Intramedullary nailing of humeral shaft fractures with a locking flexible nail

Radiologic anatomic study of the humeral medullary canal

Hypothesis/Background

Patient-specific implants have become an increasingly researched area to improve surgical outcomes. Patient-specific implants have been suggested to provide advantages for better implant alignment and thus improve surgical outcomes. One such area for application is in the use of intramedullary nails for humeral fracture stabilization. However, the anatomy of the canal is not well defined, especially in a larger scale demographic study.

Methods

In this observational cross-sectional study, axial computed tomography scans of 150 humeri were used to measure the cortical thickness and canal width in both coronal and sagittal orientations. Measurements were made at 7 evenly spaced levels along the humerus from the surgical neck to the point immediately superior to the supracondylar ridge. X-rays were used to measure the valgus, recurvatum, and procurvatum angles, along with their associated locations. Demographic data recorded included age, gender, body mass index (BMI), race, and ethnicity.

Results

The mean coronal canal widths decreased inferiorly from the surgical neck to midshaft before increasing to the supracondylar fossa. Mean sagittal widths decreased along the complete course of the canal. The ratio of coronal to sagittal canal widths decreased from 1.09 at level 1 to 0.83 at level 5 before increasing to 1.30 at level 7. Females had significantly smaller canal widths and cortex thicknesses in both the sagittal and coronal planes throughout the course of the canal. There were no significant differences in canal widths among ethnicities. Age was positively correlated with the canal width in the coronal and sagittal orientations but was negatively correlated with cortical thickness in all 7 levels. BMI was not significantly correlated with canal width.

Conclusion/Discussion

The data included in this study may be used to determine standard widths and measurements of the humerus. However, there are notable patterns or differences in the shape of the medullary canal of the humerus between subgroups. This study is the first to conduct a larger scale demographic investigation comparing the humeral canal characteristics among sex, ethnicity, age, and BMI. These data may serve as a platform to further investigate the course of the medullary canal.

Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term

Purpose

Although proximal and diaphyseal humerus fractures are frequent, the optimal management remains controversial. Antegrade nailing prevents further damage to the soft tissues and to the vascularization, but it has been associated with postoperative shoulder pain and dysfunction. During the latest years a straight nail design was developed to minimize these problems.

Methods

A total of 243 patients who had undergone surgery for antegrade intramedullary humeral nailing between January 2013 and July 2018 in A. Gemelli Trauma Center were divided into two groups according to the nail design used: straight nail group (S-group) and curvilinear nail group (C-group). Clinical data were collected using assessment forms (SF12-v2, Quick-DASH, ASES and Constant-Murley). Radiographic bone healing was assessed with RUST score at 30, 90 and 180 days after surgery.

Results

The S-group was made up of 128 patients with a mean age of 59 ± 19 (range 18–97) and a mean follow-up of 46 ± 9 months. The C-group was made up of 115 patients with a mean age of 53 ± 16 (range 18–88) and a mean follow-up of 51 ± 8 months. The S-group had a mental component summary (MCS) score of 54.3 ± 7.7 and a physical component summary (PCS) score of 46 ± 10.2, the C-group had a MCS score of 50.9 ± 8.4 and a PCS score of 44.1 ± 7.4. Quick-DASH and ASES were respectively 18.8 ± 4.3 and 78.6 ± 8.2 in the S-group, 28.3 ± 11.6 and 72.1 ± 13.5 in the C-group with statistical significance. Constant-Murley score was 73.9 ± 9.1 in the S-group (76% of the contralateral healthy side) and 69.4 ± 10.4 in the C-group (73% of the contralateral healthy side). The radiographic union score in the S-group was 4.1 ± 0.3 at 30 days after surgery, 7 ± 0.8 at 90 days and 10 ± 1.2 at 180 days, while in the C-group it was 4.2 ± 0.4 at 30 days, 6.4 ± 0.7 at 90 days and 9 ± 0.9 at 180 days.

Conclusion

Newer generation straight nails allow a faster bone healing and better functional outcome at mid-term follow up.

Level of evidence III.

Atypical use of pediatric flexible nails in the treatment of diaphyseal fractures in adults

Background and aim of the work:

Elastic intramedullary nails are commonly used for the treatment of diaphyseal fractures in adolescents and children. The major advantages are the minimally invasive nature of the technique, the short operation time, and the preservation of the growth plate and periosteum thus allowing bone healing within a closed and intact biological environment. Elastic nails are rarely applied to the adult fractures.

Methods:

Five selected adult patients affected by diaphyseal fractures were treated using paediatric flexible nails T2 Kids (Stryker®, Mahwah, NJ, USA) as consequence of their poor clinical conditions, high risk of neurovascular injuries and skin/soft tissues problems. All patients were monthly clinically and radiographically evaluated after surgery until fracture healing.

Results:

Radiological and clinical outcomes were satisfying. All fractures healed after a mean period of 3 months. No losses of reduction as well as mobilization/breakage of implant were observed. Conclusions: Use of pediatric elastic nails is a valid surgical option in treatment of diaphyseal fractures in selected adult patients who request fast and minimally invasive surgery as consequence of precarious clinical or soft tissues conditions. (www.actabiomedica.it)

Segmented interlocking nail: An in vivo evaluation of a novel humeral osteotomy fixation device in a caprine model

Objectives: To describe a novel humeral fixation device, the insertion technique, healing of humeral osteotomies, and clinical outcomes in a caprine model over a six month period.

Methods: Fourteen mature female Boer/Nubian cross goats with a mean body weight of 50.7 kg were implanted with a proprietary segmented interlocking nail (SILN) in both humeri. Each goat had one humerus randomly selected for mid-diaphyseal osteotomy.

Results: Immediately after surgery all but one goat was able to stand, although none of the goats were weight bearing on the osteotomy limb. During the six month study, clinical lameness was always associated with the osteotomy limb. One month after surgery, lameness for twelve of the goats was grade 2/5 or better. At three months, 11 of the 14 did not exhibit any signs of lameness. On radio-graphic images, notable malalignment of the osteotomy was observed, although all osteotomies went to bone union.

Clinical significance: The results of this study suggest that despite misalignment, the SILN maintained adequate osteotomy fixation to achieve bone union in the research model studied, with reduced morbidity and early return to function with bilateral implantation. The SILN used in this study allowed intramedullary fixation of humeral diaphyseal osteotomies with a limited and safe surgical approach.

Humeral shaft fractures: national trends in management

Background

The incidence of humeral shaft fractures has been increasing over time. This represents a growing public health concern in a climate of cost containment. The purpose of this study is to analyze national trends in surgical management of humeral shaft fractures and determine factors predictive of surgical intervention.

Materials and methods

Humeral shaft fractures were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 812.21 and 812.31 in the United States Nationwide Inpatient Sample from 2002 to 2011. Open reduction and internal fixation (ORIF) was identified by code 79.31 (ORIF, humerus). Other case codes analyzed were 79.01 (closed reduction without internal fixation), 79.11 (closed reduction with internal fixation), and 79.21 (open reduction without internal fixation). Multivariate regression analysis was utilized to determine predictive factors for utilization of ORIF.

Results

27,908 humeral shaft fractures were identified. Utilization of ORIF increased from 47.2% of humeral shaft fractures in 2002 to 60.3% in 2011. Demographically, patients who underwent ORIF were younger (51.5 versus 59.7 years, p < 0.001; odds ratio 0.87 per decade of age). There were modest increases in ORIF usage with private insurance, open fracture, and hospital size, which persisted with multivariate regression analysis. Surprisingly, there was a tendency to shift from a slight increase in ORIF for males with the bivariate case to a slight preference for females in the multivariate case.

Conclusion

Utilization of ORIF for humeral shaft fractures has been steadily increasing with time. Surgical intervention was more common with younger patients, female gender, private insurance, and larger hospital size. The increasing incidence of surgical management for humeral shaft fractures may represent a public health burden given the historical success of non-operative management.

Level of evidence

IV.

Clinical Outcome of Treatment of Diaphyseal Fractures of Humerus Treated by Titanium Elastic Nails in Adult Age Group

INTRODUCTION

Humerus shaft fracture is one of the most common injuries to the musculoskeletal system, which are managed both conservatively and surgically. There are pitfalls, advantages and disadvantages in each method. The individual fracture analysis determines the therapeutic options.

AIM

To assess the clinical outcome of treatment of diaphyseal fractures of humerus treated by Titanium elastic nail in adult age group by DASH scoring.

MATERIALS AND METHODS

It was a prospective study of 20 cases of diaphyseal fracture of humerus admitted to Era's Lucknow Medical College and Hospital between October 2014 and September 2015 treated with close reduction and internal fixation with titanium elastic nail. Functional outcome was evaluated using DASH scoring system and radiological outcome was evaluated by serial radiographs. The data was processed with SPSS software version 16.0 (Chicago, inc. USA) and it was summarized in proportion and percentage.

RESULTS

In our series of 20 patients, 17 were males and three were females. Most of the patients were between 30-50 years of age (mean 38 years). Most common mode of injury, side of involvement, level of fracture and fracture type were road traffic accidents (60%), right side (53.3%) and mid one third (75%), transverse (60%) respectively. So, in 65% of the patients, there was no disability of arm shoulder and hand as DASH score was within normal range and in 15% of the patients the disability was mild to moderate as scoring was slightly higher than normal and in 20% the disability was severe as the DASH score could not be calculated because of non union.

CONCLUSION

Elastic nail fixation require very minimal soft tissue dissection and being a close reduction, the biology of the fracture is also not disturbed and the chances of nerve injury are much less and as the non union was seen in oblique and spiral fracture type hence it should be used with caution or else other alternative methods of fixation should be used.

Case-Match Controlled Comparison of Minimally Invasive Plate Osteosynthesis and Intramedullary Nailing for the Stabilization of Humeral Shaft Fractures

OBJECTIVES

To compare the risk of major complications after either minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing (IMN) of humeral shaft fractures.

DESIGN

Retrospective, case-match controlled study.

SETTING

A major metropolitan tertiary referral trauma center in Australia.

PATIENTS

Thirty patients with fractures of the humeral shaft.

INTERVENTION

Either MIPO or IMN were performed on 15 patients each with traumatic humeral shaft fractures.

PRIMARY OUTCOME MEASURE

The cumulative risk of 3 major complications associated with these procedures: nonunion, infection, and iatrogenic radial nerve injury.

RESULTS

An overall major complication rate of 53% was observed in the patients treated with IMN; one complication (7%) was identified in those managed with humeral MIPO, a nonunion. Complications after IMN included 4 patients (27%) with nonunion, 3 patients (20%) with iatrogenic radial nerve injuries, and 1 patient (7%) with a wound infection. Statistical analysis revealed a significant between-group difference (P = 0.01) in the cumulative rate of major complications. When each of these complications was considered independently, no statistically significant difference was demonstrated.

CONCLUSIONS

This study suggests that humeral MIPO results in a significantly lower pooled major complication rate than that of IMN, and it should therefore be considered an attractive alternative to IMN in those patients requiring surgical stabilization of a traumatic humeral shaft fracture.

LEVEL OF EVIDENCE

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

Radiographic landmark for humeral head rotation: a new radiographic landmark for humeral fracture fixation

BACKGROUND

There is no definite radiographic landmark in plain radiographs for proximal humeral rotation, which is an important parameter for avoiding rotational malalignment during fracture fixation. Here, we used radiographic images of cadaveric humeri to determine whether the landmark of the crest of lesser tuberosity (CoLT) in plain radiographs could be used to determine humeral rotation.

METHODS

Twenty adult cadaveric humeri were collected and seven consecutive radiographic anteroposterior views (45°, 30°, 15° internal rotation; neutral rotation; and 15°, 30°, 45° external rotation) were obtained for each specimen.

RESULTS

The proportional distance (PD) of the CoLT landmark relative to the humeral head was measured and analysed. The mean PDs of the CoLT landmark were 10.2%, 17.9%, 25.6%, 35.9%, 53.4%, and 62.9% of the diameter of the humeral head, corresponding to 45°, 30°, and 15° external rotation, neutral rotation, and 15° and 30° internal rotation, respectively. We found significant differences in the mean PDs with humeral rotation.

CONCLUSION

The projection of the CoLT in plain radiographs can be used as an important landmark to assess humeral head rotation and will be a useful landmark for rotational control of fracture fixation.

Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective, randomised study

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.

HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study

Background

Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery.

Methods/design

The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective.

Discussion

Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture.

Trial registration

The trial is registered at the Netherlands Trial Register (NTR3617).

New interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: a retrospective study

INTRODUCTION

The treatment goal for diaphyseal forearm fractures in adults is to restore axial and rotational stability. The treatment of these fractures with intrmaedullary locked nailing remains sparse. We therefore evaluated IM nails for treating forearm diaphyseal fractures in adults.

METHODS

We retrospectively reviewed adult patients with isolated unilateral or bilateral fractures of the radius, ulna, or both, who were treated with closed or mini open reduction with a new IM nail between May 2008 and January 2012 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores.

RESULTS

The 43 enrolled patients (mean age, 37 years; 32 men) had 59 forearm fractures: 14 isolated radius fractures, 17 isolated ulna fractures (2 bilateral), and 28 fractures of both the radius and ulna. Mean time to fracture union was 13 weeks (range 10-14 weeks) for ulnar fractures and 12 weeks (range 10-13 weeks) for radial fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Followup ranged from 12 to 44 months. Grace and Eversmann ratings were excellent in 38 patients and good in 5. Mean DASH score was 6.5 points (range 0-13.3).

CONCLUSIONS

Intramedullary nailing of adult forearm diaphyseal fractures appears to be a good alternative to plate osteosynthesis. The advantages are short operative time, minimal invasive techniques, and sufficient stability in all planes that allows early motion without additional fracture support.

Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

Purpose:

Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper.

Materials and Methods:

We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score.

Results:

All fractures, except two, united between the 4^th and 5^th postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients.

Conclusions:

Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures.

Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes

Implant related sepsis is a relatively unusual complication of intra-medullary nail fixation of long bone fractures. Depending on the extent of infection, timing of diagnosis and progress of fracture union, different treatment strategies have been developed. The aim of this review article is to collect and analyze the existing evidence about the incidence and management of infection following IM nailing of long bone fractures and to recommend treatment algorithms that could be valuable in everyday clinical practice. After searching the P u b M e d /Medline databases, 1270 articles were found related to the topic during the last 20 years. The final review included 28 articles that fulfilled the inclusion criteria.

Only a few prospective studies exist to report on the management of infection following IM nailing of long-bone fractures. In general, stage I (early) infections only require antibiotic administration with/without debridement. Stage II (delayed) infections can be successfully treated with debridement, IM reaming, antibiotic nails, and administration of antibiotics. Infected non-unions are best treated with exchange nailing, antibiotic administration and when infection has been eradicated with graft implantation if it is needed. Debridement, exchange nailing and systemic administration of antibiotics is the best indication for stage III (late) infections, while stage III infected non-unions can successfully be treated with nail removal and Ilizarov frame, especially when large bone defects exist.

Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis

BACKGROUND

Regarding the treatment of humeral shaft fractures, the choice of plating or intramedullary nailing remains controversial. Previous randomized controlled trials and meta-analyses failed to draw a unanimous conclusion. To guide clinical decision making, we conducted an updated meta-analysis on the optimal treatment of humeral shaft fractures.

METHODS

We identified eligible studies published from 1969 to July 2011 using the Cochrane Library; Cochrane Bone, Joint and Muscle Trauma Group; MEDLINE; Embase; OVID; and Google Scholar and manually searched the references of relevant studies. Randomized controlled trials that compared nailing and plating in the treatment of humeral shaft fractures were included. After the methodologic assessment, available data were extracted and statistically reviewed. The primary outcomes were nonunion, delayed union, postoperative infection, reoperation, and radial nerve palsy. The secondary outcomes were restriction of shoulder motion, shoulder impingement, iatrogenic fracture comminution, and implant failure.

RESULTS

We included 10 studies comparing plating and nailing in patients with humeral shaft fractures, comprising 439 participants. Plating reduced the risk of shoulder impingement and shoulder restriction in comparison with nailing. Regarding reoperation risk, a secondary sensitivity analysis showed the finding favoring plating over nailing remained unstable. Otherwise, no significant differences were found in postoperative infection, nonunion, delayed union, radial nerve palsy, iatrogenic fracture comminution, and implant failure between groups.

CONCLUSIONS

On the basis of current evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures, but plating may reduce the occurrence of shoulder problems. Randomized controlled trials with larger sample sizes using appropriate blinding methods are needed to confirm these findings.

LEVEL OF EVIDENCE

Level II, Meta-analysis of prospective comparative trials.

Short, locked humeral nailing via Neviaser portal: an anatomic study

OBJECTIVE

Supraspinatus tendon trauma may contribute to residual shoulder pain after nail fixation for proximal humeral fractures. Some have proposed a more medial starting point for humeral nail insertion to avoid cuff tendon footprint damage. We hypothesized that percutaneous nail insertion via Neviaser portal would not only be possible, but would avoid tendon trauma, while sacrificing articular cartilage.

MATERIALS AND METHODS

Under c-arm guidance and in percutaneous fashion, we nailed 16 consecutive complete (head and neck, etc, intact) specimen right proximal humeri with locked short humeral nails (Aequalis) via Neviaser portal. Each shoulder was dissected to study the damage to the rotator cuff and long head of the biceps tendons as well as to the articular surfaces. We measured the humeral-thoracic abduction arc before the damaged articular surface contacted the superior glenoid. There were 5 male specimens and 11 female specimens with a mean age of 83 years at the time of death.

RESULTS

We successfully inserted 15 of 16 humeral nails through this percutaneous approach. No supraspinatus tendon or long head of the biceps tendon was damaged. All nails passed entirely through supraspinatus muscle belly. Thirteen of 15 starting points were entirely on articular surface. Mean arc of abduction before superior glenoid contact was 76 degrees (range, 50 degrees-130 degrees). Mean distance from the edge of the articular surface to the most lateral part of the nail insertion was 11 mm (0-25 mm).

CONCLUSIONS

Short, locked humeral nail insertion is possible in percutaneous fashion via Neviaser portal without tendon injury. However, successful insertion comes at the cost of articular cartilage damage.

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.

Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes?

While intramedullary nailing has been established as the treatment of choice for diaphyseal fractures of the femur and tibia, its role in the management of diaphyseal humeral fractures remains controversial. The reasons include not only the complicated anatomy and unique biomechanical characteristics of the arm but also the fact that surgical technique and nail designs devised for the treatment of femoral and tibial fractures are being transposed to the humerus. As a result there is no consensus on many aspects of the humeral nailing procedure, e.g., the basic nail design, nail selection criteria, timing of the procedure, and the fundamental principles of the surgical technique (e.g., antegrade/retrograde, reamed/unreamed, and static/dynamic). These issues will be analyzed and discussed in the present article. Proposals aiming to improve outcomes include the categorization of humeral nails in two distinct groups: "fixed" and "bio", avoidance of reaming for the antegrade technique and utilization of "semi-reaming" for the retrograde technique, guidelines for reducing complications, setting the best "timing" for nailing and criteria for selecting the most appropriate surgical technique (antegrade or retrograde). Finally, suggestions are made on proper planning and conducting clinical and biomechanical studies regarding the use of intramedullary nailing in the management of humeral shaft fractures.

Management of upper extremity injuries in obese patients

Upper extremity injuries are more prevalent in obese people than in nonobese people after low-energy falls. Because splinting and casting are inefficient methods of stabilization in the setting of obesity, internal fixation provides stability for mobilization and realignment. Morbid obesity adversely affects positioning, surgical exposures, and complications associated with operative fixation. Avoiding short cuts and complications, morbidly obese patients should be able to return to normal functioning.

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.

Surgical treatment of traumatic pediatric humeral diaphyseal fractures with titanium elastic nails

BACKGROUND

Nearly all pediatric humeral shaft fractures can be successfully treated with closed methods. Some patients, however, require internal fixation either because of an inability to maintain an adequate reduction, significant soft tissue injury, or concomitant fractures.

METHODS

This is a retrospective review of all traumatic humeral shaft fractures treated at our hospitals between 1999 and 2006. Thirteen pediatric patients ranging in age from 4.8 to 16.7 years (mean age 12.0 years) were treated surgically with titanium elastic nails (TENs). Relative surgical indications included open fractures, inability to maintain an acceptable reduction, the presence of ipsilateral forearm fractures (floating elbow), concomitant lower extremity fractures, and closed head injury. Two patients had associated radial nerve injury at presentation.

RESULTS

The patients were followed for a mean of 29 months. All fractures healed in good alignment. There were no intraoperative complications, including neurologic or vascular injury, and no patient developed an infection postoperatively. Two patients had nail migration, one of whom developed nail protrusion through the skin. One patient with preoperative radial nerve injury ultimately underwent tendon transfer to restore wrist extension. Of the 13 patients, 12 reported a full return to sports and other activities with no limitations or discomfort.

CONCLUSIONS

When surgical stabilization of pediatric humeral shaft fractures is indicated, TEN fixation is effective and has a high rate of union and a low rate of complications. This technique is familiar to most orthopaedic surgeons treating pediatric fractures.

LEVEL OF EVIDENCE

Level of evidence: IV (case series).

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.

Use of a "hybrid" locking plate for complex metaphyseal fractures and nonunions about the humerus

PURPOSE

To review one surgeon's experience with a novel type of "hybrid" locking plate (which has both 3.5mm and 4.5mm locking holes) for difficult fractures of the meta-diaphyseal humeral shaft.

METHODS

Over a 2-year period, 24 patients who presented with a metaphyseal humeral fracture or nonunion (proximal or distal) were treated surgically by a single surgeon. A "hybrid" locking plate containing 3.5mm locking holes on one end and 4.5mm locking holes on the other end (Metaphyseal plate, Synthes, Paoli, Pa) was used in all patients. The selection of this implant was based on fracture location and bone quality. Fractures were operated on through an anterolateral or direct posterior approach. All fractures were secured with a minimum of three 4.5mm screws on one side of the fracture and three 3.5mm screws on the other side. All patients were treated with a similar post-operative protocol for early range of shoulder and elbow motion.

RESULTS

Three patients were lost to follow-up. The cohort consisted of 15 women and 6 men with a mean age of 49 years (range 18-78). There were 14 acute fractures and 7 nonunions. Twelve fractures involved the distal metaphyseal segment and 9 involved the proximal metaphyseal segment. Twenty-two patients completed a minimum 6-month clinical and radiographic follow-up and form the basis for this report. All 21 patients healed their fractures or nonunions at a mean of 4.5 months. There were no infections or hardware failures. In every case the "hybrid" nature of the plate design was felt to be advantageous.

CONCLUSION

This "second generation" metaphyseal locking plate, which affords the surgeon the ability to place a greater number of smaller calibre screws within a short bone segment, while using traditional large fragment screw fixation in the longer segment, is clearly an improvement in plate design. Meta-diaphyseal upper extremity long bones may serve as the most ideal location for this implant.

Modified rush pin technique for two- or three-part proximal humeral fractures

PURPOSE

To report the outcomes of modified Rush pin fixation for proximal humeral fractures.

METHODS

42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery.

RESULTS

Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury.

CONCLUSION

The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults

BACKGROUND

Plate osteosynthesis is the most commonly used technique for the treatment of diaphyseal forearm fractures in adults. However, application of a plate can disrupt the periosteal blood supply and necessitates skin incisions that may be unsightly, and there is a risk of refracture if the implant is removed. The purpose of this study was to assess the early results of the use of a contoured interlocking intramedullary nail to stabilize displaced diaphyseal fractures of the forearm.

METHODS

Between January 2004 and July 2006, a total of thirty-eight interlocking intramedullary nails were inserted into the forearms of twenty-seven adults. Eighteen nails were used in the radius and twenty were used in the ulna to stabilize a diaphyseal fracture. The mean follow-up period was seventeen months. Functional outcomes were assessed with use of the Grace and Eversmann rating system, and patient-rated outcomes were assessed by completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

The average time to fracture union was fourteen weeks. There was one nonunion of an open comminuted fracture of the middle third of the ulna. There were no deep infections or radioulnar synostoses. According to the Grace and Eversmann rating system, twenty-two patients (81%) had an excellent result; three (11%), a good result; and two (7%), an acceptable result. The DASH scores averaged 15 points (range, 5 to 61 points).

CONCLUSIONS

Our experience indicates that the advantages of an interlocking intramedullary nail system for the radius and ulna are that it is technically straightforward, it allows a high rate of osseous consolidation, and it requires less surgical exposure and operative time than does plate osteosynthesis. We suggest that the interlocking intramedullary nail system be considered as an alternative to plate osteosynthesis for selected diaphyseal fractures of the forearm in adults.

Variability in the assessment of fracture-healing in orthopaedic trauma studies

BACKGROUND

There is a lack of consensus among orthopaedic surgeons in the assessment of fracture-healing. We conducted a systematic review of recent clinical studies of long-bone fracture care that were published in three major orthopaedic journals to identify current definitions of fracture-healing.

METHODS

MEDLINE and the computerized databases for The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and the Journal of Orthopaedic Trauma were searched from January 1996 through December 2006 with use of title, abstract, keyword, and medical subject headings. Therapeutic clinical studies of long-bone fractures of the appendicular skeleton in adults in which fracture-healing was assessed were selected. Two reviewers independently identified articles and extracted data. Any disagreement was resolved by consensus. We qualitatively and quantitatively summarized the definition of fracture union and the reliability of the assessment of radiographic fracture-healing.

RESULTS

One hundred and twenty-three studies proved to be eligible. Union was defined on the basis of a combination of clinical and radiographic criteria in 62% of the studies, on the basis of radiographic criteria only in 37%, and on the basis of clinical criteria only in 1%. Twelve different criteria were used to define fracture union clinically, and the most common criterion was the absence of pain or tenderness at the fracture site during weight-bearing. In studies involving the use of plain radiographs, eleven different criteria were used to define fracture union, and the most common criterion was bridging of the fracture site. A quantitative measure of the reliability of the radiographic assessment of fracture union was reported in two studies.

CONCLUSIONS

We found a lack of consensus with regard to the definition of fracture-healing in the current orthopaedic literature. Without valid and reliable clinical or radiographic measures of union, the interpretation of fracture care studies remains difficult.

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.

Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures

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.

Principles of fixation of osteoporotic fractures

Despite advances in the prevention and treatment of osteoporotic fractures, their prevalence continues to increase. Their operative treatment remains a challenge for the surgeon, often with unpredictable outcomes. This review highlights the current aspects of management of these fractures and focuses on advances in implant design and surgical technique.

[The AO/ASIF Flexnail : A flexible intramedullary nail for the treatment of humeral shaft fractures]

BACKGROUND

The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation.

METHOD

Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score.

RESULTS

Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome.

CONCLUSION

We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.

The natural history of new orthopaedic devices

Each year, hundreds of new devices and implants are introduced for orthopaedic surgeons. However, the proportion of new devices which ultimately will be successful is unknown. We investigated the natural history of new devices introduced to the orthopaedic market. From a list of all devices approved for use by the Food & Drug Administration 5 and 10 years before, a cohort of 100 devices was randomly selected using a random number list. Companies were contacted regarding the safety record and current availability of these devices. The company response rate was 93%. Forty-seven percent of devices approved 10 years ago and 25% of devices approved 5 years ago no longer were on the market. Of the 55 companies studied, 18 (33%) were out of business and their devices no longer were available. Devices approved 10 years ago were more likely to be unavailable than devices approved 5 years ago. Devices introduced by smaller companies were more likely to be unavailable. The majority of unavailable devices were discontinued not for clinical problems, but for poor market performance. Only 2% of devices studied had safety problems. Approximately 50% of devices approved for introduction to the orthopaedic marketplace no longer are available 10 years later. However, major device-related problems seem uncommon.

[Retrograde locked nailing of humeral shaft fractures: a prospective study of 58 cases]

PURPOSE OF THE STUDY

Appropriate treatment for humeral shaft fractures remains a debated issue. Among the classical osteosynthesis techniques proposed, closed nailing was adapted to the humerus rather late, using the anterograde method. Use of retrograde nailing, which spares the rotator cuff, is more recent. The purpose of this study was to report outcome in 58 humeral shaft fractures in adults treated using the universal humeral nail between January 2000 and December 2003.

MATERIAL AND METHODS

This work was limited to recent shaft fractures in adults with non-pathological bones. The fractures included were all situated between the insertion of the pectoralis major and a point situated 2 cm above the apex of the olecraneum fossa. The series included 58 patients with 58 humeral shaft fractures. All fractures were closed except four (Gustilo type I and II). Two patients presented preoperative radial paralysis which was not considered to be a contraindication for retrograde locking nailing. The paralysis recovered in both patients, after neurolysis performed during the nailing procedure in one. Osteosynthesis was performed without opening the fracture focus under fluoroscopic control using a static locking nail inserted retrograde in patients in the supine position.

RESULTS

There were two early deaths unrelated to the method. Healing was obtained in the surviving patients within fifteen weeks on average. Bone healing was primary in 53 patients and after secondary compression in three. At last follow-up, shoulder motion was normal in 88% of patients and elbow motion in 91%. The Rommens functional score was good in 84%. Complications included three cases of spontaneously regressive postoperative radial paralysis, three cases of reflex dystrophy including two which regressed, and two cases of humeral palette fracture requiring surgical osteosynthesis. The proximal screws were removed in six patients because of pain or migration. To date, implants have been removed in three patients without problem. There were no infections.

CONCLUSION

Retrograde insertion of this nail facilitates treatment of humeral shaft fractures by allowing immediate joint motion and the advantages of closed reduction: no infection, no late bone healing requiring conversion to another method of fixation. The residual technical problems concern proximal nailing and nail introduction.

Bending and torsional stiffness in cadaver humeri fixed with a self-locking expandable or interlocking nail system: a mechanical study

OBJECTIVES

This study was designed to gain data about a new expandable, noninterlocked intramedullary nail's capacity to stabilize unstable transverse humeral shaft fractures without the need for interlocking, thus making nail implantation simpler and to prove our goal hypothesis: that in a midshaft osteotomy of the humeral shaft the expandable humeral nail will show the same bending and torsional stiffness as an interlocked humeral nail, when implanted correctly according to the manufacturer's instructions.

DESIGN

Pair randomization.

SETTING

Mechanical laboratory testing.

PARTICIPANTS

Eight pairs of freshly harvested cadaveric humeri.

INTERVENTIONS

Fracture model was a midshaft transverse osteotomy, gapped to 3 mm. Each humerus pair received an expandable humeral nail (Fixion) or an interlocked humerus nail (Synthes) through a retrograde approach. The humeri were fixed in polymethylmethacrylate cylinders and tested in a servo-pneumatic material-testing machine.

MAIN OUTCOME MEASUREMENTS

Torsional stiffness and bending stiffness of the nail-bone-construction.

RESULTS

Expandable nails (interlocked nails) showed a lateral bending stiffness of 0.73 +/- 0.14 (0.63 +/- 0.1) KN/mm (P = 0.026) and a frontal bending stiffness of 0.67 +/- 0.18 (0.58 +/- 0.09) KN/mm (P = 0.084). Torsional stiffness values were 0.13 +/- 0.19 (0.43 +/- 0.09 Nm/degrees) (P = 0.012). Lower torsional stiffness in the expandable nail group was observed in humeri with a funnel shaped proximal intramedullary canal.

CONCLUSIONS

The nail systems showed similar characteristics for frontal bending (P = 0.084), but not for lateral bending (P = 0.026). For lateral bending, the Fixion nail showed significantly more stiffness than the UHN nail (P = 0.026). There was significantly lower torsional stiffness with expandable nails compared with interlocked nails. Clinical correlation would suggest that in rotationally unstable fractures (A2 and A3 diaphyseal fractures), interlocked nails would provide increased stability over expandable nails.

Marchetti nailing of closed fresh humeral shaft fractures

INTRODUCTION

The purpose of this study was to analyse the results of Marchetti nailing.

METHOD

Between 1995 and 2003, 143 patients with closed fresh humeral shaft fractures were treated with the Marchetti-Vicenzi nail. The fractures were classified according to the AO classification: 37 A1, 24 A2, 25 A3, 22 B1, 15 B2, 7 B3, 7 C1, 4 C2 and 2 C3.

RESULTS

Fracture healing was obtained in 136 cases. The mean healing time was 11 weeks. There were seven non-unions. The range of motion of the shoulder was excellent in 95 patients (66.4%), moderate in 43 (30%) and poor in five (4.2%). The elbow had an excellent range of motion in 89 patients (62.2%), moderate in 48 (33.5%) and poor in six (4.2%). The functional result was excellent in 56 patients (39.1%), good in 62 (43.3%), fair in 18 (12.6%) and poor in seven (4.9%).

CONCLUSION

Marchetti-Vicenzi nailing appears to be a good method for the treatment of humeral shaft fractures. It is technically easy and its results are satisfactory.

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.