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SURGICAL REVIEW

The Functional Outcome of Antegrade Unreamed Humeral Interlocking Nailing in Adults

*Shyamasunder Bhat N. MS, DNB (Ortho) Sharath K. Rao MS, D. Ortho

*Assistant Professor,Dept. of Orthopaedics,Kasturba Medical College,Manipal 576 104,India.
Professor & Head, Unit V,Dept. of Orthopaedics,Kasturba MedicalCollege, Manipal 576 104,India

Address for Correspondence

Shyamasunder Bhat N. MS, DNB (Ortho)
Assistant Professor,Dept. of Orthopaedics,Kasturba Medical College,
Manipal 576 104,India.
' +91 820 2575630, +91 94481 25630
E-mail: shyambhatn@yahoo.com

 

ABSTRACT

Background: Fractures of the shaft of humerus account for approximately 1% of all fractures treated. The technique of interlocking nailing represents the newer approach of the treatment of humeral fractures.
Methods: This was a prospective clinical study between April 2000 and December 2002 involving 41 consecutive antegrade unreamed closed humeral nailing for acute humeral shaft fractures in department of Orthopaedics, Kasturba Medical College & Hospital, Manipal. Of these, 37 patients were followed up for at least 18 months postoperatively. Radiological union, functional outcome and complications were assessed.
Results: Union rate was 91.89% by the end of 6 months. According to Rodriguez-Merchan EC criteria, 20 patients had excellent functional rating, 11 had good rating, 3 had fair rating and 3 had poor rating. There were 3 cases of nonunion, 2 cases of iatrogenic fractures, 3 cases of proximal protrusion of nail and 4 cases of stiffness of shoulder.
Conclusions: Unreamed humeral interlocking nail is an effective means of fixation of acute humeral fractures. It is also of special value in open humeral fractures due to lower incidence of infections. Shoulder stiffness is a significant problem in antegrade nailing.
Key Words: Humeral shaft fracture, humeral interlocking nailing, antegrade unreamed

 

J.Orthopaedics 2005;2(1)e2

Introduction

Fractures of the shaft of humerus account for approximately 1% of all fractures treated(1). Historically humeral shaft fractures have been classified by fracture location, fracture pattern, associated soft tissue injuries and quality of bone. This fracture has been treated by closed reduction & cast application with/without cast bracing and open reduction & internal fixation using dynamic compression plate. Many authors have documented the general good outcome that occurs after compression plate fixation(2,3,4), which is still considered the gold standard for operative treatment of acute humeral shaft fractures.  Though plate fixation has given high rates of union, it involves extensive soft tissue stripping, potential injury to radial nerve and poor fixation in osteoporotic bone. Later flexible nails of many varieties were used(5,6). The advantages of intramedullary nailing are minimal surgical exposure, better biomechanical fixation, minimal disturbances of soft tissues and early mobilization of neighboring joints.

The technique of interlocking nailing represents the newer approach of the treatment of humeral fractures. Interlocking nailing also avoids complications like lack of rotational control, migration of nail and requirement of supplementary bracing(7,8). The Seidel nail was the first nail to be tested clinically. Eventually several nail systems evolved (3,7,9,10,11).

The studies published by Cox MA(7) and Crates J(10) union rates were 87.9% and 94.5% respectively in antegrade interlocking nailing. Antegrade interlocking nailing has a higher rate of shoulder stiffness(7). The unreamed intramedullary nail has its own distinct theoretical advantages like eliminating the chances of iatrogenic fractures, sparing of cortical blood supply and eliminating the damage to rotator cuff.

The aim of this study was to evaluate the functional outcome after antegrade undreamed interlocking nailing in fracture shaft of humerus, the union rate and the causes of poor outcome.

 

Patients and method

This was a prospective clinical study between April 2000 and December 2002 involving 41 consecutive antegrade unreamed closed humeral nailing for acute humeral shaft fractures in department of Orthopaedics, Kasturba Medical College & Hospital, Manipal. Pathological fractures, nonunions, failed dynamic compression plate were excluded from the study.

All the nails were inserted antegrade through an entry point just medial to greater tuberosity. Reaming was not done to avoid damage to radial nerve and to reduce damage to the rotator cuff. All these fractures were fixed using a universal humeral nail of 6.7 mm diameter and of appropriate length calculated intraoperatively.  Distal locking was done anteroposteriorly by freehand technique using image intensification. Proximal locking was done using the jig. Rotator cuff was repaired in all cases.

In 31 patients the operated limb was immobilized for 2 days and active assisted shoulder mobilization was started from 3rd postoperative day. In the remaining 10 patients mobilization of the shoulder was delayed due to associated ipsilateral upper limb fractures. We followed up 37 patients for minimum of 18 months postoperatively. One patient died during the course of follow up and 3 were lost from follow up.

Radiological union was defined as the presence of bridging callus of there cortices in two orthogonal views(7). Delayed union was defined as failure of fracture union to occur by 4 months. Non union was defined as failure of fracture union by six months or evidence of fixation failure(3).The functional outcome was assessed using Rodriguez-Merchan EC criteria(10). The range of movements was measured by a single observer using a goniometer.

Shoulder stiffness was defined as per Benjamin Shaffer(12) and Douglas(13) criteria.

1)History of injury or repetitive trauma or surgery with onset of stiffness that functionally restricts the use of extremity.
2)An examination with limited with limited shoulder motion in a specific direction, multidirectional or globally.
3)Radiograph with normal cartilaginous joint space.
4)Range of motion of shoulder that was less than 90% of the range when unaffected contralateral shoulder.

Results

There were 33 men and 8 women in this study with a mean age of 41.1 years (19 - 77 years). There were 24 right and 17 left sided fractures. Out of 41 fractures, 32 were closed fractures and 9 were open fractures. Of the open fractures 1 was type 1, 6 were type 2, 1 was type 3A and 1 was type 3B. The fractures were classified according to AO classification. Out of these 41 cases, 37 cases were followed up for a period of at least 18 months and were analysed for the end results. The mean follow up period was 23.9 months (18 42 months).


                (Figure-1)
Union:
Twenty eight of the 37 fractures united within four months. There were 6 delayed unions of which 4 were AO type A3 fractures, 1 was B1 fracture and 1 was B2 fracture. Three of these had distraction at fracture site, two had splintering at the fracture site during nail insertion into the distal fragment and one was open type II fracture. These six fractures however united within 6 months. The overall union rate was 91.89% by the end of 6 months (Figures 1-3).

Non union occurred in 3 patients.  One was an open type 2, AO type B1 fracture and there was distraction at the fracture site. He was treated by


               (Figure-2)

bone grafting. The second nonunion was an open type 2, AO type A3 fracture and he had come back with a broken nail at the level of the fracture at 6 months. The third nonunion was an open type 3B, AO type B3 fracture. These two patients underwent nail removal, plating & bone grafting and they were rated as poor outcome because of the failure of the nail to achieve union.


              (Figure-3)

Functional outcome: According to Rodriguez-Merchan EC criteria(10), 20 patients had excellent rating. Eleven patients had good rating, 3 had fair rating and 3 had poor rating. One patient was categorized as excellent and one was rated as good after the removal of the nail.

Complications: There were four preoperative radial nerve palsies which recovered within 3 months. There were no iatrogenic radial nerve palsies and there were no post operative wound infections.

Two patients had comminution at the fracture site during nail insertion. There was one case of breakage of the distal locking screw, but it did not affect the outcome. There were 4 cases of stiffness of shoulder. Totally five patients underwent implant removal of which 3 were for the proximal protrusion of nail.

 

Discussion

Stable internal fixation of upper arm fractures enabling early active mobilization is enjoying growing popularity(4).  Intramedullary nailing allows earlier use of the limb. This is especially relevant in multiple trauma patients who need early mobilization(7).  Locked intramedullary nails allow load sharing between the implant and the fractured bone, avoid excessive soft tissue dissection required for plating, control rotation better than flexible nails, and allow early mobilization(10).

Union: Out of the 37 cases, 34 fractures had united by the end of 6 months with an overall union rate of 91.89%. This result is comparable to the union rate achieved by Chapman JR (87%)(3), Cox MA (87.9%)(7), Crates J (94.5%)(10). Chi-Chian Wu (14) reported a nonunion rate of 16.7% after Seidel interlocking nailing which required supplementary stapling. In our series, out of the 6 delayed unions, 3 fractures were fixed with distraction at the fractures site and 2 patients had splintering at the fracture site while inserting the nail. The medullary cavity narrows about three cm above the Olecranon fossa and this may cause obstruction to the nail and distract the fracture site. Several surgeons with varying experience operated on the fractures and distraction at the fracture site might also be because of technical error.

Functional outcome: The main concerns in antegrade intramedullary nailing of humeral shaft fractures are with shoulder stiifness(7). Previous reports have implicated injury to the rotator cuff, disruption of the articular cartilage or adhesive capsulitis as a result of antegrade entry(6,15). In the antegrade approach, it is essential to ensure that both the nail and the proximal locking screws are deep to the cortex to reduce impingement.

Out of 37 patients, 31 had good to excellent functional rating. Six patients had fair to poor results.  Four patients had shoulder stiffness at the end of follow up. Of these in 3 patients the nail was long and protruding into the rotator cuff which obviously had caused restriction of abduction. The role of underlying rotator cuff pathology in any of the cases has not been taken into consideration.  And also the technique of antegrade nailing has a learning curve.

Complications: None of these cases developed postoperative infection though some were open fractures. Infections rates were 5.9% and 7% in studies on treatment of humeral shaft fractures by plating conducted by Vander Griend(4) & Foster(16).

Intraoperative complications were in 2 patients in the form of splintering at the fracture site while passing the nail into the distal fragment. None in this series developed radial nerve palsy. Bell2 and Vander Griend(4) reported 2.9% radial nerve palsy following plating of humeral shaft fractures.

Conclusions 

Unreamed humeral interlocking nail is an effective means of fixation of acute humeral fractures. It is also of special value in open humeral fractures due to lower incidence of infections. Distraction at the fracture site should be avoided. Shoulder stiffness is a significant problem in antegrade nailing, which can be minimised if care is taken to prevent proximal protrusion of the nail and repair the rotator cuff properly.

 

References

1. Dobozi WR. Flexible Intramedullary Nailing of Humeral Shaft Fractures.  In: Browner BD, ed. The Science and Practice of Intramedullary Nailing: Lea and Febiger; 1987; 305-318.
2. Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY.  The results of Plating Humeral Shaft Fractures in Patients with Multiple Injuries. The Sunny Brook Experience.  J Bone Joint Surg Br. 1985; 67; 293-296.
3. Chapman JR, Henley MB, Julie A, Benca PJ.  Randomized Prospective Study of Humeral Shaft Fracture Fixation: Intramedullary Nails Versus Plates.  J Orthop Trauma. 2000; 14; 162-166.
4. Vander Griend R, Tomasin J, Ward EF.  Open Reduction and Internal Fixation of Humeral Shaft Fractures.  Results Using AO Plating Techniques. J Bone Joint Surg Am. 1986; 68; 430-433.
5. Brumback RJ, Bosse MJ, Poka A, Burgess AR.  Intramedullary Stabilization of Humeral Shaft Fractures in Patients with Multiple Trauma.  J Bone Joint Surg Am. 1986; 68; 960-970.
6. Stern PJ, Mattingly DA, Pomeroy DL, Zenni EJ, Kreig JK: Intramedullary Fixation of Humeral Shaft Fractures. J Bone Joint Surg Am. 1984; 66; 639-646.
7. Cox MA, Dolan M, Synnott K, McElwain JP.  Closed Interlocking Nailing of Humeral Shaft Fractures with the Russell-Taylor Nail.  J Orthop Trauma. 2000; 14; 349-353.
8. Rommens PM, Verbruggen J, Broos PL: Retrograde Locked Nailing of Humeral Shaft Fractures. A Review of 39 Patients. J Bone Joint Surg Br. 1995; 77; 84-89.
9. Blum J, Janzing H, Gahi R, Langendorff HS, Rommens PM.  Clinical Performance of a New Medullary Humeral Nail:  Antegrade Versus Retrograde Insertion.  J Orthop Trauma. 2001; 15; 342-349.
10. Crates J, Whittle PA. Antegrade Interlocking Nailing of Acute Humeral Shaft Fractures. Clin Orthop. 1998; 350; 40-50.
11. Lea RD, Gerhardt JJ. Range-of-Motion Measurements.  J Bone Joint Surg Am. 1995; 77; 784-798.
12. Shaffer B, Tibone JE, Kerlan RK.  Frozen Shoulder. A Long-term Follow-up. J Bone Joint Surg Am. 1992; 74; 738-746.
13. Harryman DT II. The Stiff Shoulder.  In: Rockwood CA Jr, Matsen FA III, ed. The Shoulder. Vol 2: W.B. Saunder's Company; 1998; 1075-1076.
14. Chi-Chuan Wu:  Humeral Shaft Non-union Treated by a Seidel Interlocking Nail with a Supplementary Staple.  Clin Orthop. 1996; 326; 203-206.
15. Foster RJ, Dixon GL, Bach AW, Appleyard RW, Green TM.  Internal Fixation of Fractures and Non-unions of the Humeral Shaft.  Indications and Results in a Multi-center Study.  J Bone Joint Surg Am. 1985; 67; 857-864.
16. Foster RJ, Swiontkowski MT, Bach AW, Sack JT.  Radial Nerve Palsy Caused by Open Humeral Shaft Fractures.  J Hand Surg [Am]. 1993; 18; 121-124.

 

 

 This is a peer reviewed paper 

Please cite as :

*Shyamasunder Bhat N, The Functional Outcome of Antegrade Unreamed Humeral Interlocking Nailing in Adults
J.Orthopaedics 2005;2(1)e2

URL: http://www.jortho.org/2005/2/1/e2

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