TRAUMA IN BANGLADESH
1. INTRODUCTION
Humerus is an unpaired bone, the shaft of which is totally covered by a thick layer of soft tissue. Approximately 10% of all long bone fractures occur in the humerus. Fractures of the humeral shaft are commonly encountered by the orthopaedic surgeons, accounting for approximately 30% of all humeral fractures (Ward, Savoie & Hughes 1998, p .1177). Both younger and elder people suffer from these fractures. The mechanism of injury is mainly direct trauma, motor vehicle accident, fall from height, direct blow, and penetrating injury like bullet or sharp object causing transverse or comminuted fractures. Indirect trauma due to fall on outstretched hand, twisting injuries or even violent muscle contraction results spiral or oblique fracture. Treatment of these injuries continues to evolve as advances are made in both non-operative and operative management.
Fractures of the shaft of the humerus are usually easy to treat,irrespective of the personality of the fracture.As there is a good deal of muscle envelope around it, the blood supply is abundant and the union is rapid. There is notendency to over-riding; on the contrary, the only danger isthat the fragments may be allowed to distract by the weightof the limb and cause delayed union. The middle third is themost vulnerable in relation to delayed or non-union. This isbecause the main nutrient artery enters the bone very constantlyat the junction of the middle and lower thirds or in the lowerpart of the middle third. The radial nerve is another structureat risk from fractures or operations on the humerus. It doesnot travel along the spiral groove of the humerus next to thebone as is commonly described; instead along most of its courseit is separated from the humerus by a variable layer of muscle,and lies close to the inferior lip of the spiral groove (Reynders 2003, p.214).
In general treatment of the fractured shaft of the humerus isnot usually difficult. The fractured ends can be readily alignedwith the patient sitting, when the weight of the forearm onthe distal fragment will usually achieve an acceptable position.Support of the wrist a collar and cuff or narrow sling, allowingthe elbow to lie free and unsupported may be all that is required.In the early stages when there is considerable pain a well paddedplaster of Paris U-slab is very effective in relievingdiscomfort. After two weeks the collar and cuff bandage canbe replaced by a functional orthosis for anotherfour to six weeks. A “hanging cast” popularized by Caldwellis no longer recommended because it may distract the fractureand produce delayed union (Reynders 2003 , p.215).
Though the great majority of humeral shaft fractures unite with non-operative treatment and the complication rate after internal fixation is high, there are some well defined indications for surgery. Operative treatment has been usually reserved for the treatment of nonunion (Müller, 1965, p.85), for polytrauma patients (Bell et al. 1985, p.295), bilateral humeral shaft fractures, floating elbow, segmental fractures, pathological fractures, distal humeral spiral or comminuted fractures in which radial nerve palsy develop after manipulation (Holstein and Lewis 1963, p.1385) and if treatment of associated injuries make bed rest necessary.
Operative methods of treatment include open reduction and internal fixation by plate and screws, open or close reduction and internal fixation by intramedullary nail or semi flexible pins and external fixator.
A consensus has yet to develop regarding operative treatment of diaphyseal fractures of the humerus. Intramedullary nailing is considered to be appropriate for internal fixation of long bones, as the implant lies nearer to the axis of the bone and requires less extensive exposure and less stripping of soft tissues than plating. However, intramedullary nailing of diaphyseal fractures of the humerus has the disadvantage of possible decreased mobility at the shoulder or elbow joint, depending on its site of introduction (Rakesh, Anil and Vijay 2000, p.471). Distal humeral shaft fractures are difficult to fix by intramedullary device rigidly through antegrade portal. Distal locking is often difficult and without static locking, however, fixation is not sufficiently rigid and external splintage is needed until union occur (Brumback et al. 1986, p.965). A very narrow canal in the distal part of the humerus makes intramedullary nailing difficult. It also provides very little rotational, translational and vertical stability, unless the nail is of the interlocking variety. Various unlocked nails have given poor rate of union and have tendency to back out (Foster et al. 1985, p.860). Above all Intramedullary nail fixation demands sophisticated instruments, modern equipments and technical expertise.
Among various modalities of surgical treatment Dynamic Compression Plate fixation remains the ‘gold standard’ according to Farragos, Schemitsch & Mckee (1999, p. 260).Compression plating, which is a classic method, was first used by Müller et al. ( 1991, p. 457). In selected patents of the humeral shaft fractures, it is a preferred method because of its high success rate when used by simultaneous autogenous corticocancellous grafting.
Though plating requires an extensive exposure with stripping of soft tissues from the bone, it permits excellent reduction and fixation and has the advantage that it does not interfere with elbow and shoulder function (Chapman et al. 2000, p.164). Open reduction and internal fixation of distal humeral shaft fracture provides good clinical result and should be carried out aiming for an early postoperative functional treatment (Pereles et al. 1997, p.580). Dynamic compression plate gives additional advantage of fixing the fragments putting the screw obliquely up to 450 if necessary due to its special design of holes. This ensures holding the comminuted fragments rigidly.
Rigid fixation and anatomic alignment are consistently achieved with good operative technique. The choice of surgical approach should be based upon the pathoanatomy of the fracture and the preference of the treating surgeon. Four approaches are usually applied to the humerus: the anterior approach, anterolateral, the posterior and the lateral approach. Among them the anterolateral and the posterior approaches are widely used for the distal diaphysis of the humerus.
The anterolateral approach is most often used for ORIF. It provides access to the entire diaphysis of the humerus and can be extended both proximally and distally. The approach is made lateral to the palpable mass of the biceps and brachialis muscles.
Although dissection and mobilization of the radial nerve are not mandatory with this approach , King and Johnston (1998 , p. 210 ) reported that the incision frequently transects branches of the lower lateral brachial cutaneous nerve, resulting in painful neuroma formation , numbness or tingling around the scar in 62 % cases.
The posterior approach provides exposure of the lower three fourths of the humerus, and is most often used for fractures of the distal third of the humerus (Henry 1966). For these injuries, the posterior surface of the humerus is relatively flat, and is therefore ideal for placing a plate. The radial nerve is at some risk during posterior exposures, and it must be identified and protected (Holstein & Lewis 1963, p.1385). The skin incision is made in the posterior midline of the arm. Superficially, the interval between the long and lateral heads of the triceps is separated. The deep dissection requires splitting the medial head longitudinally, with identification of the radial nerve and profunda brachii artery in the spiral groove. Because the nerve branches enter the muscle heads relatively near their origin and run down the arm in the muscle’s substance , splitting the muscle longitudinally does not denervate any part of it (The Humerus 2003, p.80)
The aim of this study is to assess the results of open reduction and DCP fixation with or without autogenous grafting by posterior approach in the treatment of fracture lower third of humeral diaphysis. Although there are numerous studies in the literature detailing the results of surgical fixation, most of them were performed with the use of surgeon-based or radiographic outcome measures. There may be a great deal of variation among these scores. But patients’ evaluations of outcome more closely correlate with the functional loss and are often different from the surgeons’ assessments of outcome. Patient-based questionnaires have been developed as outcome instruments and they have been shown to be reliable, valid and responsive for assessing a variety of orthopaedic conditions (Michael et al. 2000, p. 1701).
Hypothesis
Open reduction and internal fixation of fracture distal 3rd of humeral shaft with DCP by posterior approach is an effective modality of treatment.
2. OBJECTIVES & AIMS
General Objective:
To evaluate the results of open reduction and internal fixation with the use of dynamic compression plate by posterior approach in patients with fracture distal 3rd of the humeral shaft.
Specific Objectives:
· To assess the functional outcome of the treatment including motion of both shoulder and elbow joints.
· To study the incidence of complications of the treatment
· To ascertain the time taken for union.
· To evaluate pain after the treatment.
- LITERATURE REVIEW
Anatomical facts:
The shaft of humerus is cortical bone extending from the surgical neck proximally to the supracondylar ridges distally. The upper portion of the shaft is roughly cylindrical, the mid portion prismatic and distal portion flattened out in the coronal plane (Swanson and Gustilo 1993, p.365). The shaft can be fractured by bending or twisting forces producing transverse, spiral or oblique fractures. (Klenerman 1992,p.572). Humeral shaft can be classified by location, fracture configuration and associated soft tissues or neurovascular injuries. Fracture location can be divided into proximal, middle and distal third. Fracture configuration may be classified as transverse, oblique, spiral, segmental or comminuted with or without bone loss. Fractures may be closed or open, with open fractures further subdivided into types I, II and IIIA, IIIB and IIIC, depending upon the severity of the soft tissue injury, contamination and the presence of concomitant vascular injury.
When a fracture of the shaft of the humerus fails to unite in 3 to 4months, it is termed as delayed and if union is delayed and arrested beyond 6 to 8 months, it is defined as nonunion (Rosen 1990, p. 725). Nonunion is established when minimum of 9 months has elapsed since injury and the fracture shows no visible progressive signs of healing for 3 months (La Velle 1998, p. 2579). When the fractured fragments are more than two in number it is known as comminuted fracture. It occurs due to dissipation of a large amount of energy into a bone. The bone breaks into fragments which may impact into each other or separate and become displaced (Fractures and Dislocations 2000, p.322).
Figure 3.1: Humeral shaft extends from the surgical neck proximally to the supracondylar ridges distally and is divided into proximal, middle and distal third (Swans and Gustilo 1993, p. 366. )
Figure 3.2 : Classification of fracture shaft of humerus (Gustilo 1993, p. 368)
Causes of nonunion in humeral shaft fractures:
Ten percent of long bones fractures are humeral fractures and 10% of humeral fractures are diaphyseal fractures (Pugh & McKee 2003, p. 48). Although majority of humeral shaft fractures heal uneventfully, nonunion is not an uncommon problem. The rate of nonunion is reported to be 2 to 10% in nonsurgically treated and 10 to 15% in surgically treated humeral shaft fractures (Sarmiento et al. 2000, p. 478). The causes of nonunion in humeral shaft fractures can be mentioned as the severity of initial injury, transverse fracture pattern, distraction of fracture, fractures at the junction of middle and proximal third humeral shaft, soft tissue interposition, inadequate immobilization, obesity, alcohol abuse, smoking and inadequate treatment. Nonunion of humeral shaft fractures should be treated surgically in order to avoid problems like instability, pain and loss of function (Zuckerman & Koval 1996, p. 1025).
Various surgical methods & their advantage – disadvantages:
It is difficult and troublesome to treat the nonunion of the humeral shaft. More than one surgical intervention may be needed to treat them by surgical methods. Success rate decreases with an increase in the number of surgical interventions and complications are higher. Patients that are prone to develop nonunion should be well-known to decrease the complication rate and the preferred surgical method should be well performed. Technical errors of the surgical method and insufficient follow-up also increase the nonunion rate (Grant et al. 1994, p. 257). Rigid fixation is not always achieved in all patients by ORIF with the use of a plate and screws (Ring, Perey & Jupiter 1999, p.177 ).
Various methods are advocated especially for older, osteoporotic, badly qualified bones, also for those who are operated more than one. ORIF method can be performed by the use of onlay or intramedullary grafts combined with a locked compression plate adapted to the Schuhli nuts or a blade plate in osteoporotic patients.
Trotter and Dobozi (1986, p.162) tried to strengthen the plate and screw fixation by a bone cement inserted into the medulla. But this method has disadvantages of disturbing the medullary circulation and leakage of the bone cement into the nonunion line which may affect the healing in a negative way.
Kassab , Mast & Mayo (1998 , p. 86 ) used locking nuts with plate and screw fixation in osteoporotic patients to increase the rigidity of fixation. Wright et al. (1993, p.804) used screws by passing them through the autogenous or allogen fibula to improve the engagement and push out strengths of the screws to the bone in similar cases.
Intramedullary nailing is advised for osteoporotic and comminuted fractures in which a broad incision and soft tissue dissection is needed to apply a plate and screws. And also it is advised for the cases in whom neurolysis is very difficult because of the embedded scar tissue (Lin, Hou & Hang 2000, p. 695). It is not always possible to achieve rotational stability and to close the nonunion gap by the use of intramedullary nails. Distraction occurs at the fracture sites even in applying intramedullary implants for fresh fractures. Subacromial impingement syndrome or elbow problems are encountered in the treatment of humeral shaft nonunion due to the technique of application in the entry site.
Modabber and Jupiter (1998, p. 93) compared the results of plate-fixation and intramedullary nailing in the treatment of humeral nonunion. Disadvantages of plate fixation were noncosmotic appearance due to the extensile approach, impaired periosteal circulation, possibility of iatrogenic nerve palsy, and blood loss.
Advantages of this method were possibility of nerve repair because of direct exploration, simplicity of applying the plate to each segment of the humeral shaft, and also possibility of bone grafting, debridement and resection of the pseudarthroses site from a single incision in one operation.
Disadvantages of intramedullary nailing are shoulder or elbow problems due to the application of the technique, possibility of iatrogenic nerve injury and fractures, impairment of endosteal circulation, spread of infection of the other sites of humerus, impossibility of performing the method in cases of humeral deformities, obstruction of the medullary canal, need of a second surgery for the extraction of the implant. Advantages are: this method is stronger biomechanically, preservation of periosteal circulation, less blood loss, application of the implant for away from the surgical incision.
Although plate screw fixation has many disadvantages but union rates are higher in this method (Gregory & Sanders 1997, p. 15).
Many treatment methods are not available or are contraindicated in cases of infection. Debridement, excision of the necrotic tissue, irrigation and local antibiotherapy should be performed first. External fixators are performed in the presence of an infection.
Torsional and shearing forces are effective on the humerus because it is not bearing a load. Today Ilizarov-type fixators are performed because they resist these forces and also gradual axial compression and / or distraction is possible with this type fixator (Kocaoglu et al. 2001, p. 1).
External fixators have an advantage of less blood loss and it is possible to correct the deformity and shortness simultaneously. Development of joint movement restriction is prevented during the treatment period.
But this method has many disadvantages. Neurovascular injury and pin tract infection may occur with this method. It is difficult to perform the method and also refractures may occur after the extraction of the fixator (Sarmiento, Waddell & Latta 2001, p.1566 ).
It must not be the first choice when there is a risk of radial nerve injury, intolerance of the patient and the surgeon is not acknowledged and experienced with the system. It must be preferred in these situations: if the scar disuse is high due to the old operations, bone loss is much and also if there is an angulated deformity and infected pseudoarthrosis. Patients’ intolerance with this method and the failure of the other methods in cases of segment transport as shortness, led the surgeons to search for new methods. .
Ring et al. (2000, p. 867) treated the humeral nonunions by the use of waved plates and corticocancellous autografts. Jupiter (1990, p. 701) also used medial plate application combined with fibula grafts and was successful in this method.
Up to date plate and screw fixation is the most preferred method for the treatment of humeral shaft nonunion. When compared with other methods, plate and screw application has a high rate of union. Rosen (1990, p. 725) treated 25 patients with nonunions of the humeral shaft by ORIF with the use of compression plate and bone graft for the atrophic nonunions. He achieved union in 24 of the 25 cases and declared that union is available in 95% of the nonunions of the humeral shaft if one follows the AO/ASIF principles of open reduction and stable internal fixation.
Barquet et al. (1989, p. 95) reported 24 cases undergoing union in periods averaging 6 months after performing ORIF and corticocancellous grafting with the use of a broad DCP for 25 patients of having aseptic nonunion of the humeral shaft. As a complication there was one patient with a radial nerve lesion that underwent healing 12 weeks after the operation.
Marti et al. (2002, p. 108) treated 51 patients with a protocol of careful radial nerve exploration, autogenous corticocancellous bone grafting and application of a 4.5 millimeter DCP. In their series, they achieved union in 50 cases and also they had a complete consolidation in all of the cases after one year. 23 patients were treated by conservative methods and 28 were treated by surgical methods before. The primary cause of the humeral shaft nonunion is the insufficient surgical technique. The success of ORIF method with the use of DCP is best achieved by the fact that the rules of osteosynthesis technique is strictly obeyed and sufficient stabilization is reached.
Dynamic Compression Plate – the secrets of stabilization
Dynamic compression plate has special geometry of the hole. The holes have inclined plane towards the plate centre. A screw placed at the inclined plane, that is eccentrically, moves the underlying bone horizontally in relation to the plate until the screw head reaches the most inner border of the hole. Repeating the same process while inserting screw in the hole of the other half of plate gives the maximum compression at the fracture site. As strong compression at the fracture site is not required, only one screw is enough to give compression.
Broad DCP should be preferred in surgical practices. Narrow DCP can be used especially in the narrow humeral shaft or if the patient is woman. To enhance the stability, the screws must be fixed in different directions instead of providing a parallelism between them (Rüedi & Schweiberer 1991, p. 427). A minimum of four cortices on both sides of the nonunion site should be engaged by the screws and it may also be five or six too (Marti, Verheyen & Besselaar 2002, p.108 ).
Healy et al. (1987, p. 206) made an analysis of successful and unsuccessful results for nonunions treated by plate-screw fixation. Unsuccessful platings averaged 2.1 above and below the nonunion but successful plating averaged 6.8 (distally 7.1).
Ellipsoid holes of the DCP enables the screws to be engaged in different directions depending on the quality of the bone and also prevents new screws being directed into the older holes formed by the previous screws. Also stabilization may be improved by purchasing the corticocancellous graft and on the other cortex of the bone.
Some authors offer a two plate construct because one-plate construct does not provide sufficient stabilization. Rubel et al. (2002, p.1315) showed in an experimental study that a two plate construct provides a more stiff stability biomechanically and also decreases the micromotion at the nonunion site. However, a two-plate fixation has a limited practise because it requires an extensible dissection, increases the risk of infection and osteoporosis in humeral bone.
Figure 3.3 : Special geometry of screw hole of DCP makes it possible to achieve axial compression without the use of a tension device and the screws can be angled in the long axis of bone up to 450. Narrow DCP with thickness3.6 mm and 12 mm width. Purchasing cortical screws are of 4.5 mm in diameter.
Figure 3. 4: Biomechanics of dynamic compression ( Swans and Gustilo 1993 ).
Occasional need for Shortening of the bone for apposition
Beyond the healing of nonunion of the lower extremities, equalization of the bone length is also recommended. However, 4-5 cm difference in two upper extremities is accepted in the treatment of humeral nonunion of the shaft. No functional or cosmetic morbidity occurs. Shortening of the bone as necessary to achieve apposition and compression of the two diaphseal bone is accepted. The amount of compression is important because humerus does not carry a load. The best amount of compression to achieve union of the humeral shaft pseudorthrosis is best provided by the method of ORIF with the use of DCP.
Early Physiotherapic rehabilitation earns better results
Physiotherapic rehabilitation can be started earlier after a stable fixation performed by a good surgical technique. Restriction of the shoulder and elbow movement associated with the conventional methods can be prevented with this method. As a well-done stabilization has a good effect on achieving union and also permits earlier rehabilitation. So patients obtaining functional gains feel better. Progress in osteopenia associated with immobility and decrease in muscle tone can be prevented especially in older patients.
Complications are minimum and manageable
Radial nerve injury after the treatment of humeral shaft pseudartrosis is reported as 3 % -29 % in the literature. This rate ranged from 2% to 4% after ORIF method. A great amount of nerve injuries were neuropraxia or axonotemesis, spontaneous recovery was achieved in 90% of them. Neurolysis of radial nerve performed by a broad exposure enables the surgeon to solve mechanical problems that cause the injury (Levent et al. 2005, p. 205).
Infection rate decreases by atraumatic handling of the soft tissues even a broad exposure is used. A superficial infection can be treated by an antibiotherapy. Deep infection may also occur and can also be treated with meticulous care and antibiotics. Fixation failure after plating of the humerus is uncommon. Fixation failures are most often due to technical errors made by the surgeon. It was observed that alcoholic patients with osteoporotic bone seem to be prone to fixation failures (Yusuf et al. 2004, p. 305).
Flinkila et al. (1999, p.133) also reported various complications, like nonunion (22%), need for reoperations (21%) and shoulder dysfunction (37%) after operating on 126 patients who had a fractured shaft of the humerus.
A good surgical technique is the key to success
It is difficult and troublesome to treat the nonunions of the humeral shaft. As the number of surgical interventions increase, the success rate decreases. The surgical application should be performed after the evaluation of the patient, the nonunion and choice of the appropriate method. The primary cause of the unsuccessful outcome is the inability to perform a good and correct surgical technique. It is also true for humeral fractures. And also performing surgical procedures without a minimum number of operations decreases the success rate. ORIF by the use of a DCP provides many procedures to be performed from a single incision in one operation. In selected patients without osteoporosis and infection; this method is excellent provided that a good surgical technique is employed (Levent et al. 2005, p. 205).
4. METHODOLOGY
STUDY DESIGN:
This was a quasi experimental study.
PLACE OF THE STUDY:
The study was carried out at Dhaka Medical College Hospital , Dhaka.
PERIOD OF THE STUDY:
From January 2005 to December 2006.
STUDY POPULATION:
Patients with clinical and radiological evidence of fracture distal third of humeral shaft who attended at the OPD or emergency dept. of DMCH.
SAMPLE SIZE:
Thirty-three patients with fracture of distal third humeral shaft were selected consecutively. Cases were diagnosed on clinical and radiological basis at the outpatient or emergency department of Dhaka Medical College & Hospital. 2 patients were lost during follow up, before the measurement of final outcome. They were excluded from the final evaluation of the functional outcome. The remaining 31 were available for follow up for a period of 6 to 8 months.
SAMPLING:
All Patients with fracture at the distal third of humerus were selected purposively (non randomized) on the basis of history, clinical examination & radiological findings strictly considering the inclusion and exclusion criteria.
INCLUSION CRITERIA:
· Adult patients of age between 18 years to 60 years of either sex.
· Closed Fracture located at the distal third of humeral diaphysis.
· Fractures included :
– Early failure of conservative treatment
– Non union
– Comminuted fracture
EXCLUSION CRITERIA:
· Skeletally immature patients and the patients of age over 60 years.
· Open fractures.
· Pathological fractures
· Patients physically unfit for anaesthesia.
· Patients who were unable to cooperate the assessment of function because of head injuries or other causes (senility, neurotic etc.).
VARIABLES:
After enrollment of the patient, following variables were measured for outcome.
a) Demographic Variables:
i. Age
ii. Sex
iii. Occupation
b) Clinical Variables:
i. Causes of injury.
ii. Side of involvement.
iii. Involvement of the dominant hand
iv. Time interval between injury and operation
v. Postoperative hospital stay
vi. Time taken for union
vii. Post operative complications
viii. Need for further operation
ix. Functional outcome
x. Final outcome
DATA COLLECTION INSTRUMENTS AND METHODS:
Data were collected with a pre-tested, structured questionnaire containing history, clinical & laboratory examination findings and the findings of the follow up.
· History and clinical examinations :
A complete history of the selected case was taken with particular emphasis to the time, cause, the mechanism of injury and the past treatment. This was followed by a thorough general and physical examination to exclude any associated injuries.
Preoperative assessment following the modified Constant and Murley scoring system and a detailed local examination was then carried out with particular attention to:
1. Attitude of the limb, deformity and status of elbow and shoulder.
2. Estimation of neurovascular injury if any.
3. Any associated injury.
· Laboratory findings :
Radiological examinations:
Antero-posterior and lateral views of the arm including shoulder and elbow joints were taken. In cases where there were suspicion regarding an associated injury, additional radiograph of the concerned part was advised. Later, while preparing the patient for operation, chest radiograph (P/A view) was taken.
Laboratory investigations:
The following tests were carried out routinely in all patients as a measure of anaesthetic fitness and also to rule out the co-existing diseases.
Blood:
ü Total count and differential WBC count
ü Hemoglobin percentage and ESR
ü Routine microscopic examination of urine
ü Blood sugar estimation
ü Blood Urea and Serum Creatinine
Others:
ü ECG (patient more than 35 years of age) and
ü X-ray chest in postero-anterior view.
· Preoperative preparation:
1. The selected Patient was counseled regarding the treatment procedure with emphasis on the available treatment options along with merits and demerits of each. He/she was informed about the possible postoperative sequels. Informed written consent was taken from each case included in the study. All issues regarding the patients welfare were approved by the local ethical committee.
2. Pre anaesthetic check-up was done.
3. The patient was asked to fast for 6 hours before operation.
4. Dynamic compression plate and screws of appropriate size were selected.
5. Antibiotics: All patients received prophylactic antibiotic, a third generation Cephalosporin (Ceftriaxone), one gram i.v. at the time of induction of anaesthesia. Post operatively parenteral Ceftriaxone was given 24 hourly for 3 days. After 3 days, oral Cephalosporin ( Ceftazidime 500 mg or Cefixime 200mg 12hourly ) was given for a further week or till wound healed or infection subsided.
- Surgical Procedure:
With all aseptic precaution open reduction and internal fixation was achieved with a standard narrow DCP by posterior approach.
Details of the Surgical procedure is described in Appendix -I.
- Postoperative Care:
Adequate sedation and analgesics were given postoperatively. Upper limb elevation was maintained for the first 48-72 hours. Antibiotics were prescribed as stated earlier.
Active/passive finger exercises were advised to start immediately after the recovery from anaesthesia. Wound was inspected in 5th post operative day. Stitches were removed at 10th -12th POD.
Patients were discharged from the hospital in 7th-12th postoperative days.In cases of infection, patients were kept in the hospital for a little longer durations.
- Follow up:
Patients were usually followed up at monthly interval till the fracture union was achieved. Evaluation of the functional out come was achieved at 6 month’s visit. Six months was chosen as by that time healing of the fracture would normally have taken place, and functional improvement would have reached to a satisfactory level. This protocol had to be changed a little in some particular cases due to failure of attending the schedule or other causes. The patients were also advised to attend the OPD or contact personally if any problem regarding the treatment occurred.
Pendulum shoulder exercise was started after 2 weeks. Long arm back slab was removed after 3 weeks and were allowed to move the elbow joint.
In each follow up visit the following parameters were checked:
1. History of pain, infection, any complication.
2. On clinical examination
v look : Wound site, deformity, condition of the skin
v feel : Tenderness, fracture site mobility
v move: Both active and passive movements of shoulder and elbow joints.
v Distal neurovascular status examinations.
3. Radiological findings :
ü To see the fracture alignment
ü To see the visible / bridging callus
ü To see the position of the plate and screw
ü To see the state of fracture union.
The patients were advised to continue physiotherapy to increase muscle strength and range of motion of elbow and shoulder joints. Light work was allowed to be done after clinical and radiological evidence of fracture union. Strenuous work was allowed when there was radiological evidence of consolidation and the patients felt no pain.
- Assessment of outcome of the treatment:
v Functional assessment :
The criteria for assessing the outcome after surgery have been set by different workers. Here the patients were evaluated preoperatively and at the most recent follow up (at six months visit usually) postoperatively with the modified Constant and Murley scoring system (Ring, Perey and Jupiter 1999, p. 185 ).
In this method, the maximum score is 100 points: 15 points for pain, 20 points for activities of daily living, 40 points for range of motion and 25 points for power. The patients graded pain as severe (0 point), moderate (5 points), mild (10 points) or none (15 points). Their ability to position the hand to perform various activities (maximum score, 10 points).
The patients were asked to demonstrate the ability to bring the hand to the waist, to the xiphoid, to the neck, to the top of the head and above the head. Forward elevation and lateral elevation, as measured with a goniometer, were given a maximum of 10 points each. Internal rotation and external rotation were also given a maximum of 10 points each, on the basis of patients’ ability to perform the composite movements. Rotation is usually combined with forward elevation and abduction to perform activities of daily living.
We measured the strength of the involved upper extremity by comparing it with that of the contra lateral upper extremity. The shoulder was placed in 90 degrees of abduction (or the maximum abduction possible at the involved limb) and compared the degree of isometric resistance to forced adduction with that of the contra lateral extremity. The strength of the involved limb was expressed as a percentage of that the uninvolved one and the point value for strength was determined by dividing the percentage by four.
Table 4.1 Modified Constant and Murley score of functional assessment (Ring, Perey and Jupiter, 1999, p. 185): Details of the individual parameters are shown in Appendix no. II.
| Item | Score | Preoperative | Postoperative |
| Pain
None Mild Moderate Severe Activities of daily living Full work Full recreation/sports Unaffected sleep Hand position up to waist up to xiphiod up to top of head above head Range of motion Abduction Forward elevation Internal rotation External rotation Shoulder power |
15
15 10 5 0 20 4 4 2 2 4 8 10 40 10 10 10 10 25 |
||
| Total | 100 |
Rating of results : Final outcome :
Excellent : 80 to 100 points Satisfactory : Excellent or Good
Good : 60 to 79 points Unsatisfactory: Fair or Poor
Fair : 40 to 59 points
Poor : 0 to 39 points
v Assessment of range of motion of shoulder and elbow :
At the latest follow-up, range of motions in shoulder and elbow were assessed according to Rommens et al. (1995, P. 85). Shoulder or elbow function was graded as excellent when there was less than 10º loss of range in any direction, moderate when there was loss of between 10º to 30º and as poor with loss of range of more than 30º.
Table 4.2 Assessment of range of motion in shoulder and elbow joint (Rommens et al. 1995, p. 85)
| Excellent | Moderate | Poor | |
| Restriction in shoulder motion | <10° | 10°-30° | >30° |
| Restriction in elbow motion | <10° | 10°-30° | >30° |
v Radiological assessment (Ring, Perey and Jupiter, 1999, p. 185) :
Biplanar radiographs made at the time of follow-up evaluations were assessed to determine the presence of bridging callus (which was suggestive of healing), any loosening or failure of the fixation.
OBSERVATION AND RESULTS: (STATISTICAL ANALYSIS):
Data were processed and analysed using computer software SPSS (statistical Package for Social Sciences) version 11.5. The test statistics used to analyse the data were descriptive statistics, Wilcoxon Signed Rank Test and one-tailed Z-test. The data presented on categorical scale were expressed as frequency and corresponding percentage, while the quantitative data were presented mean and standard deviation (SD) from the mean. Comparison between preoperative and postoperative data (according to Modified Constant and Murley scoring system) were done using Wilcoxon Signed Rank Test. Post operative final outcome was evaluated using Z-test. For all analyses level of significance was set at 0.05 and p-value < 0.05 was considered significant.
ETHICAL IMPLICATION :
· The study was Rationale.
· Selected patients with clinically & radiologically diagnosed distal 3rd diaphyseal fracture of humerus were selected for the study.
· A written informed consent was taken form the patient or from the legal guardian.
· A structured questionnaire was then administered to obtain relevant information from the patients.
· Operation was then performed and the post operative follow ups were recorded.
· Confidentiality was duly maintained regarding all collected data form the study subjects.
5. OBSERVATIONS & RESULTS
The findings derived from analysis of the collected data are furnished below:
5.1 Age distribution
Out of 33 subjects one-third (33.3%) were below 30 years of age and 30.3% between 30-40 years of age thus constituting more than half (63.3%) of the subjects within 40 years of age. Of the rest subjects, 18.2% were in the age range of 40-50 years and another 18.2% were 50 or above 50 years of age. The mean age was (36.7 ± 11.2) years and the lowest and highest ages were 20 and 60 years respectively (Table 5.1).
Table 5.1 Age distribution of the patients (n = 33)
| Age (yrs)* | No | % |
| < 30 | 11 | 33.3 |
| 30 – 40 | 10 | 30.3 |
| 40 – 50 | 06 | 18.2 |
| ³ 50 | 06 | 18.2 |
* Mean age = (36.7 ± 11.2) yrs; range: (20 – 60) yrs.
5.2 Distribution of Sex
Figure 5.1 depicts that nearly three-quarter (73%) of the subjects were male and the rest were female (27%) giving a male-female ratio of 3:1 roughly.
| Cause of injury | Frequency | Percentage |
| Motor car driving | 02 | 6.1 |
| Motorcycle driving | 03 | 9.1 |
| Pedestrian | 15 | 45.5 |
| Fall from height | 04 | 12.1 |
| Assault | 02 | 6.1 |
| Machinery injuries | 01 | 3.0 |
| Accident at home | 02 | 6.1 |
| Sports activities | 04 | 12.1 |
5.3 Occupation
Figure 5.2 demonstrates that 9 (27.3%) patients were service-holder followed by 21.2% housewives and another 21.2% students. Very few were farmers (6.1%) and labourers (9.1%).
4.
Table 5.3 Fracture profile of the patients
| Fracture profile | Frequency | Percentage |
| Fracture side (n = 33) | ||
| Right | 16 | 48.5 |
| Left | 17 | 51.5 |
| Fracture type (n = 33) | ||
| Early Failure of conservative treatment | 11 | 33.3 |
| Non united | 13 | 39.4 |
| Comminuted | 09 | 27.3 |
| Involvement of dominant hand (n = 33) | ||
| Yes | 16 | 48.5 |
| No | 17 | 51.5 |
Table 5.4 Comparison of time interval among the type of fractures (n = 33)
| Type of fracture | N | Time interval (weeks) | p-value | |
| Mean | SD | |||
| Early failure of conservative
treatment |
11 | 1.82 | 0.41 | |
| Non-united | 13 | 43.92 | 14.91 | < 0.001 |
| Comminuted | 09 | 2.33 | 1.12 | |
Table 5.5 Post operative hospital stay (n = 33)
| Days | ||
| Mean ± SD | Range | |
| Post operative hospital stay | 9.76 ± 3.03 | 7-17 |
Table 5.6 Presence of bridging callus by radiographic evaluation (n = 31)
| Radiological evaluation | Weeks | |
| Mean ± SD | Range | |
| Presence of bridging callus | 17.06 ± 2.01 | 12 – 24 |
5. 7 Use of Bone graft
About 40% of the subjects (mainly the non-united cases) were given bone grafts during operation and the rest 60.6% were not given the same (Figure 5.3).
Fig. 5.3 Distribution of subjects by use of bone graft (n = 33)
5.7 Postoperative complications
More than three-quarter (75.8%) of cases did not have any complication. Four patients (12.1%) developed infection and 2(6.1%) had iatrogenic radial nerve palsy. One (3%) exhibited loosening of the screw and one (3%) had to be transfused with blood because of profuse bleeding from the donor graft site postoperatively.
Table 5.7 Distribution of patients by postoperative complications (n = 33)
| Postoperative complication | Frequency | Percentage |
| Iatrogenic radial nerve palsy | 02 | 6.1 |
| Infection | 04 | 12.1 |
| Loosening of the screw | 01 | 3.0 |
| Post operative blood transfusion | 01 | 3.0 |
| No complication | 25 | 75.8 |
5.8 Findings at 1st visit (4-10 weeks)
Table 5.8 shows the distribution of patients’ findings at first follow-up visit. Two (6.1%) patients had infection, 5(15.2%) complained of pain- 3(9.1%) had mild pain and 2(6.1%) had severe pain. All the 33 patients had intact fracture alignment. Visible callus was found in 57.6% of cases. Only 1 patient exhibited loosened screw. Of the 8 patients 3(37.5%) continued previous complications but none developed any new one.
Table 5.8 Distribution of patients by findings at 4 weeks after operation
| Findings after 1st visit | Frequency | Percentage |
| Infection (n = 33) | 2 | 6.1 |
| Pain (n = 33) | ||
| No pain | 28 | 84.8 |
| Mild | 3 | 9.1 |
| Severe | 2 | 6.1 |
| Intact fracture alignment (n = 33) | 33 | 100.0 |
| Callus formation (n = 33) | ||
| Visible | 19 | 57.6 |
| Absent | 14 | 42.4 |
| Position of plate/screw (n = 33) | ||
| Intact | 32 | 97.0 |
| Loosened (Screw) | 1 | 3.0 |
| Previous complication (n = 8) | ||
| Continued | 3 | 37.5 |
| Absent | 5 | 62.5 |
| New complication (absent) (n = 33) | 33 | 100.0 |
5.9 Findings at immediately before the last visit (16-24 weeks)
At immediately before the last evaluation, pain and infection was found to be absent as before (Table 5.9). Data show that all cases had intact alignment and also been united by the time.
Table 5.9 Distribution of patients by findings at 16 weeks after operation
| Findings after 16 weeks | Frequency | Percentage |
| Absence of infection | 33 | 3.0 |
| Pain (absent) | 33 | 100.0 |
| Fracture alignment (intact) | 33 | 100.0 |
| Callus formation (bridging) | 33 | 100.0 |
| Position of plate/screw | ||
| Intact | 32 | 97.0 |
| Loosened (Screw) | 1 | 3.0 |
| Fracture united | 33 | 100.0 |
5.10 Range of motion immediately before the last evaluation visit (16-24 weeks)
Table 5.10 shows the range of motion immediately before the last evaluation visit. The mean values and the range of different types of active and passive motions of shoulder and elbow were presented in the table.
Table 5.10 Range of motion immediately before the last evaluation visit (n= 33)
| Range of motion | Mean ± SD | Range |
| Shoulder | ||
| Flexion (active) | 130 ± 15 | 100 – 160 |
| Flexion (passive) | 136 ± 15 | 100 – 160 |
| Extension (active) | 38 ± 4 | 30 – 45 |
| Extension (passive) | 38 ± 4 | 30 – 45 |
| Abduction (active) | 129 ± 11 | 110 – 150 |
| Abduction (passive) | 134 ± 12 | 110 – 150 |
| Elbow | ||
| Flexion (active) | 116 ± 10 | 100 – 130 |
| Flexion (passive) | 116 ± 10 | 100 – 130 |
| Extension (active) | 0 ± 0 | 0 – 0 |
| Extension (passive) | 0 ± 0 | 0 – 0 |
5.11 Patients followed up to
The mean follow up time of patients was 24.58 ± 3.56 weeks and the lowest and highest time of follow up were 15 and 32 weeks respectively.
Table 5.11 Duration of follow up of the patient (n = 31)
| Followed up to | Weeks | |
| Mean ± SD | Range | |
| 24.58 ± 3.56 | 15 – 32 | |
5.12 Evaluation of pain
Figure 5.4 demonstrates that 30.3% of the subjects had moderate degree of pain followed by 27.3% of severe pain, 18.2% mild pain and another 18.2% did not have any pain preoperatively. All the patients responded to the treatment having no pain postoperatively.
Fig. 5.12 Comparison between preoperative and postoperative pain
Table 5.12 Comparison between preoperative and postoperative functional outcome score (n = 31)
| Total score | Mean ± SD | p-value* |
| Preoperative | 8.16 ± 7.23 | < 0.001 |
| Postoperative | 75.87 ± 13.47 |
*Wilcoxon Signed Rank Test was done to analyse the data; Level of significance was 0.05.
5.13 Rating of postoperative functional outcome
Rating of postoperative functional outcome demonstrates that 11 (35.5%) patients had excellent outcome, 16 (51.6%) good, 4 (12.9%) fair and none had poor outcome (Figure 5.5).
Fig. 5.13 Rating of postoperative functional outcome
5.14 Final functional outcome
Figure 5.6 shows that the majority of the subjects (87%) had satisfactory outcome (excellent and good) and the rest 3% had fair outcome. Based on Z-approximation the outcome was considered significant (p < 0.001).
Fig. 5.14 Distribution of patients by final outcome (n = 31)
5.15 Final assessment of range of motion in shoulder and elbow joint
Shoulder motion test reveals that 20 (64.51 %) of the 31 subjects had excellent range of motion (< 100 deficit) followed by 22.58 % (n= 7) moderate (100-300 deficit)and 12.90% poor outcome (> 300 deficit). More than half (67.74 %) of the subjects had moderate, 22.58% excellent and only 9.67% poor functional outcome of elbow motion.
Table 5.15 Distribution of patients by restriction in motion (n = 31)
| Outcome | Frequency | % |
| Shoulder motion | ||
| Excellent (< 100 deficit) | 20 | 64.51 |
| Moderate (100 – 300 deficit) | 07 | 22.58 |
| Poor (> 300 deficit) | 04 | 12.90 |
| Elbow motion | ||
| Excellent (< 100 deficit) | 21 | 67.74 |
| Moderate (100 -300 deficit) | 07 | 22.58 |
| Poor (> 300 deficit) | 03 | 9.67 |
6. DISCUSSION
Although the majority of humeral shaft fractures are still treated conservatively with a satisfactory rate of success, there is a growing tendency toward operative treatment, as prolonged plaster cast immobilization of the upper arm against the thoracic wall is becoming increasingly unpopular among both patients and surgeons. This tendency has led to a progressive expansion of our indications for surgical treatment. (George, Dimitrios & Pericles et al. 2004, p.247 ).When operative treatment is indicated, plate fixation probably still remains the primary choice of most surgeons, producing satisfactory functional results and union rate ( Meekers & Broos 2002, P. 462 ).
Epidemiological data of fractures, varies between communities as a result of differences in socioeconomic, cultural, degree of urbanisation and other population characteristics (Cheng & Shen 1991, p.230). Some authors have reported on trends and patterns of humeral fractures. In a study conducted by Gallagher et al. (1984, p.1340), the incidence of humeral fractures was related to age group, with a significantly higher incidence in those aged between 41 and 70 years compared with those in the younger age group (p<0.001). Out of our 33 study subjects , one-third (33.3%) were below 30 years of age and 30.3% between 30 – 40 years of age thus constituting more than half (63.3%) of the subjects within 40 years of age. The mean age was 36.7 ± 11.2 years and the lowest and highest ages were 20 and 60 years respectively.
We found that the fractures occurred more on the left humerus (52%) than on the right (48%) with less involvement of the dominant hand. The Malaysian (Chai, Aik & Sengupta 2000, p. 39 ) study also showed that the non-dominant arm was more often injured while a study conducted among the Scots (Tytherleigh, Walls & McQueen 1998, p. 249) indicated a higher incidence of fractures on the left humerus. This could be explained by the fact that about 90% of individuals world wide are right-handed and hence the right hand is more actively involved in physical mechanical action and use, as indeed a Malaysian study has indicated (Chai, Aik, Sengupta 2000, p. 40). The overall outcome of this is that the right arm has a greater bone mass than the more sedentary left arm and hence is less prone to fractures.
Christensen (1976) observed a male predominance of 61.5%, while Wright, Miller and Vander (1993) showed males to made up 55.6% and Ring et al. (2000) 60.0%. In relation to gender, analysis our study showed that males had involvement of a