Recent advances in the treatment of gunshot fractures of the humeral shaft

Radial Nerve Palsy in the Setting of Humeral Shaft Fracture

The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

Surgical management of distal humerus gunshot fractures: descriptive case series

PURPOSE

The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa.

METHODS

A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification.

RESULTS

Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months.

CONCLUSIONS

These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management.

LEVEL OF EVIDENCE

IV.

Complications Are Infrequent After Humeral Shaft Fractures Due to Low-Energy Gunshot Injuries

OBJECTIVE

To describe humerus shaft fractures after low-energy gunshot wound (GSW) and compare with blunt injuries. We hypothesized that nerve injury, infection, and fracture union would be similar.

DESIGN

Retrospective.

SETTING

Urban Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred three patients were treated for a humeral shaft fracture over 18 years. Sixty-two patients sustained injury due to GSW.

INTERVENTION

Primary open reduction and internal fixation was pursued in 59%, including 32% after GSW.

MAIN OUTCOME MEASUREMENTS

Rates of nerve injury, infection, and fracture union.

RESULTS

Patients with GSW were younger with a mean age of 30 years, more likely male (90%), with isolated injuries (84%), and less likely to have simple fractures (84%). Both groups experienced high rates of union (98% of GSW fractures vs. 99% of closed high-energy fractures). Deep infection occurred in 1 patient (1.6%) after GSW. Rates of deep infection in the closed and open blunt trauma fracture groups were similarly low at 1% and 4.5%, respectively. Nerve injury on presentation after GSW was more common than after low-energy and high-energy closed fractures (47% vs. 13% and 27%), but similar to blunt open fracture (52%). Despite higher rates of nerve injury, nerve recovery occurred at similarly high rates after both GSW and blunt injuries (78% vs. 86%).

CONCLUSIONS

Nerve injuries are more common after GSW, but most recover without intervention. Infection is uncommon after GSW, and secondary unplanned operations are rare. Initial nonoperative care of most GSW humerus fractures, even with radial nerve injury at the time of presentation, seems appropriate.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treating fractures in upper limb gunshot injuries: The Cape Town experience

BACKGROUND

Upper extremity gunshot fractures are generally treated conservatively or surgically using open reduction and internal fixation (ORIF), intramedullary nails (IM) or external fixators. However, there is no gold standard for the management of these complex, multi-fragmentary upper extremity fractures. The aim was to describe and identify the injury patterns, management, complications and associated risk factors for upper extremity gunshot fractures.

PATIENT AND METHODS

Data of patients with upper extremity gunshot injuries that presented to a Level I Trauma Unit in Cape Town, South Africa was collected prospectively over a ten-month period from June 2014 to April 2015. Clinical notes and radiographs were reviewed retrospectively.

RESULTS

Fifty-one of 90 patients (56.7%) with ballistic injuries had fractures, 30% had neurovascular injuries and 75% had additional injuries to other anatomical structures including head, neck, spine, chest, abdomen, pelvis and urogenital tract. Most fractures were diaphyseal, multi-fragmentary and extra-articular. Fractures were treated conservatively in more than half of the cases. Median fracture length was 5.5 centimetres. A longer fracture zone was statistically associated with surgical treatment. When surgically treated, open reduction and internal fixation was most often performed. Median hospital stay was six days. Infection and injury severity prolonged hospital stay.

DISCUSSION

In contrast to studies from the USA and Europe, most fractures in this study were managed conservatively. High quality prospective controlled trials are required to evaluate radiographic and clinical outcomes of treatment methods for upper extremity gunshot injuries.

LEVEL OF EVIDENCE

IV, case series.

A lifelong story: Case report of a humeral shaft nonunion successfully treated after 30 years

Nonunion of the humeral shaft occurs in 2%-10% of nonsurgically treated fractures and in up to 15% of fractures treated by primary open reduction and internal fixation. Gunshot humerus shaft fractures are a frequent type of injury; the degree of comminution and bone loss, as well as soft tissue disruption may influence the healing process, causing major sequelae with loss of function. Here we describe a 30 years old midshaft nonunion of the humerus, that occurred in a young woman after a gunshot. She was initially treated with hanging cast with definitive nonunion and secondary loss of limb function. After 30 years, careful management of the non union fracture ends, locked intramedullary nailing and bone grafting harvested from the femoral canal using the Reamer Irrigator Aspirator (RIA) system led to union with recovery of limb function.

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.

TREATMENT OF POST-TRAUMATIC HUMERAL FRACTURES AND COMPLICATIONS USING THE OSTEOLINE(®) EXTERNAL FIXATOR: A TREATMENT OPTION

To evaluate the results obtained from treatment of humeral shaft fractures and their complications using the Osteoline^® uniplanar external fixator. Methods: The radiographic and functional results from 78 patients with humeral shaft fractures treated using the uniplanar external fixation technique were retrospectively assessed. The patients' ages ranged from 23 to 71 years, with a mean of 47 years. Male patients predominated (79%). Out of the 78 patients, 45 presented open fractures, 14 presented pseudarthrosis and six presented synthesis failure. There were no losses during the follow-up and all the patients were discharged after fracture consolidation and functional recovery. The results were evaluated based on the studies by Catagni, as good, fair or poor. Results: Fracture consolidation was observed in 98% of the cases treated with uniplanar external fixation. Only one pseudarthrosis case required conversion to rigid internal fixation and autologous bone grafting. At the end of the treatment, all the patients were discharged with consolidated fractures, without pain, and good limb function. Conclusion: The external fixation described in this paper was shown to be an efficient and safe method for treating humeral shaft fractures and their complications. It preserved the local biological status and enabled passive and active movement immediately after surgery.

The role of débridement in low-velocity civilian gunshot injuries resulting in pelvis fractures: a retrospective review of acute infection and inpatient mortality

OBJECTIVES

To determine the use of surgical débridement in the management of low-velocity gunshot injuries (GSIs) resulting in pelvis fractures.

DESIGN

: Retrospective chart review.

SETTING

Level I trauma center in a major metropolitan area.

PATIENTS

Fifty-six patients from 1991 to 2007 treated for pelvis GSIs with resulting pelvis fractures with six acute mortalities and 40 patients with at least 1-year follow-up.

INTERVENTION

Patient data were reviewed for incidence of infection related to pelvis GSIs. Information regarding surgical débridement of pelvis GSI wounds, retained foreign bodies, and/or concomitant gastrointestinal (GI) injury was analyzed for relationships of such events to infection rate.

MAIN OUTCOME MEASUREMENTS

Incidence of infection related to pelvis GSIs at least 1 year after GSI date.

RESULTS

Three patients (6%) developed a deep infection related to their pelvis GSIs. There were no cases of osteomyelitis. The rate of concomitant GI injuries was 36% and the overall infection rate among those with GI injuries was 12% versus 3% for those without a GI injury (P = 0.34). There were infection rates of 7% and 6% among patients who underwent surgical débridement and those who did not, respectively. Of those with GI injuries, 41% underwent primary surgical débridement and none developed infection. In the group of remaining patients with GI injuries who did not undergo débridement of their GSI wounds, two (20%) developed an infection. The mortality rate of low-energy GSIs to the pelvis was six of 53 (11%).

CONCLUSION

There was no increased incidence of infection in the absence of aggressive surgical débridement of pelvis GSI wounds. The study also demonstrated that retained bullets and bullet fragments did not increase the risk of infection, even after penetrating the GI tract organs. Finally, this study suggests there may be an increased risk of infection related to pelvis GSIs compared with reported infection rates related to GSIs of the extremities, likely secondary to a high rate of concomitant GI injuries associated with pelvis GSIs; however, there was no incidence of osteomyelitis.

UPPER LIMB TRACTION DEVICE FOR ANTEROGRADE INTRAMEDULLARY LOCKED NAIL OF HUMERAL SHAFT FRACTURES

Diaphyseal fractures of the femur and tibia in adults are mostly treated surgically, usually by means of intramedullary locked-nail osteosynthesis. Some comminuted and/or highly deviated shaft fractures may present a veritable technical challenge. Fracture (or orthopedic) tables, which enable vertical, horizontal and rotational instrumental stabilization of the limb, greatly facilitate reduction and implant placement maneuvers and are widely used by orthopedic surgeons. Humeral shaft fractures are mostly treated nonsurgically. However, some cases with indications that are well defined in the literature require surgical treatment. They can be fixed by means of plates or intramedullary nails, using anterograde or retrograde routes. In the humerus, fracture reduction and limb stabilization maneuvers for implantation of intramedullary nails are done manually, usually by two assistants. Because muscle fatigue may occur, this option may be less efficient. The aim of this paper is to present an external upper-limb traction device for use in anterograde intramedullary locked-nail osteosynthesis of humeral shaft fractures that enables vertical, horizontal and rotational stabilization of the upper limb, in a manner similar to the device used for the lower limbs. The device is portable, of simple construction, and can be installed on any operating table equipped with side rails. It was used for surgical treatment of 29 humeral shaft fractures using an anterograde locked intramedullary nail. Our experience was extremely positive. We did not have any complications relating to its use and we believe that it notably facilitated the surgical procedures.

Prevention and management of infections associated with combat-related extremity injuries

Orthopedic injuries suffered by casualties during combat constitute approximately 65% of the total percentage of injuries and are evenly distributed between upper and lower extremities. The high-energy explosive injuries, environmental contamination, varying evacuation procedures, and progressive levels of medical care make managing combat-related injuries challenging. The goals of orthopedic injury management are to prevent infection, promote fracture healing, and restore function. It appears that 2% to 15% of combat-related extremity injuries develop osteomyelitis, although lower extremity injuries are at higher risk of infections than upper extremity. Management strategies of combat-related injuries primarily focus on early surgical debridement and stabilization, antibiotic administration, and delayed primary closure. Herein, we provide evidence-based recommendations from military and civilian data to the management of combat-related injuries of the extremity. Areas of emphasis include the utility of bacterial cultures, antimicrobial therapy, irrigation fluids and techniques, timing of surgical care, fixation, antibiotic impregnated beads, wound closure, and wound coverage with negative pressure wound therapy. Most of the recommendations are not supported by randomized controlled trials or adequate cohorts studies in a military population and further efforts are needed to answer best treatment strategies.