ender nailing in humerus

8/12/2019 Ender nailing in humerus

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Closed reduction and internal

fixation of # shaft of humerus with

ender nails

By

Dr. Rakesh KumarM.S. Ortho (std.)

Co authors: Dr. (Prof) Arjun Singh

Prof & Head

Dr. Ajoy Kumar Manav

Asst. Professor

Deptt. Of Orthopaedics

Patna Medical College & Hospital


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INTRODUCTION

Fracture shaft of humerus with or

without neurovascular complications is

a common entity.

It constitutes approximately 3-5% of allfractures.

With the growing mechanization and

increasing road traffic accidents, it

often presents in a bizarre way and

becomes difficult to manage, especially

at the ends.


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EPIDEMIOLOGY

It has a bimodal distribution.

In younger age group: males >females.

In older age group: females> males.

High energy trauma (especially motor

vehicle accidents) is more common inthe young males

Low energy trauma ( trivial fall at home)

is more common in the elderly female.


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AGE AND GENDER SPECIFIC

INCIDENCE OF SHAFT OF

HUMERUS FRACTURE
http://www.google.co.in/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=Uv39Oeo7Y6onVM&tbnid=dXy9DVC5DCSV7M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.msdlatinamerica.com%2Febooks%2FRockwoodGreensFracturesinAdults%2Fsid835419.html&ei=VVJEUpz7ApCnrAe9q4DYBw&bvm=bv.53217764,d.dGI&psig=AFQjCNEa2LYjgIVJUMc4GIs9dLfAoEBg7g&ust=1380295620738812


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There is no universal consensus on themost appropriate method formanagement.

Conservative management is a rational

option for the treatment of isolatedhumeral shaft fractures with no orminimal displacement.

Sir John Charnley in his treatise Theclosed treatment of commonFractures states that it is one of theeasiest major long bone fractures to

treat by conservative methods.


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However conservative management

has its own demerits: It requires a long period of

immobilization, which carries a risk

of prolonged shoulder joint stiffness.

Nonunion after conservativetreatment does occur in


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Surgical management is a better choice

in case of :

Polytraumatised patients

Unstable fracture (spiral/long oblique)

Comminuted fractures

Segmental fractures

Pathological fractures

Open fractures &

Fractures associated with radial nerveinjury and major vascular injury


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For the shaft portion i.e. leaving

about 5 cm form above and 5cm from below, plate is the

unanimous choice.

A variety of these plates are in

use today such as DCP,LC-

DCP, locking plate and others.

There has been a sea change

in the technique also i.e. from

open reduction to MIPO.


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In adults, interlocking intramedullary

nails are also in use.

However, injury to the rotator cuff

has restricted its use to a greatextent.

Problems such as iatrogenic fracture

comminution (especially in small

diameter canals), and nonunion

(and significant difficulty in its

salvage) have also been reported.


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Ender nails

Enders nails are flexible nail which

can be molded to any shape and

angled to most of the long bones.

It works on the principal of three

point fixation and achieve stability

by stacking.

It has been mostly used for tibia

and femur fractures, especially in

children.


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Review of Literature

Hall RF Jr, Pankovich AM.1987

found that

Average time to clinical union = 7.2

weeks. 1 out of 86 cases developed non

union.

No infection or malunion. 1 nail backed out.
http://www.ncbi.nlm.nih.gov/pubmed?term=Hall%20RF%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Pankovich%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Pankovich%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Hall%20RF%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=3571315


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Chenet alin 2000 conducted a

retrospective study of 118 cases

and found

Average operative blood loss = 105

cc

Average operation time = 57 min.

Average hospital stay =6.5 days
http://www.injuryjournal.com/article/S0020-1383%2800%2900081-4/abstracthttp://www.injuryjournal.com/article/S0020-1383%2800%2900081-4/abstract


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Average time to union =10.5 weeks

Post operative complications

included:

Superficial infections = 3/118

Iatrogenic radial nerve palsy

=1/118 Nail backouts = 8/118

Non union =8/118


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M.S. Moon et al, in 2002 performed

ender nailing in 67 patients. Theyused 1 nail in 18 cases, 2 nails in 48

cases and 3 nails in 3 cases.

Radiological visible bridging callus

was observed at 6.8 weeks on

average (5-15 wks)

Average clinical union time was 9.3weeks.


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In 6 cases, the long nail distracted

the fracture gap, and resulted in

delayed union.

In cases of proximal nail migration,

shoulder pain and partial stiffness

were complicated, which

disappeared after nail removal.


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AIM OF STUDY

To study the functional outcomes of

Ender nails in management of

humerus fractures by closed

technique.


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MATERIAL AND METHODS

This prospective study was carried

out at the Patna Medical College

Hospital, Patna, India, between

January 2008 and December 2012. 50 patients admitted from emergency

department of our hospital, with a

humeral shaft fracture suitable for

Ender nailing were included in thestudy.

Informed consent was obtained from

the patients participating in the study.


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Approval from the ethical committee

was taken.


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Fracture Side

28, 56%

22, 44%

Right Left


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15

22

10

3

0

5

10

15

20

25

10-20 21-30 31-30 41-50

Age distribution


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2225

3

0

5

10

15

20

25

Low Middle High

Socio Economic Group

Socio economic group:


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AO CLASSIFICATION

Fractures were classified according

to the AO system

1HUMERUS

2--- DIAPHYSISASPIRAL 1-PROXIMAL ZONE

2- MIDDLE ZONE

3- DISTAL ZONE

B- OBLIQUEC- TRANSVERSE


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3


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A3


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SURGICAL TECHNIQUE

The nails were introduced through a

small stab incision 1.5 cm in length on

the anterolateral aspect of the head of

the humerus lateral to the greatertubercle.

The deltoid muscle was split to

visualize the insertion of rotator cuff.

Nails were inserted through holes made

distal to the rotator cuff.

Most often only two nails were used.


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Post operative management

Patients were given arm slings and

pendulum and elbow movements were

allowed as the pain subsided.

An initial follow-up was done at 10 daysfor wound review.

At 3 weeks, patients were encouraged

to start active shoulder exercises.

Patients were further followed up at

6,12, 20, 28 weeks.


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Plain radiographs were taken to

evaluate union.

Radiographic union was defined as

observation of an osseous bridge inboth AP and lateral radiographs.

Clinical union was defined as absence

of motion or tenderness on movement

or manipulation of the arm.

We defined non union as no evidence

of union after 24 weeks.


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Shoulder function was evaluated using the

constant score, which assigns a maximum

of 100 points according to different

parameters:

Presence of residual pain

Impairment in daily functions

Recreational activities or sports, and

Limitation in active movements or in the

shoulders strength.


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Sex Ratio

32, 64%

18, 36%

Male Female


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In our study:

Average time for union: 12-20

weeks

Mean time: 12.8 weeks

Average blood loss : 10-20 ml Average exposure time for x-rays : 1

min

Primary union was achieved in - 45cases (90%)

Bone graft was required in - 5

cases.


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Time of union

Within 12 weeks- 40 cases (80%)

Within 20 weeks- 5 cases (10%)

No union upto 24 weeks- 5 cases(10%)

Revision surgery was done withbone grafting


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Case 2

Pre-operative Post-operative


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After 10 weeks


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Case 3

Pre-operative

Post operative


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Functional outcome:

Full range of shoulder and elbow

movement was achieved in40

cases (80%) within 16 weeks.

In rest of the cases, abduction was

limited to 900.

Rest 5 cases (i.e. 10%) required

vigorous physiotherapy, then

improved.


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Case 1


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External rotation Internal rotation


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Case 2 - Abduction restricted to 900


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Complications:

Superficial stitch infection- 3 cases

(managed by intravenous

antibiotics)

Proximal migration of nails- 2 cases

(realignment surgery was done)

Shoulder stiffness- 5 cases

(required vigorous physiotherapy)


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Our series did not have any post

operative nerve injuries or deep

infections.


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Comparison between different

modalities of treatment

Conservative

literature

suggests that

average time tounion ranges

from 6.2 to 9.4

weeks.

Union rates>90% due to

the excellent

blood supply of

Ender nailing

literature

suggests that

average time tounion ranges

from 7.2 to 9.3

weeks

Similar unionrates i.e. > 90

% due to

preservation of


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the bony

fragments

provided by the

surrounding softtissue and

muscle

envelopes

soft tissues

during insertion

and periosteum

and fracturehematoma at #

site.


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Ender nailing vs interlocking nail

Ender nails

Ender nails does

not require

reaming andthus relatively

preserve the

endosteal blood

supply. Ender nailing

relies on

configuration.

Interlocking nails Reaming of

interlocking nailsdestroys the

residualendosteal bloodsupply and hasdeleteriouseffects on fracture

union. With reamed

interlocking nails,locking screws

are


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and spatialorientation ofthe nails toachieve

rotationalstability.

They canachieve goodfixation inosteopenicbones

used to providerotationalstability.

They rely onbone qualityand henceachieve poorfixation inosteopenicbones


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Discussion

The use of ender nail in

management of # shaft of humerus

is not a common practice.

But in our part, where economy &time is prime concern it gives good

results.

The results are comparable with

plate and interlocking nail.

The technique is simple and require

minimum instrumentation (except

IITV).


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Overall stability of the construct

depends on the number and size of

implants and their spatial distribution

with adequate flushing in themedullary canal.

Meticulous preoperative planning

and intra-operative execution is thekey to this operation.


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The use of Ender nails in elderly

patients having multiple injuries or

pathological fractures has been

shown to be minimally invasive and

safe, and to produce excellentfunctional and cosmetic result.

This technique gives minimal x ray

exposure, short operative time and

causes less soft tissue insult. This decreases the overall morbidity

in elderly and poly traumatised

patients


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Conclusion

Ender nailing for # shaft of humerus

is a cost effective, time saving and a

technique with minimal blood loss.

Although plate osteosynthesis is

considered the gold standard, ender

nails have many benefits, with good

results attainable and comparablewith those seen with conservative

modalities.


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ender nailing in humerus

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