Two patients with New type 6 fractures had unsafisfacfoy shoulder @zction; in the four other patients poor shoulderfincfion resulted from a pre-existing condition.
Injury (1993) 24, (6), 403-406
Printed in Great Britain
Locked intramedullary
403
nailing of humeral fractures
R. M. P. H. Crolla, L. S. de Vries, G. J. Clevers Department
of Surgery, University
Hospital Utrecht, Utrecht, The Netherlands
with fresh fractures of the humerus, nine with non-unions and seven with pafhologicalfracfures were treated with a new of
46 patients, 30
locked inframedulla y nail. of 30 patients with a fresh humeral fracfure, three were losf to follow-up. All fresh fracture.5 healed within 4 months. Functionalresultsof the fresh fracfure group were excellent in eighteen patients and satisfactory in three patients. Two patients with New type 6 fractures had unsafisfacfoy shoulder @zction; in the four other patients poor shoulderfincfion resulted from a pre-existing condition. 0ut of nine non-unions, six united within 6 months. The three other patienfs with atrophic non-union required bone-grafting later, after which consolidation was obtained. The long jiozctional recovey period of he non-union group was related to the pre-existing limited shoulderjimction. The seven patients wifh a pathologicalfrarttlre died within 8 months of operation. While alive they were free from pain and could be nursed well.
Introduction Humeral fractures are generally treated non-operatively and without difficulty (Bijhler, 1964; Mast et al., 1975; WatsonJones, 1976: Sarmiento et al., 1977). Of the non-operative methods, functional bracing is preferred by most authors (Sarmiento et al., 1977; Langenberg, 1957; Peeters et al., 1957; Link and Henning, 1955). Non-operative treatment requires cooperative patients. Operative management of humeral shaft fractures should be considered in uncooperative patients. Other relative and absolute indications for operative treatment are well-established (Bone, 1988; Link and Henning, ‘1988) (Table I). Various methods of operative treatment of fractures of the humerus have been described (Rush and Rush, 1950; Kiintscher, 1955; Schweiberer et al., 1977; Dubin et al., 1953; Pritchett, 1985; Foster et al., 1985). Plate osteosynthesis is Table I. Indications
for operative
treatment
We report our early experiences with the Seidel nail in the treatment of fractures of the humerus.
Method and operative technique The Seidel nail and the technique of operation have been described elsewhere (Seidel, 1959; Jensen et al., 1992). The introduction site is critical. We open the medullary canal behind the greater tuberosity, outside the articular cartilage. The proximal end of the nail has to be countersunk beneath the cortex. In fractures of the head of the humerus or subcapital fractures, a sagittal incision is used and the deltoid muscle is separated from its insertion. The cap washer is introduced after the nail has been countersunk about 1 cm beneath the cortex. External rotation is limited during the first 2 weeks. After this period, full mobilization is allowed. In fractures of the head, the nail and cap washer are removed after 6 to 10 weeks. The material is not always removed in humeral shaft fractures. Clinical and radiographical consolidation were recorded and the functional results were assessed according to Neer (Neer, 1970). Consolidation is difficult to measure. Our criteria were a bridging callus formation on radiographs and absence of pain at the fracture site. A non-union was diagnosed if the fracture failed to unite within 24 weeks.
of humeral fractures
Between January 1987 and March 1991 the Seidel nail was used in 46 patients. There were 26 men and 20 women with an average age of 46 years (range 16-52 years). Thirty patients had sustained a fresh fracture, seven had a pathological fracture and nine had a non-union. The fracture site for each fracture type is listed in Tublefl. A fresh fracture in multiply-injured patient was the most frequent indication for operative management. This and the other main indications for operation in patients with a fresh
Relative indications Uncooperative patient Pathologic fracture Nerve lesion Multiple injuries Proximal humeral fractures Non-stable, transverse fracture
0 1993 Butterworth-Heinemann
1992).
Material
Absolute indications Open fracture Arterial lesion Non-union
OOZO-1383/93/060403-04
the most favoured method, but complications are frequent, especially radial nerve lesions (Rommens et al., 1989). Therefore, alternative methods for operative treatment of humeral fractures are sought. Recently, Seidel developed a new intramedullary humeral locking nail. The use of this nail, which provides stability without endangering nerves or vessels, may diminish complications in operative treatment of humeral fractures (Seidel, 198% Habemek and Orthner, 1991; Jensen et al.,
Ltd
Injury: International Journal of the Care of the Injured (1993)Vol. 24/No.6
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Table II. Location of humeral fractures in a group of 46 patients Fresh Capital and subcapital Proximal third Middle third Distal third
8 3 15 4
Total
30
Pathological
Non-union
1 3 3
1 2 5 1
7
9
-
Table III. Main indication for operative treatment humeral fractures with a Seidel nail (N= 30)
of fresh
Multiply-injured patients (average Injury Severity Score: 37) Uncooperative patients Proximal humeral fracture Nerve lesions Others
14 5 4 2 5
Total
30
Table IV. Nerve lesions due to original trauma in ten patients with a fresh humeral fracture Brachial plexus palsy Axillary nerve palsy Radial nerve palsy Total
4 1 6
Figure 1. Example of a multiply-injured patient with a humeral shaft fracture treated with the Seidel intramedullary locking nail. Radiographs show the situation before operation, after operation, after 4 months and after removal of the nail.
11
fracture are shown in TableIll. Of these patients, ten had 11 nerve lesions due to the original trauma (Table IV). The pathological fractures all resulted from metastases. Surgical treatment was followed by radiotherapy. The original treatment in five of the nine patients with non-union consisted of poor intramedullary nailing (Enders pins and Rush pins). In one case pin tract infections of an external fixation led to an infected non-union. In the three other patients non-operative treatment was followed by a non-union. The time from fracture to treatment of the non-union ranged from 6 to 24 months. In the total group of 46 patients, open reduction was performed in seven cases of capital and subcapital fractures and a Seidel nail with cap washer was introduced. In one patient with atrophic non-union of the proximal shaft, open reduction with autotransplantation of bone chips was performed. In all the other patients the fracture could be reduced and fixed by closed methods. All but seven shafts were reamed.
Results Fresh fradures In the fresh fracture group, consolidation occurred within 4 months in all patients with a fracture of the shaft (Figure I). All fresh proximal humeral fractures had consolidated between 6 and 12 weeks (average 9 weeks) after operation. Functional results after treatment of fresh fractures were patients, each recorded in 27 patients. Two multiply-injured with an Injury Severity Score (ISS) of 50, died within the first few days following the trauma and one multiply-injured patient remained in a coma. In all, 18 patients had excellent results (Neer score > 89) within 4 fours months; three had satisfactory results (Neer score 80-89); two patients had
unsatisfactory results (Neer score 70-79), both in Neer type 6 fractures treated with a cap washer. Of the four patients with poor results, two had a persistent traumatic brachial plexus lesion, one had a persistent axillary nerve palsy, caused by the trauma, and one was severely debilitated. Pathological fractures The seven patients with pathological fractures- all died within 8 months. They were all free from pain and could be nursed well. Radiographic follow-up was not performed routinely in these patients. Non-unions Out of nine non-unions, six united within 6 months, including the infected non-union and the atrophic non-union primarily treated with bone chips. No consolidation was obtained 8 months after introduction of the Seidel nail in the three other patients. These non-unions also united, after autotransplantation of bone chips. Three young patients of the non-union group (23,27 and 38 years old) had excellent functional results within 4 months. In the six other patients with a mean age of 60 years (range 40-75 years), functional recovery took longer. The mean Neer score in these six patients rose from 26 (range X5-40) before introduction of the Seidel nail to 88 (range 68-95) after a mean follow-up of 25 months (range 15-54 months). Of these six patients, three had excellent results, one a satisfactory result and two had poor results. Complications There were four minor device- and procedure-related complications. Once the proximal target device was broken, due to inadequate handling. Three times an additional fracture was created during introduction of the nail.
Crolla et al.: Locked intramedullary nailing of humeral frachmes
There were no early postoperative complications. Late complications occurred in two patients. In one case a consolidated fracture presented with the clinical signs of late low-grade infection near the introduction site of the nail. The inflammatory reaction disappeared within a few days after removal of the nail. Multiple cultures and stain tests of allergy for metals were negative. In one patient with a distal pseudarthrosis, the nail broke 8 months after introduction. We conclude that the nail was too short, but longer nails were not available at that time. The pseudarthrosis had to be opened in order to remove the distal part of the broken nail. A new, longer nail was introduced and bone chips were autotransplanted. A transient radial nerve lesion occurred after this second operation. Consolidation was attained after 4 months.
Discussion Plate osteosynthesis of humeral fractures requires an open procedure, endangers the radial nerve and may result in an unsightly scar (Foster et al., 1985, Rommens et al., 1989). Intramedullary nailing is a closed procedure, which leaves a small scar. Radial nerve lesions caused by intramedullary nailing are rarely reported. The distal locking of the Seidel nail theoretically provides more stability than unlocked intramedullary nails and does not endanger the radial nerve. The operative technique proved to be relatively simple. A closed reduction could be obtained in all fresh fractures of the shaft. Proximal locking was performed without difficulty, except in one case where the target device broke during introduction of the nail. Distal locking did not always result in radiographic evidence of spreading the vanes. However, the rotational stability tested during the operation seemed adequate in all cases. During the first 2 weeks of the functional after-treatment, external rotation was limited to prevent possible loosening of the distal locking. In practice, rehabilitation was not delayed, as mobility was mostly restricted by pain in the first weeks. All fresh fractures showed ra id consolidation. NO delayed union or non-union occurre B, Six patients with fresh fractures had some loss of function. However, in all these patients accompanying circumstances predisposed to loss of shoulder motion. We expected the cap washer to reduce mobility of the shoulder. Function was normal in three out of seven patients in which the cap washer was used. The poor result in two patients may have been caused by concomitant problems. Application of the cap washer may be useful in some cases of proximal humeral fractures. However, experience with the’cap washer is too short to draw any definite conclusions. In pathological fractures of the humerus, this method allowed a quick and pain-free rehabilitation. Multiple metastases along the shaft can be managed with this nail, while plate osteosynthesis in these cases may be very difficult. In the nine patients with a non-union, a 100 per cent consolidation was achieved after introduction of the Seidel nail, although in three patients a second operation was indicated. The long period of functional recovery in nonunions was related to age and pre-existing limited shoulder function. In hypertrophic non-union, the use of this nail is the most logical solution of the problem, because the medullary canal is opened and an adequate fixation is obtained. Our results seem to confirm this theory. The three non-unions requiring a second operation with bone grafting were all atrophic non-unions. Therefore, in atrophic nonunion primary bone grafting should be considered.
405
Conclusions In our view, the locked intramedullary humeral nail is an effective addition to the existing forms of operative treatment of humeral fractures. It is a relatively simple method with a good cosmetic result. Fresh fractures are treated with good results and without major complications. In pathological humeral fractures, this locking nail is, in our opinion, the method of choice. In non-union a distinction between hypertrophic and atrophic non-union must be made. The results of this study suggest that in the former the locked intramedullary nail may be a good choice.
Acknowledgement The authors would like to thank Dr Chr. van der Werken for his advice.
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Sarmiento A., Kinnan P. B., Galvin E. G. et al. (1977) Functional bracing of fractures of the shaft of the humerusI. Bone]oinf Sr.q 59A, 596. Schweiberer L., Poeplau P-and Gr;iber S. (1977) Plattenosteosvnthese bei Obera~schaftsfrakturen. Sammelstudie der Deutschen Sektion der AO-International. Unfalltilklmde 80,231. Seidel H. (1989) Humeral locking nail: a preliminary report. OrfhopecIics 12,219.
Watson-Jones R. (1976) Fmcfxres and Joint Injuries. 5th Edinburgh: Livingstone Ltd. 587. Paper accepted
21 January
6 ed.
1993.
Requests fur reprinfs should be addressed fo: Mr R. M. P. H. Crolla, Department of Surgery, University Hospital Utrecht, PO Box 85500,3508 GA Utrecht, The Netherlands.
