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Table of Content - Volume 14 Issue 2 - May 2020
Study between interlocking nail and dynamic compression plate in the management of diaphyseal fractures shaft humerus
Siddhartha Kumar Shrest1, Ravi Shankar Kumar2*, Dilip Kumar Pal3
1,2Junior Resident, 3Professor Department of Orthopaedics, MGM Medical College & L.S.K. Hospital, Kishanganj, Bihar, INDIA. Email: r.shankar102@gmail.com
Abstract Background: The goal of this study is to compare interlocking nail and dynamic compression plate in the treatment of fracture shaft of humerus in terms of union, functional outcome and complication. Methods: The proposed study was undertaken in the Department of Orthopaedics, during the period of December 2017 to July 2019. The Patients Belong to the Catchment Population of M.G.M. Medical College and L.S.K Hospital, Kishanganj, Bihar. Patients selected were admitted from either the Orthopaedics Outdoor or the Casualty Department of this institute. 29 patients with fracture of shaft of humerus were treated operatively in the Department of Orthopaedics. Of these, 15 patients (Group-A) underwent internal fixation by dynamic compression plating, with or without bone grafting and 14 patients (Group-B) underwent internal fixation by humeral interlocking nail. Results: The mean age of patients were treated by Dynamic compression plate was 45.33 years while those treated by humerus interlocking nail was 45.78 years. Two patients (14.4%) treated by Dynamic compression plate and one (8.3%) treated by humerus interlocking nail developed superficial infections. One patient (7.2%) treated by Dynamic compression plate developed deep infection and subsequent sinus formation. Restriction of elbow movement was 21.42% in Dynamic compression plating patients and 24.3% in interlocking nail patients. Overall in patients treated by Dynamic compression plate excellent result was seen in 71.4% patients; good result in 7.1% patients; fair result in 14.2% patients and poor result in 7.1% patients. Conclusion: These findings suggest that humeral interlocking nailing is a better alternative to dynamic compression plating in the management of fractures of humeral shaft and the ideal treatment for spiral fractures, segmental fractures, osteoporotic bones, implant failures and fractures for which conservative management and dynamic compression plating are ill-suited. Key Word: elbow, road traffic accident, humeral shaft fracture, humerus interlocking nail.
INTRODUCTION Fractures of humeral shaft are commonly encountered by orthopaedic surgeons, accounting for roughly 3% of all fractures1. The most common reason for a humeral shaft fracture is a motor vehicle accident, followed by fall. Other causes that account for less than 10% of humeral shaft fractures include sporting activities, accidents during work, fall from a height, violence, and bone pathology2. The humerus is the longest and largest bone in the upper limb and the only bone in the arm. It connects the scapula and the two bones of the forearm, namely the radius and ulna. Many powerful muscles that help in movement of the arm at the shoulder and the forearm at the elbow are anchored to the humerus. Movement of the humerus is essential to all of the varied activities of the arm, such as throwing, lifting, and writing. Several features make humerus unique and significantly influence the treatment:
Many methods have been described for the management of humeral shaft fractures. Good to excellent results have been reported in most series of humeral shaft fractures treated closed or with open reduction and internal fixation. Both patient and fracture characteristics, associated injuries, soft tissue status and fracture pattern need to be considered to select appropriate treatment.
METHODS Inclusion criteria
Exclusion criteria
Pre-operative treatment: After diagnosing the cases as humeral shaft fractures, they were stabilized with the help of POP U-slab to prevent movement at fracture site and reduce pain and neurovascular injury. Any other associated injuries were treated accordingly. A day prior to operation, local part preparation and antiseptic dressing with povidine iodine was done. Patients were given light meal in the previous night and 5 mg of alprazolam tab at bedtime. Additional advices given by the anaesthetist were followed. Pre-operative planning Patient must be fully informed about the nature, expected outcomes, and potential complications of the operation while the anesthetist should be fully involved in the whole process of preoperative assessment and planning, because each surgical technique requires a different anesthetic approach. Preoperative measurement of the humeral length and the width of the narrowest part of the intact humeral canal will help to determine the desired nail length and diameter. Whenever fracture lines extend toward the shoulder or elbow joints further x-ray views, centered in the suspected area, may be needed. If there are still doubts about the integrity of the joints, a CT scan should be performed. 72 | P a g e Preoperative checking of operating room facilities and other actions that can facilitate the procedure, such as the drawing of the fixation, confirming implants and tools availability, and image intensifier working status. Anaesthesia: The patients were taken up for surgery under general anesthesia/brachial plexus block according to anesthetist’s choice. Post-operative treatment: The limb was elevated and antibiotics were used. 1. From the 1st postoperative day isometric exercises of the muscles of upper and lower arm were carried out. 2. Stitches were removed on the 10th day and shoulder joint moved actively with support as soon as pain allowed. 3. Elbow joint was moved freely but no rotational movements were attempted during the first 2 weeks. 4. During first 3-6 weeks the arm was supported by a cast. 5. Dynamization of fracture by removal of proximal screw was carried out at 6- 12 weeks after operation depending on fracture healing. 6. Nail was removed after consolidation of fracture (around 12 months after operation). ANTEROLATERAL APPROACH TO HUMERUS
POSTERIOR APPROACH TO HUMERUS
POST OPERATIVE
RESULTS AGE DISTRIBUTION: The youngest patient was 22 years old and the oldest was 77 years old. 2 patients were lost in follow-up, so the total number of patients evaluated was 27. Most of the patients in either group were of the age 20-50 years. Table 1:
SEX DISTRIBUTION: In Group A, 9 patients (60%) were male and 6 patients (40%) was female while in Group B, 8 patients (57.14%) were male and 6 patients (42.85%) were female. More number of males in our study can be attributed to the fact that in our society males are predominantly outside workers and so, are more commonly involved in road traffic accidents. Table 2:
Flexion at elbow joint There were 14 patients in follow-up available in Group A and 12 in Group B. 11 patients of Group A (78.57%) and 9 patients of Group B (75%) had full flexion at elbow joint. Loss of flexion of <30o was seen in 2 patient of Group A (14.28%) and 1 patients of Group B (8.3%). Loss of flexion of >30o was seen in 1 patient of Group A (7.1%) and 2 patients of Group B (16%).
Table 3:
Extension at elbow joint 7 patients of Group A (50%) and 9 patients of Group B (75%) had full extension at elbow. Loss of extension of <30o was seen in 5 patients (35.7%) of Group A and 2 patients of Group B (16%). Loss of extension of >30o was seen in 2 patient of Group A (14.2%) and 1 patients of Group B (8.3%).Table 4:
PERCENTAGE UNION Out of 14 patients available for follow up in group-A and 12 in group-B, 13 (92.8%) united in group-A and 11 (91.6%) in group-B. 1 patient of group A (7.2%) and 1 patient in group B(8.3%) had non union. The union rate of either group in this study was found to be identical and so was the non union rate. Table 5:
COMPLICATIONS Three patients of group-A (30.8%) managed by Dynamic compression plating developed infections. Two of them were superficial infections that responded well to antibiotics and dressings and later healed well and united. One patients developed discharging sinuses and subsequently infected union. Later the plate was removed and sinus tract excised. The sinus tract healed but left unsightly scar marks over the arm. Only one patient (7.7%) of group-B developed superficial infection. One non-union was seen in each group. While the screws of one Dynamic compression (7.7%) went loose, no implant failure occurred in interlocking nails. One patient in group A had radial nerve palsy. She was initially given dynamic cock up splint and later tendon transfer was performed on her. Restriction of shoulder movement was 14.28% in group A while it was in 50% in group B; out of which 16.8% had severe restriction and 33.33% had mild near terminal restriction of movement.
Table 6:
FUNCTIONAL RESULTS All patients, except one from each group returned back to their previous jobs. Both these patients developed non union. They were able to do day to day activities but not able to join their previous jobs. Thus the functional result was good in 92.3% of patients and poor in 7.7% of patients of either group. An advantage of humerus interlocking was that, even when the patient developed non union, he was able to perform daily activities but the patient with loosening of screws found it difficult to do so.
Table 7:
Rodriguez-Merchan criteria142 (1995) were used to compare the postoperative results of interlocking nailing and plating procedures at follow-up. Criteria for evaluating functional results Table 8:
Rodriguez-Merchan criteria Table 8:
According to Rodriguez-Merchan criteria, 71.4% patients in group A and 83% patients in group B had excellent result. 7.1%patients in group A and 8.3% patients in group B had good result. 14.2% patients in group had fair result. 7.1% patients in group A and 8.3% patients in group B had poor result.
DISCUSSION Dynamic compression plating is a time tested method of stabilizing transverse diaphyseal fractures of humerus. The plate produces a compression at the fracture site promoting osteosynthesis. But the technique is not suitable for segmental fractures, pathological fractures, communited fractures, gross osteoporosis, non union and fractures much proximal or distal to shaft. Introduction of interlocking nailing has largely solved problems faced by the standard dynamic compression plating. The advantages of a stable reduction maintained by a humeral interlocking nail must be weighed against the technical problems and the need for prolonged fluoroscopy to target the distal holes. We treated a total of 29 patients in the Department of Orthopaedics, MATA GUJRI MEDICAL COLLEGE, KISHANGANJ between the period of December 2017 to JULY 2019. 15 patients were treated by Dynamic compression plating (group-A) and 14 patients were treated by internal fixation by humerus interlocking nail (group-B). Bolano et al4(1995), Chapman et al.[5] (2000), McCormack et al.6 (2000) and Putti et al.(2009)[7] also compared DCP with interlocking of humerus. Their findings will also be discussed here with special reference to the present study. The majority of patients in both groups were males (60% males in group-A and 57.14% in group-B) and were in the age group of 20-50 years (73.33% of group-A and 57.14% of group-B). Most of the patients sustained trauma as a result of road traffic accidents (66.66% in group-A and 80% in group-B). Group A (Dynamic compression plating): 15 patients were treated by Dynamic compression plating of which one was lost to follow up. The average time of clinico-radiological union was 9.3weeks. There were 3 infections (21.42%). 2 were superficial infection (14.4%) and one case developed deep infection and subsequently sinus formation (7.2%). The incidence of infection after plating in the other studies was: 0% (Bolano et al.), 6.5% (Chapman et al.), 0% (McCormack et al.) and 5.5% (Putti et al.). The infection rate observed in Dynamic compression plate as compared to interlocking humerus was comparatively high. One case (7.2%) of non-union was seen. The incidence of non-union after plating in the other studies was: 7% (Bolano et al.), 6.5% (Chapman et al.), 4.3% (McCormack et al.) and 5.5% (Putti et al.). Bridging callus was actually not visible in all patients but partial obliteration of fracture site and loss of tenderness was seen at an average of 9.3 weeks. Shoulder problem was present in 14.28%. No shoulder problems after plating were reported in the studies of Chapman and McCormack. However, Bolano reported 1 case (7%) and Putti reported 1 case (5.5%) with shoulder problems following plating. Group B (Humerus Interlocking): 14 patients were treated by antegrade humeral interlocking. The average time of clinico-radiological union (absence of bony tenderness clinically and presence of bridging callus on X-ray) was 5.9 weeks. Shoulder problems: In group B of this present study, restriction of >30o abduction was seen in (16.6%); Shoulder movements were restricted in terminal degrees of movements somewhat more in Group B than in group A. (33.33%) patients had restriction of abduction <30o. Shoulder problems after nailing in other studies were as follows: Bolano et al.– 43%; Chapman et al.– 16%; McCormack et al.– 14% and Putti et al.-18.75%. There was one infection (7.2%). Chapman et al.reported no infection in their series; McCormack et al.reported 1(4.7%) infection and Putti et al.reported no infections in the nailing group. There was no implant failure. Implant failure leading to re-operation was required in 16% cases (Chapman et al.), 33.33% (McCormack et al.) and 1% cases (Putti et al.) in the respective studies. One case of non-union was seen (7.2%). The incidence of non-union after interlocking in the other studies was: 28.5% (Bolano et al.), 5% (Chapman et al.), 9.5% (McCormack et al.) and 0 (Putti et al.). No case of nail migration was seen. In 5 patients of interlocking nail good callus was seen as early as 3-4 weeks. The early callus and union in group-B is due to early mobilization of all types of fractures. Early mobilization will generally hasten union by allowing the hydrodynamic forces of muscle activity to enhance local blood supply and encourage the organization of healing granuloma by allowing stress forces to function. Though the patients of Dynamic compression plating have a better shoulder function than the patients undergoing antegrade humeral interlocking, it is to some degree due to uncooperative patients, pain and impingement of rotator cuff by nail and fibrosis. But this restriction can be corrected by the removal of nail after consolidation followed by mobilization and physiotherapy. Humeral interlocking nailing as compared to dynamic compression plating is complicated as well as exacting in detail. Specialized costly equipments (high quality image intensifier, modern flexible drills, nail insertion and targeting devices) are necessary and no compromise in that respect is permitted if this operation is to be successful. But the advantage of the procedure is definitely that the rate of infection is low as compared to DCP. In DCP, stripping of soft tissues and periosteum leads to an increase in union time as compared to interlocking nail. The disadvantages of humeral interlocking may be limited to mild restriction of shoulder movements which is correctable by removal of the nail after consolidation of the fracture. The advantages of interlocking of diaphyseal fractures of shaft of humerus are early union (5.9 weeks as compared to 9.3 weeks in DCP), minimal exposure of soft tissues, less blood loss, minimal scarring and so a cosmetically better procedure. Moreover, it is ideal for patients with segmental fractures, communited fractures, pathological fractures, patients with gross osteoporosis, patients in which DCP cannot be done, distal end fractures and implant failures. There is less chance of radial nerve damage and the patient undergoes early mobilization. The removal of the implant is much easier than removal of dynamic compression plate and associated with less blood loss and lesser chances of nerve injury (due to nerve being caught in fibrosis). Also, after removal of DCP there are more number of stress risers created that may lead to refracture.
CONCLUSION 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. Dynamic compression plate is a time tested method for treatment of fracture shaft of humerus for providing compression and excellent result in transverse fractures or short oblique fracture. Though the sample study is small and the period of follow up to assess the complications and results short, from the above observation it is clear that interlocking nailing has following advantages over plating.
Disadvantage of humerus nail was that shoulder complication were high with interlocking nail. These findings suggest that humeral interlocking nailing is a better alternative to dynamic compression plating in the management of fractures of humeral shaft and the ideal treatment for spiral fractures, segmental fractures, osteoporotic bones, implant failures and fractures for which conservative management and dynamic compression plating are ill-suited. REFERENCES
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