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A COMPARATIVE STUDY OF

INTERLOCKING NAILING AND PLATING

IN THE TREATMENT OF FRACTURE OF SHAFT HUMERUS

Dissertation for

M.Ch (Ortho.)

Boolean Education

In affiliation to

University of Seychelles

American Institute of Medicine (USAIM)

March 2011

Dr.Shenvi Amey Welingker

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INDEX

PAGE NO.

1. INTRODUCTION 3

2. AIMS & OBJECTIVES 5

3. MATERIAL & METHODS 6

4. OUTCOMES (OBSERVATIONS & RESULTS)

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5. DISCUSSIONS 27

6. SUMMARY 47

7. CONCLUSIONS & RECOMMENDATIONS 48

8. MASTER CHART 51

9. REFERENCES 53

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INTRODUCTION

Trauma has been the leading cause of mortality and morbidity since the beginning of mankind and is on the rise in the present age. The victim of bony injury, often the sole earning member of the family, faces prolonged immobilization, loss of wages and tough time for the entire family. Besides, the patient has often to live with the sequelae of stiff joints and functional disability. Early restoration of joint motion, return to the normal physiologic function and minimal morbidity is now regarded as the ideal fracture treatment.

Diaphyseal fractures of humerus accounts for 3% of all fractures. With increasing automobile accidents it is likely to be more future.

Fracture of humerus is the most challenging fracture of upper limb to be treated. However, irreparable damages can occur if fractures are not understood and treated properly.

Fractures of the shaft of humerus have been treated conservatively since ages with good

result. Sir John Charnley41 in his thesis, The closed treatment of common fractures states, it is perhaps one of the easiest major long bone fractures, to be treated by conservative methods.

However, conservative treatment has its demerits such as prolonged limb immobilization, the need for constant co-operation and repeated hospital visits. Secondly it cannot be recommended in every case like unstable fractures (spiral/long oblique), comminuted fractures, segmental fractures, pathological fractures, open fractures, fractures with delayed union or nonunion, fractures with radial nerve injuries or vascular injury. Such fractures require operative line of treatment.

The operative line involves open reduction of fracture and internal fixation with plate osteosynthesis or intramedullary implant or external fixation.

Intramedullary nailing with conventional V-nail of kuntischer, Rushrods, Ender or Hackethal nails do not provide rotational stability and therefore some form of external protection in some form or the other is needed, coupled with restricted movements.

With the advent of Rigid intramedullary nailing with transverse locking screws the surgeons are now trying to couple the advantages of conservative management with the advantages of operative treatment.

Closed interlocking nailing involves minimal surgical intervention, biological fixation, no periosteal stripping with rotational and torsional stability, anatomical reduction, early mobilization preservation of hematoma. With the advent of image intensifier control this method has become extremely easy. However it has a disadvantage of rotator cuff impinchment and restricted elbow movements.

Plate osteosynthesis has given high rates of fracture union with anatomical reduction and good compression across fracture site, with no damage to the rotator cuff and the elbow joint, but has the disadvantage of excessive periosteal stripping, extensive incision, increased chances of infection or nerve damage, less secured fracture of osteopenic bone. Further there is a stress shielding of bone by the plate and reduced strength of union due to primary bone healing compared to the callus healing seen in biological fixation with intramedullary nailing.

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Hence a comprehensive study is conducted to find the ideal mode of surgical management of different types of closed fractures of mid shaft humerus and their functional outcomes.

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AIMS AND OBJECTIVES

1. To study the results of plating and interlocking nailing in the

treatment of the closed fractures of shaft humerus.

2. To study the incidence of complications.

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Methods of Internal Fixation of Shaft Humerus

The various methods of internal fixation

1. Plate and screws. 2. Intramedullary nails.

1. Plate and screws

EVOLUTION OF PLATE OSTEOSYNTHESIS

Plating of fractures is traceable into the last century when Hans Mann 14 described a percuteneous removable plates in 1886.

Lambotte 15 (1990) and Lane 16 are the first well known protagonists of plate fixation. They met with multiple failures.

Sherman 17 (1912): Modified Lane’s plate by using a stronger alloy (Vanadium chrome steel).

The first attempt to demonstrate the effect of compression applied to healing bone fragments was made in 1949 by Eggers et.al.18 Using slotted plate, he hypothesized that muscle contraction would bring about compression across the fracture site. In practice however it often failed to achieve compression especially if the screws are tightened enough to fix the fracture rigidly and thus cannot slide as necessary in the slots of the plate.

Danis of Belgium 19, 20 in the same year used a compression plate, different from that of Eggers and presented his data which was widely accepted. Danis was first to describe a plate that actively compressed the fragments; a blot was used to apply pressure against the end screw in the plate before this screw was tightened.

Venable and stuck 28 in United States also designed a similar plate.

Muller 20 : The founder of the AO institute, Davis, Switzerland who worked with Danis, grasped the tremendous potential of this compression fixation method. In 1957 he devised a compression device with excellent results. It effects compression across the fracture site by pulling on the plate already fixed with one fragment of the bone.

Bagby and James 25 in 1958 designed a self compression plate and this does away with external tensioning device, thus reducing the larger incision and an additional hole in the bone. However it didn’t get much acceptance at that time.

Allgower, Pareen and Matter 19, 20 of the AO Institute in 1970 developed the dynamic compression plate. The word dynamic implies that plate achieves compression across the fracture site as the screws are inserted and tightened due to the special geometry of the screw holes. The compression achieved is however static. Such plate gives excellent results.

AO Group recently improved on the dynamic compression plate and reduced the contact of plate to the bone to minimize the compression of the periosteal blood supply to the bone and stress shielding of the bone. This includes the Limited Contact Dynamic Compression Plate (LC-

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DCP), Point Contact Fixation (PC-Fix). LC-DCP includes several modifications including a structural undersurface, oblique cut screw holes and a trapezoidal cross section.

Advantages of plating:

1. Direct visualization of the fracture site, enable anatomical reduction. 2. Very stable fixation. 3. There is good compression across the fracture site due to the dynamic compression plate,

this causes primary fracture healing.

This makes plate osteosynthesis the gold standard in a non union.

Disadvantages of plating:

1. The fracture haematoma and biological factors are drained. 2. Large exposure which increases chances of infection. 3. Excessive stripping and soft tissue damage.

All above factors cause increased chances of nonunion or delayed union.

4. Higher chances of radial nerve injury. 5. Higher incidences of refracture due to less callus formation due to primary healing, or

fracture through the screw holes after implant removed. 6. Stress fractures at plate ends. 7. Plate irritation. 8. Immunological reaction (rarely). 9. Being load shielding it increases bone rarefactions and increases the chances of fractures.

2. Intramedullary Nailing

Evolution of intramedullary nailing:

The History of orthopaedics is repeated with writings of various inventors who tried different materials of internal splintage in the medullary canal. Notable amongst these are:

Stimson 21 in 1888 was the first to be successful in uniting fractures by Jamming Ivory Pegs in the medullary canal. Others who tried this method before him, included Brutcher and King, were largely unsuccessful.

Hey Groves 22 in 1912 probably inserted the first metallic intramedullary device in a gunshot wound of the femur during the First World War. He was defeated by inadequacy of metallic quality, radiography and instruments.

The Rush Brothers 24 between 1936 and 1939 introduced flexible intramedullary nails of special design and the principle of three point fixation.

Intramedullary nailing gained worldwide acceptance only after it was popularized by Gerhand B. Kuntscher 26, 27 who in 1939, during the Second World War performed intramedullary nailing on femur, tibia and humerus. All credit goes to him and his metallurgist Ernst Pohl who designed and fabricated his implants using corrosive resistant V2A stainless steel.

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In his first publication in 1940, Kuntscher laid down the principles on intramedullary nailing which are even followed now, they are as follows:

1. Nailing should be done closed, with incision as far as possible away from the fracture site. 2. Nail should be strong enough to resists the stress of muscle contraction, joint movement

and weight bearing to prevent bending or breakage of the nail. 3. The nails should have sufficient elasticity to be compressed during insertion and re-expand

in the medullary canal.

The original Kuntscher nail was ‘V’ shaped, which are retained at present for humerus and tibia, however later changed to leaf shaped.

Ender and Hackethal 7 respectively in 1961 introduced flexible intramedullary nailing for long bones fractures and achieved stability by stacking multiple nails in the canal, also called as Bundle nailing.

In 1968 Kuntscher 26, 27 improved on the original nail named after him and introduced what he called the detensor nail the fore runner of the present interlocking nail. It had transversely threaded bolts passed through prefabricated holes in the nails anchoring the implant directly to bone and controlling length, rotation and alignment.

In 1972, Klemm and Shellman 29 developed an intramedullary nail for femur retaining the original clover leaf cross section and continuous longitudinal slot of Kuntscher, but adding two interlocking holes proximately and two distally.

Gross and Kempf 7, 28, 30 in 1981 introduced their modification of the interlocking nail for femur and tibia named after them, which was first available in France and then in the rest of the world. It gained wide acceptance.

H. Seidel 31 in 1989 reported 100% union rates in a series of 80 fractures of humeral shaft treated by humeral nails inserted by closed technique. His device had a distal locking facility whereby a long bolt threaded down the nail causes flaring out of the flanges at the distal end of the nail. This device has since been used and studied and reported by several workers with varying results.

In 1992 Russell and Tayler 32 introduced their interlocking intramedullary nailing system, including the humeral nail and reported excellent results treating traumatic and Pathological fractures.

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Different types of intramedullary nailing

Flexible nails Solid nails

Rush Intramedullary Interlocking

Hackethal nail nail

Enders kuntscher nail AO

Seidel nail CK

Russell Taylor

Interlocking nails

Interlocking nails for humerus are generally solid nails. They are smaller in diameter than the K-nail. Due to locking mechanism both proximally and distally it gives translation and rotational stability and therefore ideal for comminuted fractures.

There are different types of Interlocking nails:

1. Seidel humeral locking nails (Howmedia GmbH, Schonkirchen, Germany) :

It is a unslotted 9 mm wide nail. The distal locking mechanism is by spreading the 3 flanges distally by using a long flexible screwdriver inserted from the proximal tip of the nail. So no instruments are required for distal locking in the elbow regions. However the rotational stability and hence the rate of union is poor.

2. To increase the rotational stability Russell and Taylor came with a new interlocking nail which had smaller diameter 7-9 mm) and is slightly curved both proximally and distally and has two locking screws proximally and distally. This nail can be used either in antegrade or retrograde manner.

The advantages of closed intramedullary nailing of diaphyseal fractures include: (source : Rockwood and green fractures in adult fourth edition 1994)7.

1. Preservation of fracture exudates: The exudates produced at the fracture site is very important for healing. It contains prostaglandins, various growth factors, bone morphogenetic proteins (BP) and hyaluronates. All these and many unknown factors take part in the stimulation, formation and maturation of the callus of normal bone. This is all lost once fracture site is opened and the exudates drained.

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2. Stability of fracture reduction : The medullary canal is closed to the mechanical axis than the usual plate position on the external surface of bone, thus intramedullary nails are subjected to smaller bending loads than plates and are less likely to fail by fatigue. Further, stabilization leads to increased vascularization of the fracture ends and faster healing.

3. Preservations of vascularity: The periosteal blood supply is undisturbed and endosteal circulation recovers at the earliest. In comminuted fractures, it provides a biological fixation by preserving the soft tissue attachment of bone.

4. Minimal risk of infection due to the shortened operative time and minimal incision, the risk of infection is much less compared to open procedures.

5. Allows early mobilization of the limb with advantages of improved blood supply to the limb, aiding in faster fracture healing with a negligible risk of joint stiffness and muscle wasting.

6. Re-fracture after implant removal is rare with the use of intramedullary nails, secondary to the lack of cortical osteoporosis and since fewer stress risers are created.

7. It is a treatment of choice in polytrauma patients where early mobilization is necessary. 8. It can be done in patients with bad skin condition overlying the fracture as in burns patients. 9. Segmental fractures are best treated with this mode of intramedullary nailing. 10. It can maintain the length in cases of comminuted fracture with bone loss by static locking

mechanism. 11. Due to closed technique minimal chances of any nerve damage.

Special indications for interlocked humerus nail

These include non union and pathological fractures.

Non union of humeral shaft fractures (source: Rockwood and Green textbook of fractures and joint injuries).7

According to the literature, 4 months is a reasonable period of time for humerus shaft fracture to unite. A nonunion is present when healing is no longer evident. Factors associated with nonunion include:

Compression plating with bone grafting and reamed intramedullary nailing is probably the most effective methods for the treatment of established non-unions. With the use of either device, some basic principles must be followed.

1. Obtain osseous stability. 2. Eliminate the nonunion gap. 3. Maintain or restore across vascularity. 4. Eradicate infection.

Generally reamed intramedullary nails are used for nonunion located in the mid-shaft of humerus, while plates are chosen for those located in the proximal and distal regions. Interlocked nails are also preferred if the humerus is osteopenic or compromised from prior implant. The bone grafting is indicated when nonunion is atrophic type or where there is bone loss.

There recent studies deal specifically with the treatment of non unions of humerus or non-unions after treatment with the interlocked nails.

Lin. Hon and Hang 53 in April 1999, reported their experience with the use of locked humeral nails in treating 13 delayed unions and 28 non-unions with a single operation (open nailing and bone grafting) all but 2 patients achieved

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osseous union in an average of 5.6 months. They conclude that humeral locked nailing seems effective for delayed union and nonunion of humerus and is an acceptable alternative for fractures unsuitable for plate fixation such as these with communition, osteoporosis or a severely adhered radial nerve.

Mc Kee and Miranda 54 in 1996 reported non-unions after the failure of locked nailing, and stated that open reduction and internal fixation with plate and screw fixation with bone grafting was superior to exchange nailing.

However a similar study by Raschke et.at 55 of the University of Berlin in 1998 proved best result with the Ilizarov hybrid fixator in his cases.

Pathological fractures of humerus shaft: (Source: Orthopaedics clinics of North America Oct 2000). 56

The humerus shaft is a relatively common site for metastatic disease and pathological fractures may result. Rigid intramedullary nailing of impending or complete pathologic fractures is a convenient and effective means of stabilization. In impending diaphyseal lesions, closed nailing without PMMA augmentation may be performed when some degree of cortical continuity is preserved, especially when the lesion is known to be radiosensitive.

When cement augmentation is desired without exposure of the lesion, it may be infected through the entry portal or through two drill holes, one above and one below the fracture. Risks associated with this technique include extravasations of cement with injury to the adjacent neurovascular structure and setting of the cement before rod insertion is complete.

In most cases exposure of the fracture site for cement augmentation is prudent. By this method, after placement of the interlocking bolts, cement is placed through the defect into the canal proximally and distally as far as possible followed by packing the defect around the rod. The aim of fixing pathological fractures is to provide a pain free functional limb so that the patient can have a reasonable quality of life ahead.

Most reported studies on the use of the interlocking humeral nail include cases of pathological fractures stabilized with the interlocking nails. Few authors have worked only on pathological fracture fixation with the locked humeral nail, these include:

Redmonel Blasier and Bier Mann 65 of the University of Michigan, USA performed a retrospective study reported in June 1996 of 12 patients with 16 pathological fractures in shaft humerus secondary to metastatic disease stabilized by closed interlocked nailing. Pain relief and return to normal function was rated as good or excellent in all but one patient. There were no problems related to the wound, deep infections nerve palsies or failures of the implants. They claimed that immediate stability could be accomplished with a closed technique, brief operative time and minimal morbidity.

A similar study by Dijkstrn et.al 66 at Rotterdam, Netherland in 1977, compared the result of interlocking nails with plate fixation and adjunctive bone cement for metastatic fractures of humeral shaft. The operative course was complicated in 6 out of 20 (30%) patients treated with plate fixation and cement augmentation and 4 out of 18 (22%) treated with the reamed Russell Taylor nail. However they found no significant difference in the end results and recommended both the methods as means to restore arm function and improved quality of life in these patients.

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Tom cars et.al 67 of Madrid Spain, conducted a retrospective study in 1998 of 14 patients with pathological fractures of humerus treated with interlocked nailing. Early pain relief was obtained in 85% patients, and functional results were good in 70% patients.

Damron 68 and associates of the Mayo clinic USA conducted a cadaveric study in 1997, to determine the most bio-mechanically desirable construct for prophylactic fixation of impending pathological fractures in the middle third of the shaft. Intramedullary interlocked nailing provided statistically significantly better total energy absorbed failure and stiffness than did dynamic compression plating with added biomechanical advantage.

Disadvantage of interlocking nail

A. Disadvantage of Antegrade interlocking nails :

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1. High chances of shoulder stiffness. 2. Iatrogenic bone splintering while reaming and impaction.

B. Disadvantage of Retrograde interlocking nails :

1. Not a good method for proximal 1/3rd fractures of the humerus. 2. Iatrogenic fracture chances are more common while entering the olecranon fossa. 3. Elbow joint stiffness is present. 4. Distal end of the nail should not go proximal than humeral neck or else the axillary

nerve will get damaged while proximal locking. 5. The nail should not be very short as the proximal 1/3rd of humerus has a wide

medullary part. Therefore it does not give enough stability and therefore it should enter the cancellous part of the humerus.

6. Long learning curve. 7. At the entry point the nail has to be flushed with the posterior cortex or else it will

irritate the triceps tendon and interface with elbow extension.

MATERIAL AND METHODS

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The aim of this study was to evaluate the results of plating and interlocking nailing in the treatment of the fractures of shaft Humerus.

The study was conducted on 52 patients with fractures of the shaft of humerus were treated. Four patients were lost at follow up.

Patients under 18 years of age were excluded. An attempt was made to correlate the age and sex incidence with the various studies. The average age was 40 years ranging from 18-79 years. Majority of the patients were in the age group of 21 years – 30 years.

The modes of fractures were classified as motor vehicular fractures, fractures from fall from height, blunt traumas. The commonest mode was motor vehicular fractures (54%), followed by fall from a height (27% blunt trauma 19%).

The commonest site of fracture of humerus was the middle 1/3 followed by the upper 1/3rd.

In acute stage, the radial nerve injury and vascular injuries were evaluated.

Number of patients with pre-existing radial nerve injury was 3 (6.25%).

Only compound gradel and grade 2 (according to Gustilo and Andersons classification) fractures were included.

Radiological evaluation at the time of fracture involved a good anterio-posterior view and a lateral view of the humerus which included the shoulder and elbow joints. Based on this X-Rays the fracture was classified by the AO system of classification and the management of fracture was decided.

The patients were followed up for a average period of 6 months (ranging from 3-9 months). Each case was reviewed clinically and radiologically during the follow up period.

Non operative or surgical treatment depended on the clinical findings, radiological findings and associated injuries.

Only operative cases were selected

Indications of operative treatment included:

1. Polytrauma patients who require early mobilization. 2. Failed conservative treatment. 3. Patients insist for early return to work, where prolonged immobilization was not possible. 4. Comminuted fractures or short oblique fractures or spiral fractures which could not be

reduced by closed methods. 5. Fractures associated with radial nerve or brachial artery injuries. 6. Floating elbow (associated fractures of forearm) or bilateral fracture humerus. 7. Compound fracture (Grade 1 and Grade 2) were included.

Operative treatment includes:

1. Plate osteosynthesis

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2. Interlocking humerus – Antegrade technique.

Plate osteosynthesis

This method was employed for:

1. Closed transverse fracture/ Oblique fractures with minimal communition. 2. Fractures associated with radial nerve palsy or vascular injury. 3. Closed and compound grade 1 fractures were included.

Method employed

The anterolateral approach of Henry and posterior approach was taken and fracture site approached. Fracture site was reduced and fixed with a narrow 4.5 mm dynamic compression plate (DCP) with minimal of 7 cortices on either side. Depending on fracture stability external splint in form of ‘U’ shaped slab was used. Post operatively a check X-Ray was taken and patient was called for follow up visit at OPD level.

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Follow up visits

1st visit – 2 week after surgery.

Stitch removal was done and the shoulder and elbow mobilization was advised. Whenever patient’s cooperation was doubtful a U-shaped slab was continued for another 4 weeks.

2nd visit – 6 weeks following surgery.

During this visit both shoulder and elbow movements were evaluated.

Tenderness at fracture site noted.

Repeat X-Ray – to see for sign of fracture union. If evidence of union was seen full mobilization was advised.

Interlocking humerus

In our institute only antegrade interlocking was done. We use Dalvi’s interlocking nails / Yogeshwar interlocking nails.

This method was used for:

1. Closed communited fracture of shaft humerus. 2. All polytrauma patients were early mobilization is required. 3. Non-unions following failed plate osteosynthesis. 4. Compound grade 1and grade 2 fractures. 5. Stress fractures at plate ends.

Method

Antegrade technique:

The length of the nail was measured in centimeters, by measuring the length between the greater tuberosity and the lateral epicondyle and 3 cms were subtracted from it. Diameter was roughly assessed by the X-Ray of the Humerus.

Procedure:

- Patient was given either a scalene block or general anesthesia. - Patient was kept supine with the head turned on contralateral side and pillow under the

scapular blade; this increases the exposure of the shoulder. - Proper scrubbing, draping and painting were done. - Small incision over the acromion was given. Deltoid muscle fibers carefully dissected to avoid

unnecessary damage to rotator cuff and greater tuberosity was approached. - Entry point with the help of a curved owl entry point is created just posterio-medial to the

greater tuberosity.

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The selected nail was then directly introduced in the entry point of humerus and advanced to the fractured site. After manipulations the nail tip was advanced into the distal fragment of the bone. The position was confirmed with a image intensifier. If proper reduction was not possible minimal opening of the fractured site and manipulation was done, without disturbing much of periosteum and fracture hematoma. Later the nail was passed into the distal fragment approximately 1-2 cms. away from the olecranon fossa and the proximal end is countersunk with the greater tuberosity. With the help of a comparing parallel nail the distal

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locking was done. Proximal locking was done with the help of the guide jig. Later the fracture site stability was checked by internal and external rotation.

In selected cases, like with radial nerve palsy minimal opening at fracture site was done to explore the radial nerve.

Entry site was properly irrigated and incisions closed. Postoperatively a sling was given to the patient and called for follow up visits at OPD.

Following visits:

1st visit – Patient was called for follow up after 2 weeks following surgery – During this visit stitches were removed and active shoulder and elbow movements were encouraged.

2nd visit – after another 4 weeks – During this visit a check X-Ray was taken to see sign of union. The elbow and shoulder movements were assessed and compared to the Constant-Murley Score and function was assessed as a whole using the scoring system of American shoulder and elbow surgeons (ASES).

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CLINICAL PROFORMA

Name : …………………………. Age : ……….. Sex : ………..

Address : ………………………. Occupation : …………………..

OPD No. : …………… IPD No. : …………………..

Date of inquiry : ……………… Date of admission : ……………..

Date of discharge : ……………

Mode of injury : ……………………………………………………...

CLINICAL EXAMINATION :

- Closed/Open fracture – (Description of wounds if open) : …………

- Examination for Radial nerve-Normal/Involved : …………………. - Distal circulation status : ……………………………………………

RADIOGRAM :

- Level of fracture : …………………………………………………… - Type of fracture (Acc. To A. O. Classification) : …………………... - Details of associated injuries (if any) : ……………………………… - Treatment of associated injuries : ……………………………………

OPERATIVE DETAILS :

- Date of surgery : …………………………………………………….. - Anesthesia : ………………………………………………………….. - Approach : …………………………………………………………… - Nail size and diameter used : ………………………………………. - Open / Closed reduction : ………………………………………….. - Number of screws used distally : ………………………………….. - Intraoperative difficulties (if any) : ………………………………...

REHABILITATION AND FOLLOW UP :

Date Week since

injury Complaints (if

any) Constant score

$ ASES score

* Radiogram

NB : *Refer Annexure

$ Refer Annexure II

- Complication (if any) : ……………………………………….

- Status of associated injuries at final follow up : …………….

- Final result : …………………………………………………

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OBSERVATION AND RESULTS

The analysis of the results of this study is discussed as follows:

Table I

(See Graph – I)

Age distribution of patients

Age group (years) No. of patients Percentage

11-20 2 4%

21-30 18 38%

31-40 8 16%

41-50 6 13%

51-60 8 16%

61-70 2 4%

71-80 4 9%

Total 48 100%

Of the 48 cases treated in our series, the youngest was 18 years old and oldest 79 years old. The commonest age group affected was 21-30 years (38%) and maximum number of patients were below the age of 40 years (58%). The mean age affected was 40 years.

Table II

(See Graph – II)

Sex distributor

Sex No. of patients Percentage

Male 32 67%

Female 16 33%

Total 48 100%

A male preponderance 67% was seen in this study.

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Table III

(See Graph – III)

Mode of injury

Mode of injury No. of patients Percentage

Motor vehicular accidents 26 54%

Blunt trauma / Assault 9 19%

Fall from height 13 27%

Sports injury -- --

Fire arm injury -- --

Pathological fracture -- --

Total 48 100%

The majority of fractures (54%) were the consequences of motor vehicular accidents followed by fall from a height (27%).

Table IV

(See Graph – IV)

Side Distribution

Side No. of patients Percentage

Right 26 54%

Left 22 46%

Total 48 100%

Higher incidence of fractures were seen on the right side (54%).

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Table V

(See Graph – V)

Anatomical level of fracture

Anatomical level No. of patients Percentage

Upper third 6 13%

Upper 1/3rd – middle

1/3rd junction

10 20%

Middle third 26 54%

Middle 1/3 lower 1/3rd 6 13%

Lower third - -

Total 24 100%

Majority of fractures (54%) were in the region of the middle 1/3rd of the shaft of the humerus, followed by fractures at the upper third/ middle third juncture (20%).

Table VI

(See Graph – VI)

Type of fracture

AO Type No. of patients Percentage

A1 – Simple spiral fracture 6 13%

A2 – Simple Oblique fractures 8 16%

A3 – Simple transverse fracture 18 38%

B1 – Spiral wedge fracture 4 8%

B2 – Bending wedge fracture 10 21%

B3 – Fragmented wedge fractures -- --

C1 – Complex spiral fracture 2 4%

C2 – Complex segment fracture -- --

C3 – Complex irregular fracture -- --

Total 48 100%

Majority of patients (38%) had a simple transverse type of fractures, followed by bending wedge fracture in 21% patients.

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Table VII

(See Graph – VII)

Indication for surgery

Indication for surgery No. of patients Percentage

Polytrauma 31 64.58%

Ipsilateral forarm fractures 4 8%

Unstable closed reduction 2 4%

Obesity 2 4%

Compound fractures (G 1 & G2

5 10.5%

Elderly patient 4 8%

Total 48 100%

Majority of patients were polytrauma (64.58%). They were operated due to associated multiple injuries of the axial or appendicular skeleton.

Table VIII

(See Graph – VIII)

Associated injury

Associated injury No. of patients Percentage

Head injury 10 21%

Chest injury 2 4%

Abdominal trauma 2 5%

Additional fractures

Rib fractures 6 12%

Hip fractures 4 8%

Pelvic fractures 2 4%

Fracture of shaft femur 2 4%

Fracture forearm bone 4 8%

Fracture tibial shaft 6 12%

Fracture malleoli 2 4%

Fracture metacarpals 2 4%

Vertebral fracture 2 4%

Contra lateral Colle’s fracture 2 4%

Total 48 100%

The commonest associated injury was trama to the head (21%) followed by associated injuries to the axial or appendicular skeleton. Radial nerve palsy was present in 6 (13%) patients at admission.

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Table IX

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(See Graph – IX)

Type of surgery

Type of technique No. of patients Percentage

Interlocking 20 42%

Plating 28 58%

Total 48 100%

Table X

(See Graph – X)

Time taken for union in Interlocking

No. of patients 20

Time in weeks No. of patients Percentage

< 10 weeks 13 65%

10 – 16 weeks 5 25%

16 – 20 weeks 2 10%

20 – 24 weeks --

24 – 30 weeks --

30 – 36 weeks --

Total 20 100%

Most of the patients (90%) united within < 16 weeks. 68% of patients united within <10 weeks. The average time of union was 10.5 weeks. The two patients which united after 16 weeks were actually failed plating with backout of implant which were revised with reamed antegrade interlocking nailing with bone grafting. One united in 18 weeks (51 years/F) and the second in 20 weeks (33 years/M).

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Table XI

(See Graph – XI)

Time taken for union in Plating

No. of cases 28

Time in (weeks) No. of patients Percentage

< 10 weeks 12 43%

10 – 16 weeks 6 23%

16 – 20 weeks 4 15%

20 – 24 weeks 2 8%

24 – 30 weeks 1 4%

30 – 36 weeks - -

Total 25 100%

Most of the patients (81%) united in less than 20 weeks interval and 43% united in less than 10 weeks. 3 patients went into nonunion due to implant failure and were later revised with bone grafting and intramedullary interlocking nailing. Both the cases united later. The average union time being 13 weeks.

Table XII

(See Graph – XII)

Functional assessment of shoulder joint in the interlocking cases.

No. of cases - 20

Constant Murley

Score

No. of patients Percentage

50 – 60 8 40%

50 – 54 7 35%

45 – 49 4 20%

40 - 44 1 5%

< 40 - -

Total 20 100%

Using the Constant Murley Score for shoulder evaluation, 40% of patients who under went a Antegrade interlocking nailing had the score between 55-66 (excellent shoulder functional). No patient had the score less than 40.

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Table XIII

(See Graph – XIII)

Functional assessment of whole upper limbs function

ASES Score No. of patients (Interlocking)

Percentage No. of patients

(Plating) Percentage

42 - 52 12 60% 26 93%

42 - 46 6 30% 2 7%

36 - 41 2 10% - -

31 - 35 - - - -

< 30 - - - -

20 100% 28 100%

From the above table it is clear that in interlocking nailing 90% of the patient had excellent upper limb functional status at the end of the treatment with ASES 42-52. Only 10% had ASES 36-41 which implies to fair functional upper limbs.

For plating 93% of patient had ASES Score 47-52 which implies excellent upper limb function. Only 7% had ASES Score 42-46 which is also a good functional upper limb. This 7% where mostly those comminuted fracture which were protected with a external splint and nonunion which were previously put in functional cast till radiological evidence of union.

Table XIV

(See Graph – XIV)

Complications

Complication encountered postoperative

In interlocking I M nailing

In Plating Percentage In interlocking I

M nailing

Percentage In Plating

1.Infections

-Superficial 1 5 5% 18%

-Deep 0 2 0% 7%

2.Delayed union 2 3 10% 11%

3.Nonunion 0 3 5% 11%

4.Iatrogenic radial nerve

0 2 0% 7%

5.Shoulder stiffness

4 1 20% 3%

6.Elbow stiffness 1 0 5% 0%

7.Anesthesia in the regimental badge area

1 0 5% 0%

34

35

From the above observation it is seen that in intramedullary nailing the most important complications are shoulder stiffness 20%. Delayed union was observed in 10% and no case of non-union was observed. No case of deep seated infection was seen in spite of using in grade 2 compound fractures. Superficial infection was seen in one (5%) case which was treated with regular dressing and antibiotics. No case of iatrogenic radial nerve palsy was observed. Elbow stiffness was encountered in only one case (5%) which was due to associated elbow dislocation for which closed reduction was done. Only one patient (5%) had regimental badge anesthesis due to trauma to the upper lateral cutaneous nerve of the arm which was recovered later after four months.

The most significant complication of plating was infection 25%. The 2nd most commonest complication was delayed union 11% and nonunion 11%, followed by 7% of iatrogenic radial nerve palsy.

36

DISCUSSION

The main goal of the present study is to evaluate the results of plating and interlocking nailing in the treatment of the closed fractures of shaft humerus.

While discussing this, the rate of union, the final functional recovery, early return to pre- fractured state and the complications of individual methods were compared.

The plate osteosynthesis was used for the closed transverse and oblique fractures, with minimal comminuted of the shaft of the humerus.

The Russell Taylor humeral interlocking 32 nail was used for closed comminuted fracture of the humerus or pathological fracture or nonunion due to fracture of plate osteosynthesis.

Crolla and De Vries 33 of the Netherlands reported in 1993, 46 cases treated by interlocking humeral nails of which 27 were acute fractures and rest nonunion. All healed within 16 weeks with excellent to good functional results in 43 (93%) and satisfactory results in 3 (7%) cases. Three out of the nonunion, required subsequent bone grafting but rest united with intramedullary nailing.

In 1993, R.S. Watanbe35 of UCLA, USA reported the use of interlocking humerus nails in 22 patients with 91% good to excellent results. He recommended antegrade interlocking nailing over routine use of compression plates and screws because incision and surgical time both are minimal and fracture site is not exposed unless there is radial nerve involvement. According to him, closed reduction and internal fracture remain the preferred treatment for fracture shaft humerus.

In 1994 Ingman and Water36 of the Royal Adelaude Hospital, South Australia, reported a series of 51 patients by interlocking humerus nails of which 21 had acute fractures, 15 non union and 15 pathological fractures. They concluded that rehabilitation was faster after retrograde nailing through the distal entry postal used in 30 of the 51 patients. There was only one failure of union after acute fracture. According to them, interlocking intramedullary nailing provided secured fixation of comminuted and osteoporotic fractures in any part of the shaft, allowing the early use of crutches and walking frames.

J.Ipkeme37 of North Yorkshire, UK reported in September 1994 his experiences with the Russell Taylor humerus interlocking nail on 39 patients of which 30 fractures were acute and 9 pathological. Using Neer’s scoring system for shoulder function, he claimed 88% excellent and satisfactory shoulder function and pain relief in all pathological fractures.

In June 1996 Kessler and Kolb et.asl. 29,38 at the university of Munich, Germany reported a study of 18 patients and concluded that although plate osteosynthesis is still a good standard, the advantage of interlocking nailing in early rehabilitation and low radial nerve damage rates and higher union rates.

Mckee.et.al.39 of the university of Toronto, Canada, reported in 1996 three cases of facture shaft humerus which occurs at the tip of the interlocking nail inserted previously for acute factures. All this facture occurred through the distal interlocking screw after the patient sustained a rotational force to the arm.

Rupf and chrissos 40 of the Ohio Medical College, USA performed a cadaveric study in 1996, to evaluate the risk of neurovascular injury with distal locking screw, in humeral locking nails.

37

They found the radial nerve is at risk with lateral to medial screw placement, and ulnar, median nerve, brachial artery at risk due to over penetration of medial cortex. With anterior-posterior placement the musculocutaneous nerve is at risk.

Hems and Bluellar42 of the oxford university, UK reported in 1996 a series of 43 factures of which 22 were pathological factures treated by interlocking humerus nails. Of the 21 acute factures 5 went into nonunion and 4 patients had unsatisfactory or poor shoulder functions. They advice caution for use of nails.

In 1997 Sims and Smith43 of New Carolina USA treated 21 patient with interlocking humerus nails of which 4 where open factures. Time of union averaged 7.6 weeks and there were two non unions both in open factures. Shoulder impinchment due to nails was noted in one case. Functionally all patients had normal or mildly limited results of the 8 nonunion treated with reamed nailing 5 went on to union.

Blum and Rommens44,45 In August 1997 reported results of treatment of 100 humeral shaft fractures with Russell Taylor nail by closed retrograde undreamed interlocking nailing. They found the number of radial nerve palsies significantly lower than with plate osteosynthesis. They also highlighted the advantage of the biological type of stabilization with minimal invasion of soft tissue and minimal damage caused to periostal and endosteal blood supply with these method.

Lin, Hou and Hang46 of Chinese Taipei reported in September 1997, 48 patients treated by retrograde interlocking nailing. All factures and nonunion achieved union within an average time of union of 8 weeks for acute factures, and 14.2 weeks for nonunions. They had excellent shoulders and elbow functions in all but one patient.

Crates and Whittle47 of the Campbell Clinic USA, in 1998 reported 71 patients treated with antegrade interlocking nailing of which there were two nonunion requiring secondary bone grafting. Two iatrogenic nerve palsies occurred and both were transient. Full shoulder function retained in 66 patients (90%). 2 patients had impingement from the proximal locking bolt and one from the prominent nail. 96% patients recovered normal elbow function. Those that did not recovered full shoulder or elbow function had concomitant injuries.

Modabber and Jupiter 48 of Massachusetts general hospital USA in February 1998 stated after a study that in most indication for operative management, internal fixation with plate and screws is preferred. Stable fixation, sparing adjacent joints from iatrogenic injuries and direct visualization and protection of radial nerve in most cases overweighs the potential advantage of a load sharing implant inserted through a more limited incision.

Thompson and Mikkelsen 49 of the university of Copenhagen Denmark in 1998, treated 48 fractures with the interlocking nail and emphasized, the importance of countersinking the tip of the nail in the humeral head to avoid impingement of the shoulder. All fractures united and only in 5 of the 12 nonunions did the procedures fail. Pathological fractures were all effectively treated.

Romans et.al.3 in May 1998 reported a study of 48 fractures treated by retrograde interlocking nailing, he had one case of iatrogenic radial nerve palsy and 3 cases of iatrogenic comminution at the fracture site consolidation took an average of 13.7 weeks and shoulder and elbow function was excellent in 87% cases.

Lin 50 in May 1998 reported his study comprising locked humeral nails with plate and screw fixation in fracture shaft humerus, and concluded that nailing offered a less invasive technique and more favorable outcome than plate fixation.

38

In 1999 Lal, Sharmer et.at. 51 of the Safdarjung Hospital New Delhi, reported a study of 22 patients treated by interlocked humeral nails. 71% patients showed radiology nonunion by 8 weeks, 95% by 16 weeks. No case of wound infection or refracture occurred. They concluded that the undreamed humerus nail is a better alternative than the DLP.

In 1999, Mc Cormack et.at52 reported a randomized prospective trial comparing the Dynamic Compression Plate (DLP) with Russell Taylor nail fixation for humerous shaft fracture. He concluded that the DLP remains the gold standard and that locked intramedullary nailing is more likely to be associated with higher complications and reoperative rates.

In 1990, Flinkkil et.al18 of the Oulu University Hospital, Finished reported a study of 43 cases treated by the Russell Taylor nail and concluded that antegrade with nailing leads to a substantial risk of non union and impairment of shoulder function. They recommended it as primary treatment only when non-operative treatment is likely to fail.

Hans Huber and Bern14 reported in June 2000, that although open reduction and internal fixation with plate and screw is still considered the gold standard for operative treatment of fracture shaft humerus, unreamed humerus nailing which allows for stable fixation and immediate functional return, could become an equal alternative. Their study included 19 fractures fixed by the unreamed interlocking nail. Two cases went into non unions. One case had a rotational malalignment of 450, in whom a secondary procedure was done. Good palliation was achieved in all pathological fractures. Shoulder and elbow function was symmetric in all but two patients.

In this series conducted in Goa Medical College, in which 52 cases of fracture shaft humerus, 28 patients were stabilized with DCP Plates and 20 patients with Russell Taylor’s interlocking nail (4 cases were lost at follow-up visits). The finding of this are analyzed here:

1. Age distribution

Series Mean age (Years)

Lal et al 51 39.6

Rommens et al 3 43.8

Robert J Foster et et al 102 39.5

Present Series 40

In this study 58% of patients were in the 3rd and 4th decade, the commonest age group affected. The range was between 18 – 79 years and the mean age was 40 years.

This series can be compared to the Lal et al, in whose series 55% of the patients were in the range of 20 – 40 years and mean age was 39.6 years.

This age group represents the actual earning period, in the life time of the individual. Due to early mobilization these patients gain full range of movements at an early with minimal loss of productivity.

2. Sex distribution

Series Male Female Total Ratio

No. of patients

Percentage No. of patients

Percentage

39

McCormack et.al52

13 62 8 38 21 1.6:1

Rommens et.al3

20 51 19 49 39 1.05:1

Lin 50 29 60 19 40 48 1.5:1

Present 32 67 16 33 48 1.8:1

Males formed the majority of patients in this series, which is comparable to the series of McCormack, Rommens and Lin.

The male prepondence in the series can be attributed to the fact that most of the traumas were as a result of motor vehicular accidents and fall from height and males are more likely to be involved in such activities.

3. Side distribution

Series Left Right

No. Percentage No. Percentage

Lin 50 21 44 27 66

Present Series

22 46 26 54

In this study the right side of the humerus was involved more often, which corresponds with the study of Lin 50

The right side involvement is this series can be due to the right sided dominance or merely incidental.

4. Mode of injury

Series Commonest cause

Second commonest cause

McCormack et. al 52 RTA 67% Fall 30%

Lal et al 51 RTA 77% Fall 18%

Rommens et al RTA 53% Household 30%

Present series RTA 50% Fall 25%

In this series the majority of the fractures (50%) were caused by road traffic accidents followed by fall from a height (25%). This is comparable with most reported series.

5. Type fracture

AO Type A1% A2% A3% B1% B2% B3% C1% C2% C3%

Rommens et.al 3

21 8 36 10 15 0 5 5 0

Ingmann et.al 36

7 20 54 2 15 2 0 0 0

Strong et.al 104

29 11 23 17 8 1 5 3 2

Flinkkila et.al 34

17 22 33 10 9 3 3 2 0

Present 13 16 38 18 21 0 4 0 0

40

Series

In this series the commonest type was A3 (simple transverse fracture). The second commonest was type B2 (bending wedge fracture) followed by A2 (simple oblique fracture).

This corresponds with most of the reported series.

6. Radial Nerve Palsy

In the series of Flinkkila et.al 34, 10 out of 126 cases (8%) had a primary radial nerve palsy, of which 5 (4%) required exploration.

Lin 50 in his studies recorded 4 cases of preoperational radial nerve palsy (21%). All but one case resolved in 1 – 9 months after fixation. The one which remained showed laceration on exploration.

In Ingmanns 36 series (15%) 6 cases had preoperative nerve palsy.

In our series three patients (6.25%) presented with radial nerve palsy of which two recovered within 4 months and one persisted.

The rate of radial nerve palsy in this study is thus comparable with other series.

The management of the radial nerve palsy associated with a humeral shaft fractures still remains controversial.

Holstein and Levis 61 described oblique fracture of the distal third of the humerus in which radial nerve palsy occurred due to displaced spike of the distal bone fragment. The nerve is least mobile in this place where it pierces the lateral intermuscular septum. He strongly advised against manipulation in this fracture pattern and advocated the need of exploration of the nerve with internal fixation to avoid further damage to the nerve.

In a study done by Pollock et al 105 of 24 cases of fracture shaft humerus with associated radial nerve damage, the initial treatment was noninvasive in all but one patient in whom, debridement of a penetrating wound revealed laceration of the nerve. Except for 2 cases which did not show complete recovery and required exploration, the rest 22 cases completely returned to function with conservative management. In two cases delayed exploration and delayed repair was done and both did well later. Exploration should be done at 31/2 to 4 months after injury if there is still no clinical or electromyographic evidence of months after injury if there is still no clinical or electromyographic evidence of recovery.

Shah and Bhatti 106 reviewed 62 cases of radial nerve palsy associated with fracture shaft humerus and stated that the use of dynamic splits and exercise to keep all joints of the hand and wrist supple, should be an integral part of the treatment. EMG studies are recommended at 4-6 months. If there is no recovery, the nerve should be explored. Indications for early surgery according to them are, unacceptable fracture reduction, open fracture requiring debridement associated vascular injury.

41

In our series out of the 3, 2 recovered fully, within a period of 4 months, one persisted as the radial nerve was stretched and contused. All 3 patient were fixed on day one with intramedullary nailing with radial nerve exploration and were given dynamic kock-up splint postoperatively for mobilization.

7. Time taken to union

Interlocking nailing series Time of union Range

Lin50 8.6 weeks 6-12 weeks

Rommens et.al3 13.7 weeks 8-38 weeks

Lal et.al51 8.38 weeks 5-10 weeks

LMPH Crolla et al107 9 weeks 6-12 weeks

Present series 10.5 weeks 8-16 weeks

Most of the fractures in this series (90%) united in < 16 weeks with average time of 10.5 weeks. No case of non-union was observed in the series. Delayed union was seen in 2 cases which were actually non-union following plating due to implant failure, and revised with interlocking nailing with bone grafting. This results coincides with LMPH Crolla et al., Lal et al. In Lal et al. 100% union occurred at 16 weeks.

Thus the rate of union was 100%.

Plating Series Time of union Range

Robert Vander et al101 16 weeks 12-24 weeks

Robert J Foster et.al102 14 weeks 8-20 weeks

Present series 13 weeks 8-20 weeks

In the present series the rate of union was 89% with only 3 patients going into nonunion all 3 patients were later revised by interlocking intramedullary nailing.

Here the rate of union is less than that of interlocking intra medullary nailing as there is extensive stripping of periostium, drainage of fracture haematoma and late mobilization.

8. Complications

1. Shoulder stiffness

It is the commonest complication of antegrade interlocking intramedullary procedure.

Robinsons et. al.103 reported 17% of patient with shoulder stiffness.

In the series of Srivastava et. al.108 15% and 11% in Lin’s 50 series.

In the present series, 4 patients (20%) of the patients had shoulder stiffness as assessed by constant Murley score.

The present series is comparable with the ‘Robinson et. al. series.

The average time of return of full shoulder function was six weeks with adequate compliance to the rehabilitation. The causes of the stiffness are protrusion of nail at the entry point, damage to the rotator cuff at the time of nail insertion inadequate removal of bone debris after nailing from the entry point and lack of patient’s cooperation with the postoperative physiotherapy regimen. In the present series, of the 4 patients two patients had protrusion of nail at entry

42

point. The other two had minimal shoulder movement restriction which improved after adequate physiotherapy and rehabilitation.

Riemer et al109 state that residual irritation or thickening of the rotator cuff tendon or coracoacromial ligament is the cause of shoulder stiffness.

Shoulder stiffness was encountered in only one patient with plating which was due to prolonged immobilization in a external splint as it was a case of nonunion.

2. Superficial infection and deep infection

This complication is more common in plating than interlocking.

In the series done by Robert Foster et. al.102 on plating, he encountered 3% of cases having deep seated infection and 11% with superficial infection.

In the present series, in plating (7%) 2 patient had deep seated infection for which later implant removal was done and treated with debridment of all infective material which also included reaming of medullary canal and insertion of gentamycin impregnated PMMA beads. Later the cases where revised by interlocking nailing once the infection settles. 5 patient (18%) had superficial infection which settled with local dressing.

In the series by Lin50, Lal et. al.51 and Rommens et. al.3 there was no deep seated infection, while Robinson et al reported 7% of cases with deep seated infection treated with nail in situ. In McCormack52 et. al. series only one patient (5%) had deep infection which improved after removal of the nail and debridment.

In case of interlocking intramedullary nailing in the present series there were no cases of deep seated infection in spite of being used for grade 2 compound fractures and only one patient (5%) had superficial infection which was also a grade 2 compound fractures, which settled with local dressing.

Thus the result of this series coincides with that of the others.

Higher infection rate in plating is due to extensive exposure for plating, excessive periosteal stripping.

3. Delayed union

In the series by Robert Vander101 et. al on plating he encountered 13.8% of cases with delayed union.

In the present series, in plating there were 3 patients (11%) who showed delayed union.

In the series by LMPH Crolla107 et. al. on interlocking nailing, he encountered 9% cases of delayed union.

In the present series of interlocking intramedullary nailing where there were 2 patient (10%) with delayed union. Both the patients were implant failure after plating which were revised by interlocking nailing with bone grafting.

43

The results of this series coincides with that of others.

The delayed union is more in plating on account of excessive periosteal stripping, loss of biological substances and due to higher incidence of infection.

4. Non union

In the series of interlocking done by Lal et. al.51 there were no cases of non-union, 10% in Robinson103 and 8.5% in McCormack et. al.52 cases of non union.

In the present series there was not a single case of nonunion in the interlocking series. Similarly the plating series done by Robert Foster et. al.102 revealed 4 cases with nonunion.

In the present series, of the 3 patients (11%) from plating series went into nonunion all 3 were revised with interlocking nailing with bone grafting.

Thus the present series results are comparable with those of others.

Higher rates for non union in plating is on account of excessive periosteal stripping, loss of biological substances.

5. Iatrogenic radial nerve palsy

In the present series there were no cases of iatrogenic radial nerve palsy in the interlocking group but 7% in the plating group.

In plating, there is wide dissection at the fracture site so there is higher chance of damage to the radial nerve whereas in interlocking group, the fracture site remains unexplored therefore there are less chances of radial nerve damage.

6. Elbow stiffness

It was encountered in only one patient (5%) in the interlocking series. This was due to associated elbow dislocation which was closed reduced.

No cases of elbow stiffness were noted in the plating series.

7. Anesthesia in the regimental badge area

Such a complication was encountered in Lal et. al.51 in one case (4.5%). This complication is encountered due to damage to the upper lateral cutaneous nerve of the arm while performing proximal locking.

Only one case (5%) in the present series of interlocking had anesthesia in the regimental badge area which was transient and lasted for 2 months and recovered completely.

Proper precaution have to be taken to avoid such complication. The Wheeless Online Textbook of Orthopaedics states that the nail should ideally be counter-sunk 5 mm below the entry point. If the nail is counter sinked more than 1 cm bellow the articular surface, the proximal interlocking screw comes at the level of axillary nerve and risks the nerve. One should

44

therefore be sure that the proximal locking screw should be above the surgical neck of the humerus to avoid this complication.

This complication was not seen in the plating series.

45

S U M M A R Y

The present study was conducted on a series of 52 cases of fracture of shaft humerus was treated by internal fixation – 20 cases by interlocking intramedullary nail and 28 cases by plating (4 lost at follow-up).

The youngest patient was 18 years old and the oldest was 79 years old. The commonest age group affected was 21-30 years (38%) and maximum number of patients were below the age of 40 years (58%).

Male preponderance 67% was seen in this study.

The commonest mode of injury was road traffic accidents (54%).

Right sided predominance of 54% was seen.

Majority of fractures (54%) were in the region of the middle 1/3rd of the shaft of the Humerus.

Majority of patients (38%) had a simple transverse type of fractures.

The commonest indication for fixation was polytrauma (64.58%) followed by compound fractures (10.4%).

The commonest associated injury was trauma to the head (21%) followed by associated injuries to the axial or appendicular skeleton.

The average time of union was 10.5 weeks in interlocking series and that in plating series was 13 weeks.

Radial nerve palsy was present in 3 (6.25%) patients at admission 2 of which recovered within 4 months and 1 persisted.

Superficial infection occurred in 5% of the patients treated with intramedullary nailing and 18% of the patients treated with plating. All healed after regular sterile dressings and antibiotics.

Deep seated infections were encountered in 7% of patients treated with plating but not encountered in interlocking intramedullary nailing.

Shoulder stiffness was seen in 20% of the cases of interlocking intramedullary nailing and in 3% of patients with plating.

Delayed union was observed in 10% of cases in interlocking intramedullary nailing and 11% in plating series.

Non-union was seen in 11% of cases of plating and was not observed in interlocking series.

Anesthesia in regimental badge area was seen in 5% of cases in interlocking intramedullary nailing but not observed in plating series.

46

In short, of the 48 fractures of humerus, 20 were treated with interlocking intramedullary nailing of which mean union time was 10.5 weeks (8-16 weeks) with 100% union. 28 were treated with plating, with a mean union time of 13 weeks (8-24 weeks) with union rate of 92.85%.

47

C O N C L U S I O N

The present study was aimed to evaluate and compare the results of plating and interlocking nailing in the treatment of the fracture of the shaft of the humerus.

From the above observation it is clear that interlocking nailing has following advantages over plating.

I. Higher union rate. II. Interlocking nailing being a load sharing implant is a more physiological

fixation than plating and hence early return to pre-fracture state is possible. III. Lower rate of infection. IV. Lower Radial nerve complication.

Hence these makes it an ideal method of fixation for following fractures.

Closed comminuted fractures of shaft humerus. Compound fractures. Delayed unions and non-unions. Pathological fractures, which includes osteoporotic fractures. Stress fractures at plate ends. Polytrauma patients were early mobilization is a goal.

However when used one has to take following precautions:

1. To prevent shoulder movement restriction by : Proper countersinking the nail at entry point. Irrigation of entry point site to remove all reamed bone

debris. Careful dissection of rotator cuff to prevent its damage. Early mobilization and proper post-operative

physiotherapy and rehabilitation. 2. To prevent tilting and angular deformities when used in

fractures of lower third humerus.

48

Annexure I

THE CONSTANT MURLEY SCORE FOR SHOULDER FUNCTION

CRITERIA POINTS MAXIMUM POINTS

Forward flexion

0 - 300 0

31 - 600 2

61 - 900 4

91 - 1200 6

121 - 1500 8

151 - 1800 10

Adduction 10

0 - 300 0

31 - 600 2

61 - 900 4

91 - 1200 6

121 - 1500 8

151 - 1800 10

0 - 300 0

External rotation

(hands not allowed to touch head)

10

Hand not reaching head 0

Hand behind head with elbow forward 2

Hand behind head with elbow back 2

Hand on top of head with elbow forward 2

Hand on top of head with elbow back 2

Full elevation of hand from on top of head 2

Internal rotation 10

End of thumb to lateral thigh 0

End of thumb to buttock 2

End of thumb to lumbosacral junction 4

End of thumb to L3 spine (waist) 6

End of thumb to T12 spine 8

End of thumb to T7 spine 10

Strength 20

Measured in four different direction on a 5 grade scale

1. Elevation 5

2. Abduction 5

3. Internal rotation in 00 abduction 5

4. External rotation in 00 abduction 5

Strength is graded as follows : No contraction 0 Flicker of contraction 1 Movement with gravity eliminated 2 Movement against gravity 3

49

Movement against some resistance 4 Normal power 5

Annexure II

THE AMERICAN SHOULDER AND ELBOW SURGEONS SCORING SYSTEM OF UPPER LIMB FUNCTION

Scoring:

4 = Normal

3 = Mild compromise

2 = With difficulty

1 = With aid

0 = Unable

Criteria:

- Reaching back pocket

- Wash opposite axilla

- Comb hair

- Carry 10 pounds weight on side

- Sleep on affected side

- Use hand overhead

- Lift weights

- Perineal care

- Eat with utensil

- Use arm at shoulder level

- Dress

- Pull

- Throw

50

MASTER CHART

No Age Sex Side Type

o

Com/clo# Mode

of

Assoc. inj. Type of Time for Complications

(yrs

)

#(AO) Injury Surgery Union (wks)

1 18 M R A1.2 Closed RTA Head injury Plating (AL approach) 8

2 20 M R A2.2 Closed RTA Head injury Plating (AL approach) 8

3 30 M L A2.3 Closed BT Metacarpal# Plating (AL approach) 16 Superficial infection

4 24 M R A1.2 Closed FALL Hip # Plating (AL approach) 18

5 21 M R A2.2 Closed RTA Abd. Trauma Plating (AL approach) 8 Superficial infection

6 23 M L A1.3 G-I com RTA Forearm # Plating (AL approach) 9 Deep infection

7 27 M L B1.1 G-I com FALL Rib # Plating (AL approach) 20

8 26 M R A2.2 Closed FALL Rib # Plating (AL approach) 18

9 22 M R B2.3 Closed RTA Head injury Plating (AL approach) 7

10 23 M R A1.2 Closed BT Chest inj. Plating (AL approach) 9

11 24 M R B1.1 Closed BT Metacarpal# Plating (AL approach) 8

12 25 M R A2.2 Closed RTA Head injury Plating (AL approach) 5

13 29 M L A3.3 Closed FALL Hip # Plating (AL approach) 8

14 30 M L B1.1 Closed BT Rib # Plating (AL approach) 8

15 21 M L A2.2 Closed RTA Head injury Antegrade IL Nailing 6 Superficial infection

16 22 M R B2.3 Closed RTA Forearm # Antegrade IL Nailing 8

17 51 F R B1.2 G-II com BT Chest inj. Antegrade IL Nailing 18 Delayed union

18 27 M L A1.2 Closed FALL Rib # Antegrade IL Nailing 13

19 28 M R A2.2 Closed BT Colles # Antegrade IL Nailing 8

20 24 F R B2.3 Closed BT #Femur Antegrade IL Nailing 11

21 32 M L A2.1 Closed FALL Rib # Antegrade IL Nailing 8

22 34 M L B2.3 Closed BT Colles # Antegrade IL Nailing 10

23 33 M L A3.1 Closed FALL Head injury Antegrade IL Nailing 8

24 39 M R B2.2 Closed FALL Hip # Antegrade IL Nailing 8

25 38 M R A3.1 Closed FALL Vertebral # Antegrade IL Nailing 16 Shoulder Stiffness

26 37 M R A3.2 Closed RTA Tibial # Antegrade IL Nailing 9

27 40 M L B2.1 Closed FALL Rib # Antegrade IL Nailing 7

28 33 M L B2.2 G-II com RTA Tibial # Antegrade IL Nailing 20 Delayed union

29 41 F R A3.2 Closed FALL Hip # Antegrade IL Nailing 9

30 44 M R B2.2 Closed FALL Vertebral # Antegrade IL Nailing 9

31 46 F L A3.2 Closed RTA Head injury Antegrade IL Nailing 6

32 49 F R B2.2 Closed RTA Abd. Trauma Antegrade IL Nailing 9

33 50 F R A3.1 Closed RTA Head injury Antegrade IL Nailing 7

34 43 M L B2.2 Closed RTA Pelvic # Antegrade IL Nailing 8

35 23 F R A3.1 Closed RTA Head injury Antegrade IL Nailing 6

36 54 F R B2.1 Closed RTA Forearm # Plating (AL approach) 9 Radial Nerve Palsy

37 55 F L A3.1 Closed RTA Pelvic # Plating (AL approach) 8 Superficial infection

38 53 F L A3.2 Closed RTA Tibial # Plating (AL approach) 30 Delayed union

39 55 F L A3.2 Closed RTA Head injury Plating (AL approach) 14

40 56 F R A3.1 Closed RTA Forearm # Plating (AL approach) 12 Superficial infection

41 57 F R A3.2 Closed RTA Tibial # Plating (AL approach) Nonunion

42 60 F L A3.2 Closed RTA # Femur Plating (AL approach) 16 Superfi inf.+Shou.Stif

43 61 M R A3.1 Closed RTA Tibial # Plating (AL approach) 20 Delayed union

44 70 F L A3.2 Closed BT Plating (AL approach) 24 Delayed union

45 71 F L A3.2 Closed RTA Tibial # Plating (AL approach) 10

46 80 M L A3.1 G-II com FALL Plating (AL approach) 16 Deep Infection

47 74 F L C1.2 Closed RTA Malleolar # Plating (AL approach) Nonunion

48 78 F R C1.2 Closed RTA Malleolar # Plating (AL approach) 14

49 20 F L B2.2 Closed RTA Plating (AL approach)

50 24 F L B2.3 Closed RTA Plating (AL approach) Lost for follow-up

51 32 M R A2.1 Closed RTA Head injury Antegrade IL Nailing

52 18 M R A2.1 Closed RTA Antegrade IL Nailing

RTA – Road Traffic Accident inj – injury

Fall - Fall from a height Abd - Abdomen

51

BT - Blunt trauma Shou.Stif. - Shoulder Stiffness

Shou.lmp -Shoulder impinchment AL - Anterio-lateral P-Posterior

# - Fracture IL - Interlocking

com-compound clo – closed

52

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