Iatrogenic Radial Nerve Injury Research Articles

Treatment of Distal Third Humeral Shaft Fracture with Intramedullary Nail Combined with Anterior Minimally Invasive Plate Osteosynthesis.

The treatment of distal third humeral shaft fracture is difficult. Studies have shown that anterior minimally invasive plate has lower probability of complication and higher healing rate. However there is no applicable anatomical plate at present. This study is to investigate the clinical effect of intramedullary nail combined with anterior minimally invasive plate in the treatment of distal humeral shaft fractures. The data of 83 patients with lower humerus shaft fracture treated from September 2015 to January 2020 were analyzed. According to different treatment methods, they were divided into two groups: 40 patients were treated with intramedullary nailing combined with minimally invasive anterior plate fixation (group A), and 43 patients were treated with double plate fixation through posterior approach (group B). General preoperative data, operative time, intraoperative blood loss, total incision length, fracture healing time, shoulder and elbow visual analogue scale (VAS) score, Constant-Murley shoulder function score, Mayo elbow function score, and complications were recorded and compared between the two groups. Two independent sample t-tests was used for follow-up, age, BMI, operation time, intraoperative bleeding, total incision length, fracture healing time, Constant-Murley score and Mayo score, and rank sum test was used for VAS score of shoulder and elbow. There was no significant difference in preoperative general data between the two groups (p > 0.05), indicating comparability. There were no significant differences in operation time, total incision length, fracture healing time, Constant-Murley shoulder function score at the last follow-up, Mayo elbow function score, and shoulder and elbow VAS pain score between 2 groups (p > 0.05). The amount of intraoperative blood loss in observation group was 76.98 ± 16.46, which was significantly less than that in control group, and the difference was statistically significant (p < 0.01). There were no radial nerve injury, musculocutaneous nerve injury, incision infection and fracture nonunion in the observation group. In the control group, four cases of iatrogenic radial nerve injury, three cases of incision infection and three cases of fracture nonunion were found. The complication rate was 23.3% (10/43). There was statistical difference in the incidence of complications between the two groups (p < 0.01). A humeral intramedullary nail combined with an anterior minimally invasive plate in the treatment of distal humeral shaft fracture has the advantages of less soft tissue damage, less blood transfusion, high fracture healing rate and low risk of iatrogenic radial nerve injury, which is an effective method for clinical treatment of this type of fracture.

Biomechanical performance evaluation of a modified proximal humerus locking plate for distal humerus shaft fracture using finite element analysis

The extra-articular distal humerus plate (EADHP) has been widely used for surgical treatment of distal humerus shaft fracture (DHSF). However, the surgical approach, fixation methods, and implant positions of the EADHP remain controversial owing to iatrogenic radial nerve injury and complaints such as skin irritation related to the plate. Anterior plating with a modified (upside-down application) proximal humerus locking plate (PHILOS) has been proposed as an alternative, However, research on its biomechanical performance remain insufficient and were mostly based on retrospective studies. This study quantitatively compared and evaluated the biomechanical performance between posterior plating with the EADHP and anterior plating with a modified PHILOS using finite element analysis (FEA). The FEA simulation results that both the EADHP and PHILOS had adequate biomechanical performance and stability under axial, bending, and varus force load conditions. The PHILOS has a fixed stability comparable to that of the EADHP, and fixation was achieved using only four locking screws within a fixed range of 30 mm just above the olecranon fossa. The results show that the PHILOS could be an option for the fixation of a DHSF when considering the dissection range and complaints (e.g. skin irritation) associated with the EADHP.

Treatment of Iatrogenic Nerve Injury After Humeral Shaft Fracture Fixation: A Case Report

Background. Iatrogenic neuropathies of the radial nerve following intramedullary nailing of the humerus are observed in 2.9% of patients. In 30% of cases, iatrogenic nerve injury is associated with distal nail locking. Questions about the timing and volume of diagnostic measures to determine the nature of nerve damage, methods of conservative and surgical treatment, and their effectiveness remain relevant.&#x0D; Aim of the study to illustrate the causes, prevention methods, diagnosis, and treatment of iatrogenic radial nerve injuries in humeral shaft fractures through a clinical example.&#x0D; Case presentation. A 30-year-old female patient was admitted with a nonunion fracture of the left humerus and iatrogenic radial nerve injury three months after the fracture was fixed with a locking nail. A revision operation was performed: removal of the nail from the left humerus; re-fixation of the left humerus with a plate; revision, neurolysis, and plastic repair of the left radial nerve using autografts from the right sural nerve. Postoperative courses of medication therapy, physiotherapy, and therapeutic exercises were conducted. At 26 months after the surgery, complete range of motion and restoration of strength in active extension of the left wrist and three phalanges, abduction of the first finger, partial extension of the first finger, and restoration of sensitivity on the outer surface of the left forearm and the back of the hand were observed.&#x0D; Conclusion. Iatrogenic radial nerve injury primarily occurs as a result of incorrect technique when introducing locking screws during intramedullary nailing of humeral shaft fractures. Delayed examination and surgical treatment of patients with injured radial nerve lead to a lack of full functional recovery, potential muscle atrophy, and impairment of their motor function. Surgical treatment aimed at restoring the radial nerve at an early stage after injury, combined with a full range of postoperative rehabilitation for a year, is the only correct treatment approach.

Medial minimally invasive plate osteosynthesis for humeral shaft fractures: a case series.

This is a study conducted in our university hospital, which is a Level 1 academic trauma center. A retrospective analysis of 21 patients with HSFs who received minimally invasive treatment using plate osteosynthesis through a medial approach over a 5-year period was conducted. The outcomes measured included time for radiographic consolidation, disabilities of the arm, shoulder, and hand score, and complications such as infection, iatrogenic radial nerve injury, loss of reduction or fixation, and nonunion. Twenty-one patients who underwent the procedure were identified. Bone healing was achieved in all patients with an early and aggressive range of motion. There were no cases of infection or iatrogenic radial nerve injury. The mean radiographic fracture union time was 15.76 weeks (range: 8-40 weeks). The mean disabilities of the arm, shoulder, and hand score was 3.29 (range: 0-14.17) at the time of the last follow-up. The mean screw density was 0.43. The proposed algorithm is effective in addressing the challenges of iatrogenic nerve injury and extra-articular distal fixation of HSFs with conventional MIPO techniques.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis.

Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anatomic consideration of the radial nerve in relation to humeral length for unilateral external fixation: a retrospective study using magnetic resonance imaging findings in korean

BackgroundThis study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images.MethodsAll patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated.ResultsA total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9–34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0–10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1–30.8%). The minimum ratio was 15.1%.ConclusionA percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury.

Use of lateral-exit crossed-pin fixation for pediatric supracondylar humeral fractures: a retrospective case series.

Surgeons have been reluctant to perform crossed-pin fixation for displaced pediatric supracondylar humeral (SCH) fractures because it carries a risk of iatrogenic ulnar nerve injury. This study aimed to introduce lateral-exit crossed-pin fixation for displaced pediatric SCH fractures and to evaluate its clinical and radiological outcomes, with a particular focus on iatrogenic ulnar nerve injuries. Children who underwent lateral-exit crossed-pin fixation for displaced SCH fractures between 2010 and 2015 were retrospectively reviewed. Lateral-exit crossed-pin fixation involved the introduction of a medial pin from the medial epicondyle, as in the conventional method, followed by pulling the pin through the lateral skin until the distal and medial aspects of the pin were just under the cortex of the medial epicondyle. The time to union and loss of fixation were assessed. Flynn's clinical criteria (cosmetic and functional factors) and complications including iatrogenic ulnar nerve injury were investigated. A total of 81 children with displaced SCH fractures were treated with lateral-exit crossed-pin fixation. All but one patient achieved union with good alignment, with an average time to union of 7.9 weeks (3.9-10.3 weeks). Only one patient exhibited cubitus varus deformity associated with loss of reduction. All patients recovered to almost their full range of motion. No case of iatrogenic ulnar nerve injury developed; however, iatrogenic radial nerve injury developed in one patient. Lateral-exit crossed-pin fixation provides sufficient stability with a lower risk of iatrogenic ulnar nerve injury in children with displaced SCH fractures. This method is an acceptable technique for crossed-pin fixation.

Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail. We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded. There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (P>0.05). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (P<0.05). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (P=0.0004). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing (P>0.05). The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.

Risk of Radial Nerve Injury in Anterolateral Humeral Shaft Plating.

The purpose of this study was to evaluate and compare the risk of iatrogenic radial nerve injury between arm positionings of 45° and 60° abduction in anterolateral humeral plating using a 4.5-mm narrow dynamic compression plate. Fifty-six humeri of cadavers in the supine position with 45° of arm abduction were exposed through the anterolateral approach. A hypothetical fracture line was marked at the middle of the humerus, and a precontoured ten-hole 4.5-mm narrow dynamic compression plate was applied and fixed to the anterolateral surface. After the fixation, the radial nerve was exposed through a triceps-splitting approach. Screws in contact with or which had penetrated the radial nerve were deemed to be injuries. Then, the screws and plate were removed, the arm changed to the 60° arm abduction position, and the steps of applying the plate and inserting the screws were followed as in the 45° arm abduction step. The screws which could potentially injure the radial nerve were those of the second to sixth screw holes in both the 45° and 60° of arm abduction positions. The incidences of iatrogenic radial nerve injury of the second to sixth screw holes in the 45° position were 5.36%, 39.29%, 80.36%, 60.71%, and 10.71%, respectively, and at the 60° position were 5.36%, 53.57%, 83.93%, 60.71%, and 7.14%, respectively. There were no statistically significant differences in risk of injury between the two positions in all screw holes (all P-values > 0.05). In anterolateral humeral shaft fixation, arm abduction position did not affect the risk of iatrogenic radial nerve injury, with the main risk from certain screw holes. The surgeon should be careful in screw insertion, especially at the fourth and fifth screw holes. IV; cadaveric study.

How to treat proximal and middle one-third humeral shaft fractures: the role of helical plates.

To evaluate the outcomes of patients affected by proximal and middle one-third humeral shaft fractures treated with humeral helical plates. From October 2016 to June 2020, twenty-four (twenty women, four men) underwent humeral reduction and fixation with humeral helical plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet) that preserve deltoid muscle insertion and reduce the risk of iatrogenic radial nerve injury. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (eighteen months on average), clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. Only descriptive statistical analysis was conducted. At six months, all fractures have healed. At last follow-up (average eighteen months, 13-28) mean Constant score was 71 (range 33-96), mean Dash score was 19.2 (range 1.7-63). The average range of motion was calculated as follows: flexion 137.8° (range 90-180); abduction 125.8° (range 85-180°); external rotation 55° (range 20-80°), internal rotation at L3 (range between scapulae-trochanter). Three patients experienced temporary radial nerve palsy from injury, while in one case, a temporary iatrogenic palsy occurred. In our opinion, the helical plate may be an effective surgical tool for management of proximal and middle one-third diaphyseal humeral fractures. The humeral helical plate allows stable fixation avoiding the deltoid tuberosity proximally and radial nerve distally, thus increasing the possibility of rapid functional recovery after surgery.

Functional and Radiological Outcome in the Management of Diaphyseal Humeral Shaft Fracture Using the Minimally Invasive Percutaneous Plate Osteosynthesis (MIPO) Technique

Introduction: Minimally invasive percutaneous plate osteosynthesis (MIPO) is gaining preference nowadays compared to other treatment modalities for diaphyseal fracture of the humerus. We have evaluated the functional and radiological outcome of diaphyseal humeral shaft fracture with the MIPO technique.&#x0D; Methods: A hospital-based prospective study was conducted on 23 adult patients with diaphyseal fracture of the humerus and treated with the Minimally Invasive Percutaneous Plate Osteosynthesis (MIPO) technique. In all cases, 4.5mm locking compression plates were applied. Clinical and radiological evaluation was done at 6 weeks, 3 months, and 6 months.&#x0D; Results: Out of 23 patients, the mean age of patients was 40.3 years. The maximum number of cases were caused due to road traffic accidents 14 (60.9%). The left side was commonly affected with a maximum number of them being Type A fracture 13 (56%) as per AO/OTA classification. The mean operative time was 106 minutes and fracture union was achieved in all patients by the end of 20 weeks (mean 14.83 weeks). In the study group, 1 patient had superficial infection with no evidence of iatrogenic radial nerve injury or implant failure. Shoulder and elbow ROM was restored to normal range.&#x0D; Conclusion: MIPO is a safe and effective technique for the management of diaphyseal humerus fractures, with early fracture healing, less risk of complications such as superficial or deep infection, implant failure, and iatrogenic radial nerve injury, along with a cosmetically acceptable scar.

Prospective comparative study between antegrade interlocking undreamed nail versus compression plate fixation of acute closed humeral mid third shaft humerus in adults

Objective: To assess the functional outcome, time to union, shoulder pain, blood loss, operative time, iatrogenic radial nerve injury, hospitalization, and infection. Methodology: It is a prospective randomized study on 30 patients with mid-shaft humerus fracture according to AO classification (1.2A1, 2, 3 and 1,2B) with functioning radial nerve. They were randomly dividing into two groups. Group A were treated by a closed antegrade interlocking nail, and group B treated by open reduction and locked compression plate fixation. The follow-up was up to 6 months, including time to union, shoulder pain, intraoperative blood loss, operative time and iatrogenic radial nerve injury. Functional outcome was assessed by quick DASH score. Results: Road traffic accident was the main cause of trauma (70%). The average time to union were statistically not different in both groups. Quick DASH score was good in both groups and statistically not significant. Shoulder pain in group A was (40%), while none patient in group B (p&gt;0.017). The operative period time, mean hospital stays, and blood loss of group B were significantly higher than in group A Conclusion: Nailing is minimally invasive, has less infection rate, iatrogenic nerve injury, operative time, intraoperative blood loss, and hospitalization.

The risk of iatrogenic radial nerve and/or profunda brachii artery injury in anterolateral humeral plating using a 4.5 mm narrow DCP: A cadaveric study.

Fixation of humeral shaft fractures with a plate and screws can endanger the neurovascular structure if proper care is not taken. No studies to our knowledge have studied the risk of iatrogenic radial nerve and/or profunda brachii artery (RNPBA) injury from each screw hole of a 4.5 mm narrow dynamic compression plate (narrow DCP). The purpose of this study is to evaluate the risk of RNPBA injury in anterolateral humeral plating with a 4.5 mm narrow DCP. 18 humeri of 9 fresh-frozen cadavers in the supine position were exposed via the anterolateral approach with 45 degrees of arm abduction. A hypothetical fracture line was marked at the midpoint of each humerus. A precontoured ten-hole 4.5mm narrow DCP was applied to the anterolateral surface of the humerus using the fracture line to position the center of the plate. All screw holes were drilled and screws inserted. The cadaver was then turned over to the prone position with 45 degrees of arm abduction, and the RNPBA exposed. The holes through in which 100% of the screw had contact with or penetrated the RNPBA were identified as dangerous screw holes, while lesser percentages of contact were defined as risky. The relative distance ratios of the entire humeral length from the lateral epicondyle of the humerus to the 4th, 3rd, 2nd and 1st proximal holes were 0.64, 0.60, 0.56 and 0.52, respectively. The most dangerous screw hole was the 2nd proximal, in which all 18 screws had contacted or penetrated the nerve, followed by the risky 1st (12/18), 3rd (8/18) and 4th (2/18) holes. In humeral shaft plating with the 4.5mm narrow DCP using the anterolateral approach, the 2nd proximal screw hole carries the highest risk of iatrogenic radial nerve and/or profunda brachii artery injury.

Percutaneous fixation with helical bridge combined fixation system for long split fractures involving the middle and upper humerus

To evaluate the effectiveness of percutanous fixation with helical bridge combined fixation system (BCFS) for treatment of long split fractures involving the middle and upper humerus. Between February 2018 and February 2020, 15 patients of long split fractures involving the middle and upper humerus were treated. There were 6 males and 9 females, with an average age of 62 years (range, 37-82 years). The fractures were caused by slipping in 7 cases, falling from height in 3 cases, and traffic accident in 5 cases. According to AO classification, the shaft fractures were rated as type A in 4 cases, type B in 9 cases, and type C in 2 cases. And all fractures extended to proximal humerus; and the proximal fractures were rated as one-part fracture in 11 cases and two-part fracture in 4 cases according to Neer classification. The interval between injury and operation was 1-7 days (mean, 3.2 days). Nine patients underwent closed reduction and 6 patients underwent open reduction after lengthening the incisions. All fractures were percutaneously internal fixated with helical BCFS after reduction. The operation time, intraoperative blood loss, incision healing, and fracture healing were recorded. Constant-Murley score was used to evaluate shoulder joint function, and Mayo score was used to evaluate elbow joint function. The operation time ranged from 55 to 175 minutes, with an average of 76.5 minutes; the intraoperative blood loss ranged from 80 to 300 mL, with an average of 185.5 mL. All incisions healed by first intention, without infection or radial nerve injury. All patients were followed up 12-23 months, with an average of 16 months. The fractures all reached clinical healing, and the healing time was 12-20 weeks, with an average of 14.5 weeks. At 1 year after operation, the Constant-Murley score of the affected side was 88.7±7.6, and there was no significant difference when compared with that of the healthy side (90.8±8.3) ( t=1.421, P=0.052). According to the elbow Mayo score, the score of the affected side was 97.6±6.5, and there was no significant difference when compared with the healthy side (97.7±7.3) ( t=0.433, P=0.913). The helical BCFS can avoid the dissection of deltoid insertion and prevent the iatrogenic radial nerve injury. With satisfied effectiveness, it is suggested for minimally invasive surgical treatment of long split fractures involving the middle and upper humerus.

A PROSPECTIVE FOLLOW UP STUDY OF EVALUATION OF SHOULDER FUNCTION AFTER ANTEGRADE INTERLOCKING NAILING IN HUMERUS SHAFT FRACTURES IN ADULTS

INTRODUCTION: This study was conducted to assess the shoulder function after antegrade interlocking humerus nailing in humerus shaft fractures, duration of union, complications (immediate and late) of this xation. METHODS: In this prospective study 40 cases with humerus shaft fractures were treated with antegrade interlocking humerus nailing and followed up for functional outcomes and complications. RESULTS: The age of patients ranged from 18 to 57 years. The assessment of shoulder function was made according to CONSTANT score. Out of 40 patients shoulder function was excellent in 35 cases (87.5%), very good in 3 cases (7.5%) and fair in 1 case (2.5%). Period of fracture union ranged from 12 to 18 weeks, average period being 13.7 weeks. None had iatrogenic radial nerve injury and/or infection. CONCLUSION: We concluded that Locked intramedullary nailing is a novel treatment option for diaphyseal fractures of the humerus. By making correct entry, repairing rotator cuff, placing the nail inside proximal end and proper physiotherapy; shoulder function outcome can be improved to excellent in cases of humerus diaphyseal fractures treated with antegrade interlocking humerus nailing.

Influence of Timing on Surgical Outcomes for Acute Humeral Shaft Fractures.

Surgical treatment for humeral shaft fractures has been reported to yield satisfactory results; however, there may be complications, such as delayed bone union, nonunion, iatrogenic radial nerve injury, and infection. The risk factors for postoperative complications remain largely unknown. This study aimed to investigate the influence of timing of surgery on the incidence of postoperative complications of acute humeral shaft fractures. We retrospectively reviewed 43 patients who underwent osteosynthesis for acute humeral shaft fractures between 2006 and 2020. The patients were divided into early (21 patients) and delayed (22 patients) treatment groups based on the timing of the surgical intervention (within or after four days). Outcomes were the incidences of complications (delayed union, nonunion, iatrogenic radial nerve injury, and infection) and postoperative fracture gaps. We evaluated the outcomes using plain radiographs and clinical notes. In addition, we performed subgroup analyses on outcomes in a subgroup of patients who underwent intramedullary nailing and one who underwent plate fixation. The frequency of delayed union was significantly higher in the delayed group (P=0.046), and the postoperative fracture gap size was also significantly greater in the delayed group (P=0.007). The subgroup analyses demonstrated a significant association between the increased incidence of delayed union and delayed surgical interventions only in the intramedullary nailing subgroup (P=0.017). This study suggests that performing surgery within four days after acute humeral shaft fracture is recommended to reduce the occurrence of delayed union, particularly in cases requiring intramedullary nailing fixation.

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BACKGROUND This case series was conducted to evaluate the intraoperative and post-operative outcomes of fracture shaft of humerus managed by indirect reduction and minimally invasive plate osteosynthesis (MIPO) via anterior approach. METHODS In this case series 26 diaphyseal fractures of the humerus treated with MIPO, between June 2017 and February 2020 at a tertiary care hospital were included. All the patients were followed up for a minimum period of 2 years postoperatively. The objective was to evaluate these cases clinically for shoulder and elbow range of motion and document any complications. Other parameters such as duration of surgery and radiological time for fracture union were also documented. RESULTS The mean duration for surgery was 86.5 minutes. The University of California Los Angeles (UCLA) shoulder scoring system rated 18 patients (69.2 %) as excellent outcome, 07 patients (26.9 %) as good outcome, and 1 patient (3.8 %) as fair outcome. The MAYO Elbow Performance Scoring system rated 20 patients (76.9 %) as excellent outcome and 06 patients (23.1 %) as good outcome. About 96 % of patients achieved fracture union by the end of 16 weeks post-operatively (mean 13.4 weeks). No complications related to infection, iatrogenic radial nerve injury or implant failure were noted in the study. 4 cases had varus angulation deformity but did not affect shoulder or elbow function. CONCLUSIONS MIPO is a safe and effective technique for the management of diaphyseal humerus fractures, with early fracture healing, less risk of complications such as infection and iatrogenic radial nerve injury, along with a cosmetically acceptable scar. KEYWORDS Fracture Fixation, Fracture Healing, Humeral Fractures, Radial Nerve, Shoulder

Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures

BackgroundThe surgical approaches remain controversial for the treatment of middle and distal-third humeral shaft (MDTHS) fractures. This study compared clinical effects of the anterolateral approach with two incisions (AATI) and the posterior median approach (PMA) in the treatment of MDTHS fractures.MethodsA retrospective analysis was carried out. One hundred sixty-six patients with MDTHS fractures were selected from January 2015 to January 2017 in Xi’an Hong Hui Hospital. According to surgical approaches, patients were divided into AATI (86 cases) and PMA group (80 cases). All patients were treated with open reduction and plate fixation. Operation indexes were compared, including incision length, operation time, and bleeding. Bryan-Morrey score was used to evaluate elbow joint function. Complication incidence was compared, such as incision infection, iatrogenic radial nerve injury, and nonunion.ResultsThe AATI group showed smaller incision length, less bleeding, lower iatrogenic radial nerve injury rate, and better elbow function than that of PMA group (P<0.05).ConclusionsThe middle and distal-third humeral shaft fractures can be successfully cured by both approaches. Compared with the posterior median approach, it has better clinical effects of the anterolateral approach with two incisions, which is worthy of clinical application and promotion.

Comparison between osteosynthesis with interlocking nail and minimally invasive plating for proximal- and middle-thirds of humeral shaft fractures.

Options for the treatment of proximal- and middle-thirds ofhumeral shaft fracturesinclude intramedullary interlocking nail (IMN) and minimally invasive plate osteosynthesis (MIPO). However, whether IMN provides better clinical outcomes than MIPO surgical technique still remains unclear. This study was designed to compare clinical outcomes of the IMN with MIPO technique for the treatment of proximal- and middle-thirds of humeral shaft fractures. A retrospective cohort analysis of 55 proximal- and middle-thirds of humeral shaft fracturessurgically treated using IMN (n = 25) or MIPO (n = 30) from January 2012 to January 2016. Peri-operative and follow-up data (a minimum of 1 year) of the patients (aged from 18 to 56 years) were collected. Operative time, union time, VAS scores, surgery-related complications, and implant removal rate were compared between the two groups in this study. Besides, the functional outcomes were evaluated using the Rating Scale of American Shoulder and Elbow Surgeons' Form (ASES) and Mayo Elbow Performance Score System (MEPS). We found significantly shorter operative time and much less blood loss in IMN group, and lower VAS scores in the IMN group after surgery at first and third months but not at the sixth month. Complication rate was found to be relatively higher in the MIPO group when compared to the IMN group. No significant difference was observed between these two groups regarding ASES and MEPS scores. Three patients in the MIPO group suffered iatrogenic radial nerve injury and recovered after four to five months later. No implant failures occurred in either group. Intramedullary interlocking nail seemed to be superior to minimally invasive plate osteosynthesis in the treatment of proximal- and middle-thirds of humeral shaft fractures due to shorter operative time and union time, less early post-operative pain, and fewer complications. The intramedullary interlocking nail could be considered a better surgical option for the management of proximal middle humeral fractures, though it may also depend on the surgeons' skills and learning curve. Further in-depth prospective studies are in great need to verify our conclusion.

Avoiding iatrogenic radial nerve jeopardy during Humerus fixation by unshackling the nerve: A Study of simple and effective technique

Background: Radial nerve is prone for iatrogenic injury during open reduction and fixation of humerus fractures. The Lateral Intermuscular Septum (LIS) acts like a rigid noose around the nerve and prevents free mobilization of nerve during the process of surgical fixation. Hence this study is conducted in an attempt to verify the chances of nerve injury when the lateral intermuscular septum is released. Material and methods: A total of 39 cases of shaft of humerus fractures were studied. All the cases were free of preoperative radial nerve injury and underwent plate fixation via anterolateral approach. A simple maneuver of lateral intermuscular release was done in all these cases. Appropriate proforma was made and data was expressed in percentages. Results: There was no incidence of iatrogenic radial nerve injury in any of these cases. Conclusion: Unshackling the radial nerve by releasing Lateral intermuscular septum would improve the excursion thereby circumventing the possibility of iatrogenic radial nerve injury.