literature evaluating the clinical results of the approach remains limited. The objective of this study was to compare clinical outcomes between type 13C2 and type 13C1 distal humeral fractures after open reduction and internal fixation performed using the same approach and same type of plate.MethodsA total of 52 adults with type 13C1 or 13C2 distal humeral fractures were treated surgically at our institution during 2006 to 2018. We retrospectively analyzed data from 29 of these patients (19 with type 13C1 fractures and 10 with 13C2 fractures) who met the inclusion criteria. All subjects were followed for a minimum of 2 years postoperatively. Clinical and radiologic results were analyzed to determine differences in outcomes between the two types of fractures. Clinical results were evaluated using elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. Alignment, fracture union, and presence of posttraumatic arthritis were evaluated radiologically.ResultsThe patients’ mean age was 51 years, and the mean duration of follow-up was 29 months. Mean ROM was 129.5° ± 21.5° in the type 13C1 group and 123.0° ± 20.6° in the 13C2 group (p = 0.20). Mean Q-DASH score was 12.6 ± 11.7 in the 13C1 group and 16.2 ± 19.8 in the 13C2 group (p = 0.60). Mean MEPS was 92.9 ± 8.5 in the 13C1 group and 85.0 ± 14.1 in the 13C2 group (p = 0.09). Carrying angle did not differ significantly between the 13C1 and 13C2 groups. No patient in either group exhibited nonunion or posttraumatic arthritis.ConclusionsAlthough the paratricipital approach has the disadvantage of limited visualization of articular surfaces, there were no differences in surgical outcomes between type 13C1 and type 13C2 distal humeral fractures after fixation using this approach. Thus, surgeons may need to consider using the paratricipital approach for open reduction and internal fixation of 13C2 distal humeral fractures.     

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.     

Treatment of humeral shaft fractures with antegrade intramedullary locking nail

Antegrade interlocked humeral nailing for stabilization of humeral fractures was introduced many years ago, and studies on this method in the orthopedic literature have shown mixed results. The purpose of this investigation was to document the clinical outcome and complications associated with the use of an antegrade intramedullary nail (T2, Stryker) for the humeral fractures. Between 2005 and 2008, 52 fractures of the humeral shaft were treated operatively with this intramedullary nail in our department. Eight patients were polytraumatized, and four patients had an open fracture. The mean age of patients was 51.7 years. Forty-eight patients had an adequate duration of clinical follow-up (a mean of 18 months) for analysis. Complications were recorded, and the time to union was measured. Shoulder and elbow functions were assessed using the Constant Score and the Morrey Score, respectively. Forty-six fractures healed, with a mean time to clinical union of 10.3 weeks. Two patients developed pseudarthroses. There were four adverse events: two proximal screws backed out, one superficial infection at the insertion point, and one fracture at the distal end of the nail. Ninety-one percentage of patients had an excellent or good shoulder function. Five further operations were necessary: two for treatment of pseudarthroses, two for removal the backed out proximal screws, and one wound debridement for superficial infection. Antegrade humeral nailing is a valid therapeutic option for stabilization of humeral shaft fractures. By strictly adhering to the operation technique, the number and the severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional results is the rule.