Postoperative Radial Nerve Palsy Research Articles

Outcomes of Arthroscopy-assisted Closed Reduction and Percutaneous Pinning for a Displaced Pediatric Lateral Condylar Humeral Fracture.

Since 2015, we have performed arthroscopy-assisted closed reduction and percutaneous pinning (A/S-CRPP) for children with a displaced lateral condylar humeral fracture (LCF). The purpose of this study is to introduce our A/S-CRPP method and present its outcomes. In total, 39 displaced (>2 mm) LCFs for which A/S-CRPP was initially attempted and with available follow-up data of >12 months were retrospectively reviewed. A/S-CRPP is performed in the following order: closed reduction, 1 provisional K-wire fixation, arthroscopic verification of the reduction status, rereduction if needed, and additional fixation. Our reduction technique using articulations of the ulnohumeral and radiohumeral joints and direct compression is introduced. For rereduction, modified reduction forces were applied based on the arthroscopic findings. To evaluate the learning curve effect, the initial 6 months after the first case of A/S-CRPP was regarded as the "initial period." There were 12 cases during this period. Among the 39 cases, surgical method was intraoperatively converted to open reduction and percutaneous pinning in 9 and A/S-CRPP was completed in 30. Among the 9 open reduction and percutaneous pinning conversion cases, 7 conversions occurred in the initial period. Among the 30 patients who underwent A/S-CRPP alone, 10 needed rereduction after an arthroscopic examination. No patients presented with >10-degree angular deformity or elbow motion limited >20 degrees, compared with the contralateral elbow. Postoperative radial nerve palsy occurred in 2 patients, all in the initial period. Both were resolved within 5 months, postoperatively. We suggested our A/S-CRPP surgical technique for displaced pediatric LCF. It may require a 6-month learning curve period. Although more studies are needed, it seems to be a safe and appropriate surgical technique for treatment. Level IV-therapeutic study.

A study of anterior bridge plating via MIPPO (Minimal invasive percutaneous plate osteosynthesis) for diaphysial fracture of humerus

The internal fixation of shaft humerus fractures has evolved in recent years with a change of emphasis from mechanical to biological priorities. One such biological internal fixation is MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis). Objectives were to document functional and clinical outcomes of anterior bridge plating in diaphyseal humerus fracture, range of motion at elbow and shoulder joint following MIPPO, different complications, and radio-logical parameter like time for fracture union. We have done a obervational study of the 30 patients of fracture humerus treated with minimally invasive percutaneous plate Osteosynthesis from April 2017 to April 2018. More than 50% patients are in the age group of 30 to 50 years.Based on AO classification38% of patients were having simple spiral fracture/A1, 32% of patient was having simple transverse fracture/A3,24% of patients were having simple oblique fracture/A2, 6% of patients were having complex segmental fracture/C2.86% of patient’s post-operative period went event free. 2 patients were having post-operative radial nerve palsy, 2 patients were having superficial infection of stich line. On DASH questionnaire 86% of patients are able to perform activities. The UCLA scoring system rated 21 patients (70%) as a excellent result; 07 patients (26%) as a good result and 2 patients (4%) as a fair result. The MAYO Elbow performance scoring system rated 24 patients (80%) as a excellent result; 05 patients (17%) as a good result and 01 patients (3%) as a fair result. 50% of patients were having union within 12 to 16 weeks, and 43% patient having union within 17-20 weeks and 7% of patient having union at 22 weeks. In comparison with non surgical treatment for humerus fracture and with conventional platting MIPPO technique has very good clinical and functional outcome and also there is less chances of failure of the procedure.

A study of 40 cases of diaphyseal fracture of shaft of the humerus treated with plate osteosynthesis

Introduction: Different modalities of treatment are available for fracture shaft of humerus. It includes various conservative methods like immobilization in a sling, Thomas arm splint, U slab, hanging cast, shoulder spica cast and surgical treatment such as intramedullary nailing, plate osteosynthesis, and external fixator. These different methods have their own advantages and disadvantages. Method of plate osteosynthesis is sometimes associated with infection and iatrogenic damage to radial nerve. The selection of a method for treating fracture shaft of the humerus depends on various factors which are related to patient and type of fracture. We decided to undertake the study of fracture shaft humerus treated with plate osteosynthesis. Aim: To study patients with diphyseal fracture of shaft of the humerus treated with plate osteosynthesis. Materials and Methods: This was a prospective study of 40 patients with diaphyseal fractures of humerus treated by plate osteosynthesis. All the patients were treated as indoor patients at the Department of Orthopaedics, New Civil Hospital, Surat from January, 2004 to March, 2006. The maximum period of follow-up was 2 years and the minimum period of follow-up was 5 months with average follow-up of 6 months. Patients were operated as soon as they were fit for surgical procedure under anaesthesia. An informed written consent was taken. Most of the patients were operated by posterior approach except two operated through anterolateral approach. AO type narrow 4.5mm dynamic compression plates with 4.5mm cortical screws were used. Patients were called for follow-up regularly at interval of 2-4 weeks as per need. At each visit, patients were examined for pain, tenderness, skin condition, elbow and shoulder movements. All the findings were recorded. Final results were evaluated as per criteria laid down by Hunter. Results and discussion: In the present series, 88% had excellent to good results which were almost consistent with the series reported by Dominik Heim et al. One patient had superficial infection which responded to daily dressing and proper antibiotic use. In Robert and Vander series, postoperative infection rate was 5.6%. In our study, 2 patients had radial nerve palsy at the time of trauma and 1 patient had postoperative radial nerve palsy. Usually, these injuries are neuropraxia. All 3 patients had full recovery within 3-4 months. Conclusion: Though the series is relatively small and the period of follow-up is small, however it appears that: Plate fixation appears to be a good surgical option for treatment of the diaphyseal fractures of humerus. Radial nerve palsy is usually of neuropraxia and it recovers within 4-6 months.

Minimally invasive percutaneous plating of complex metaphyseal-diaphyseal proximal humeral fractures

Background: Many anatomic, cadaver studies have shown safe anterior and anterolateral percutaneous plating of the humerus; however, there is paucity of information on this in clinical case series. The aim of the current study was to assess outcome of minimally invasive plate osteosynthesis in complex metaphyseal-diaphyseal humeral fractures. Methods: Eighteen patients with acute, complex, proximal humeral fractures with diaphyseal extension were operated on using a long proximal humeral plate through a percutaneous minimally invasive technique. Results: Union was obtained in all patients with good alignment and good shoulder and elbow function. The average time to union was 15 wk (range, 9-21 wk). Two patients developed postoperative radial nerve palsy that recovered after 3 wk in the first and 9 wk in the second patient. There were no obvious neurovascular injuries or major complications. Conclusions: Mini-invasive percutaneous plating of complex metaphyseal-diaphyseal humeral fractures is feasible and safe and has good clinical outcomes.

Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: management by excision of non-union, bone grafting and stabilization by LCP in different modes

Non-union of the humeral shaft is infrequently noticed after surgical fixation. Sixty eight patients whose osteosynthesis of humeral shaft had failed leading to non-union were identified over a duration of 10 years from (January 2006 to December 2015). Clinical and radiographical follow-up was available for 64 patients (4 patients were lost for follow-up), with a mean age of 58 years (range 25–78 years). All patients had aseptic atrophic non-union of either: proximal shaft (n=12), mid shaft (n=38), and lower shaft (n=14). All these patients had failure of primary fixation, with a minimum duration from 36 to 110 weeks. Non-unions were operated by excision of non-union, autogenous bone grafting and osteosynthesis by locking compression plating. Adequate fixation of non-union with bone grafting was achieved in all patients. All non-unions healed well at an average of 16 weeks (range 6–36 weeks). The mean length of follow-up was 120 weeks (range 60–250 weeks). The mean range of movements following healing of non-union was forward flexion of 140°, external rotation and internal rotation of 30° at shoulder and average fixed flexion deformity of 10° and flexion of 130° at elbow. Two patients had postoperative radial nerve palsy because of neuropraxia, which recovered in eight weeks. Three patient developed superficial infections at the iliac crest, which settled with antibiotics, dressings in 3 weeks time and two patients had some discomfort over the fibular graft harvest site. In all patients complete clinical and radiological union was achieved with satisfactory outcome in terms of relief of symptoms and functional improvement in the range of movements. The main points in surgical treatment were complete excision of non-union, correction of deformity, use of plenty of corticocancellous graft, furthermore the use of intramedullary fibula and osteosynthesis by long locking compression plating in different modes of fixation provided good to excellent results and clinical outcome.

Predictors of radial nerve palsy recovery in humeral shaft fractures: A retrospective review of 17 patients

BackgroundRadial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. HypothesisFactors predicting the outcome of radial nerve palsy can be identified. MethodsOf 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12–84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. ResultsOf the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. DiscussionThese findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. Level of evidenceIV, retrospective study with no control group.

Lower radial nerve palsy in mid shaft humerus fracture using medial plating

Background: The fixation of the fracture is considered to be the best treatment option for early mobilization in midshaft humerus fracture. The aim of the present study is to compare the functional outcome after fixation of midshaft humerus fracture using medial and anterolateral plating techniques. Materials and Methods: Sixty-one patients with midshaft humerus fracture were operated using medial and anterolateral plating technique. In Group A (n = 30), the patients were operated using medial plating for fixation while in Group B (n = 31), the patients were operated using anterolateral plating. The patients were assessed clinically, radiologically and using Mayo elbow score and the University of California-Los Angeles (UCLA) shoulder rating scale. Results: Both the groups were matched in terms of age, gender, mode of injury, side involved, and duration of injury to surgery. Postoperative radial nerve palsy was observed in four patients in Group B which was found to be statistically significant (P = 0.04). The mean UCLA shoulder score improved significantly, 28.53 in Group A and 29.16 in Group B at the final follow-up (P

Distal-third diaphyseal fractures of the humerus: choice of approach and surgical treatment.

Distal-third diaphyseal fractures of the humerus are often hard to treat due to location and pattern of the fractures, radial nerve injury, and quality of bone and age of patients. The aim of this retrospective study is to propose the best approach and the best surgical technique according to the pattern of extra-articular fracture of the distal humerus. We have treated 37 fractures of the distal humerus between January 2010 and July 2015 classified according to the AO classification. There were 2 open fractures. We treated all fractures with open reduction and internal fixation with plates and screws. In 20 cases, we performed a posterior midline triceps-splitting approach, with patients in prone decubitus position; in 2 cases, the triceps-splitting approach with the patients in supine decubitus position; in 3 cases, the olecranon osteotomy approach in prone decubitus position; and in 12 cases, the lateral approach in supine decubitus position. Thirty cases had a medium follow-up of 6months. We observe 2 post-operative radial nerve palsies healed in 5months and 2 cases of non-union. The average time to union of remaining cases was 16weeks (range 12-24). Elbow motility was complete in 25 cases, in 4 cases there was an extension loss of 5°, and in one case there was an extension loss of 10°. The use of plates allows an anatomical fracture reduction, a better control of alignment of humerus and, with a rigid fixation, an early elbow mobilization. The best approach and the best surgical technique depend on the pattern of the fracture of distal humerus.

Fracture Shaft Humerus: Plating OR Nailing?

Background: Conservative management of fracture shaft humerus yield in satisfactory results in most of the cases. Dilemma between dynamic compression plating and ante grade intra-medullary nailing occurs when a surgery is indicated. Method: A total of 42 patients with fracture shaft humerus were treated surgically. 22 were subjected to plating and 20 were subjected to intra-medullary nailing. Functional outcome of patients were recorded using Constant and Murley score along with other parameters such as duration of surgery, intra-operative blood loss, complications and union time. Results: Mean duration of surgery in plating group was 125.13 minutes and in the nailing group was 51.95 minutes. Average amount of blood loss in plating group was 209.09 ml and in nailing group was 60.5 ml. In the plating group 17 (77.27%) patients had complication free recovery period. 2 (9.09%) patients were found to have post-operative radial nerve palsy. 3 (13.63%) patients reported with superficial surgical site infection with wound dehiscence. In the nailing group 17 (85%) patients had uneventful recovery. 2 (10%) reported pain at shoulder and 1 (5%) patient complained of decreased abduction of shoulder at 1 year follow up. As per the Constant and Murley score, in the plating group 14 (63.63%) patients yielded excellent, 4 (18.18%) good, 2 (9.09%) fair and 2 (9.09%) poor results. Whereas, in the nailing group 14 (70%) patients yielded excellent, 4 (20%) good, 1 (10%) fair and 1 (10%) poor results. Mean radiological union time in plating group was 15.63 weeks and in the nailing group was 14 weeks. Conclusion: Both intra-medullary nailing and dynamic compression plating are excellent methods for surgical fixation of shaft humerus fractures. Both of these methods yield in comparable results in terms of functional outcomes and union rates. Intra-medullary nailing holds edge over plating in terms of lesser blood loss, lesser operative time, shorter stay in hospital and less incidence of complications such as radial nerve palsy.

Posterior minimally invasive plate osteosynthesis (MIPO) of distal third humeral shaft fractures with segmental isolation of the radial nerve

The aim of this study was to evaluate the clinical, radiographic, and functional outcomes of a cohort of patients with distal third humeral shaft fractures treated using a posterior minimally invasive plate osteosynthesis (MIPO) technique. Twenty-one patients were retrospectively evaluated, 13 men and 8 women with an average age of 37 years. The surgery was performed through two posterior incisions away from the fracture site. The radial nerve was identified and protected. The fracture was fixed with a narrow 4.5/5.0mm locking compression plate. After an average follow-up of 22 months, flexion–extension of the elbow was 138°±7°, with a range of motion of 131°. Shoulder motion was 160° in forward flexion, 59° in external rotation, and internal rotation was to the spinous process of 9th thoracic vertebra. Pain severity was 0.5 on the VAS. The DASH score was 9. Average Constant score was 84. MEPI was 97. Fracture union was obtained in all patients. One patient developed transient postoperative radial nerve palsy. These results demonstrate that the posterior MIPO technique is a reliable option for treating distal third humeral shaft fractures. Level of evidence4.

Does Total Humeral Endoprosthetic Replacement Provide Reliable Reconstruction With Preservation of a Useful Extremity?

Controversy exists regarding the ideal method of reconstruction after proximal humeral resection and several reconstructive techniques have been reported. The reconstructive options are very limited when resection of the entire humerus is required. One option is endoprosthetic reconstruction, but there have been few published studies on the outcome of total humeral endoprosthetic reconstruction. The purposes of this study were (1) to assess the longevity of total humerus prostheses in those patients who survived their disease; (2) to review the complications associated with this prosthesis; and (3) to assess the Musculoskeletal Tumor Society functional score in survivors. Thirty-four patients (10 males, 24 females) with a mean age of 26 years (range, 7-86 years) were included in this study. Histological diagnosis was osteosarcoma in 15 patients, chondrosarcoma in seven, Ewing's sarcoma in seven, metastatic carcinoma in three, liposarcoma in one, and giant cell tumor of bone in one remaining patient. Twenty-nine patients had their total humeral endoprosthetic replacement for primary reconstruction, whereas the remaining five patients received their implants for failures with other reconstructive techniques. At a minimum followup of 3 months (mean, 8.2 years; range, 3 months to 29 years), 16 patients were alive with no evidence of disease, whereas 13 of the remaining 18 died with metastatic disease. Local recurrence was seen in five patients and all eventually died of disease progression. According to the Kaplan-Meier survival analysis, the cumulative 10-year implant survival rate was 90%. Periprosthetic infection was seen in four patients, postoperative radial nerve palsy in one, and proximal migration of the prosthesis in three, whereas three patients needed a change of the articular elbow bushings at a mean of 16 years after the implant insertion. The mean Musculoskeletal Tumor Society functional score of the 28 patients who survived their disease for more than 12 months after the index procedure and could therefore be functionally assessed was 83% (range, 60%-93%). From this small, preliminary report, we suggest that total humeral endoprosthetic replacement may be a reasonable option of reconstruction after tumor resection. We have shown that this prosthesis preserves the function of the hand. The local recurrence rate observed suggests that careful selection of patients is crucial. Infection was our most common surgical complication, but we showed that in those who survived their tumor, this prosthesis offers a method to preserve a functional upper extremity in some patients. Further study with more patients is necessary to confirm the value of this reconstruction method. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Avulsive Axillary Artery Injury in Reverse Total Shoulder Arthroplasty

In addition to neurologic injuries such as peripheral nerve palsy, axillary vessel injury should be recognized as a possible complication of reverse total shoulder arthroplasty. Limb lengthening associated with Grammont-type reverse total shoulder arthroplasty places tension across the brachial plexus and axillary vessels and may contribute to observed injuries. The Grammont-type reverse total shoulder arthroplasty prosthesis reverses the shoulder ball and socket, shifts the shoulder center of rotation distal and medial, and lengthens the arm. This alteration of native anatomy converts shearing to compressive glenohumeral joint forces while augmenting and tensioning the deltoid lever arm. Joint stability is enhanced; shoulder elevation is enabled in the rotator cuff–deficient shoulder. Arm lengthening associated with reverse total shoulder arthroplasty places a longitudinal strain on the brachial plexus and axillary vessels. Peripheral nerve palsies and other neurologic complications of reverse total shoulder arthroplasty have been documented. The authors describe a patient with rotator cuff tear arthropathy and a history of radioulnar synostosis who underwent reverse total shoulder arthroplasty complicated by intraoperative injury to the axillary artery and postoperative radial, ulnar, and musculocutaneous nerve palsies. Following a seemingly unremarkable placement of reverse shoulder components, brisk arterial bleeding was encountered while approximating the incised subscapularis tendon in preparation for wound closure. Further exploration revealed an avulsive-type injury of the axillary artery. After an unsuccessful attempt at primary repair, a synthetic arterial bypass graft was placed. Reperfusion of the right upper extremity was achieved and has been maintained to date. Postoperative clinical examination and electromyographic studies confirmed ongoing radial, ulnar, and musculocutaneous neuropathies.

Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator

Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture. Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique. There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°-9°) in the coronal plane and 1.2° (range 0°-8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3-38.4 weeks) and a mean follow-up of 20.8 months (range 13.5-31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation. Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.

Distal Humeral Fractures

We retrospectively reviewed supracondylar distal humeral fractures that had been treated with fracture-specific plating and definitive fixation through a lateral approach with a medial triceps mobilization technique. We determined the incidences of preoperative and postoperative radial nerve palsies (RNP) to evaluate the impact of the plating and fixation technique on RNP. Seventy-three patients treated at our institution from 2006 through 2009 were included in the study. The patients were assigned to 2 groups: 57 to the blunt injury group (motor vehicle collisions, falls, struck pedestrians, throwing) and 16 to the gunshot wound group. The incidence of known preoperative RNP in the blunt injury group was 27% (13 of 48 nonintubated patients); the incidence of known preoperative RNP in the gunshot wound group was 20% (2 of 10 nonintubated patients). The incidence of postoperative RNP for the combined groups of nonintubated patients who had intact radial nerve function preoperatively was 12% (5 of 43 patients). We found a high frequency of preoperative RNP, and we found postoperative RNP rates similar to those reported in the literature despite the use of the lateral approach medial triceps mobilization technique with a fracture-specific plate.

Extra-Articular Distal-Third Diaphyseal Fractures of the Humerus

There are strong advocates for both operative and nonoperative treatment of distal-third diaphyseal fractures of the humerus, but there are few comparative data. We performed a retrospective comparison of these two treatment methods. Fifty-one consecutive patients with a closed, extra-articular fracture of the distal one-third of the humeral diaphysis were identified from an orthopaedic trauma database. Forty patients were followed for at least six months or until healing of the fracture. Eleven patients were excluded because of inadequate follow-up. Nineteen patients had been managed with plate-and-screw fixation, and twenty-one had been managed with functional bracing. Among the operatively treated patients, one had loss of fixation, one had a postoperative infection, and one required tendon transfers for the treatment of a preoperative radial nerve palsy that did not resolve. Three new postoperative radial nerve palsies developed, and one had not resolved when the patient was last evaluated, three months after surgery. All operatively treated fractures healed with <10 degrees of angular deformity, and one patient lost 20 degrees of shoulder or elbow motion. Among the nonoperatively treated fractures, two were converted to plate fixation because of the treating surgeons' concern regarding alignment and radial nerve palsy. Only one patient had >30 degrees of malalignment in any plane. Two patients had development of skin breakdown during treatment and completed treatment in a sling. Two patients lost >/=20 degrees of elbow or shoulder motion. For extra-articular distal-third diaphyseal humeral fractures, operative treatment achieves more predictable alignment and potentially quicker return of function but risks iatrogenic nerve injury and infection and the need for reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but function and range of motion are usually excellent.

EXTRA-ARTICULAR DISTAL-THIRD DIAPHYSEAL FRACTURES OF THE HUMERUS

Background: There are strong advocates for both operative and nonoperative treatment of distal-third diaphyseal fractures of the humerus, but there are few comparative data. We performed a retrospective comparison of these two treatment methods. Methods: Fifty-one consecutive patients with a closed, extra-articular fracture of the distal one-third of the humeral diaphysis were identified from an orthopaedic trauma database. Forty patients were followed for at least six months or until healing of the fracture. Eleven patients were excluded because of inadequate follow-up. Nineteen patients had been managed with plate-and-screw fixation, and twenty-one had been managed with functional bracing. Results: Among the operatively treated patients, one had loss of fixation, one had a postoperative infection, and one required tendon transfers for the treatment of a preoperative radial nerve palsy that did not resolve. Three new postoperative radial nerve palsies developed, and one had not resolved when the patient was last evaluated, three months after surgery. All operatively treated fractures healed with <10° of angular deformity, and one patient lost 20° of shoulder or elbow motion. Among the nonoperatively treated fractures, two were converted to plate fixation because of the treating surgeons' concern regarding alignment and radial nerve palsy. Only one patient had >30° of malalignment in any plane. Two patients had development of skin breakdown during treatment and completed treatment in a sling. Two patients lost ≥20° of elbow or shoulder motion. Conclusions: For extra-articular distal-third diaphyseal humeral fractures, operative treatment achieves more predictable alignment and potentially quicker return of function but risks iatrogenic nerve injury and infection and the need for reoperation. Functional bracing can be associated with skin problems and varying degrees of angular deformity, but function and range of motion are usually excellent. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Interlocking nailing of humeral shaft fractures a retrospective study of 114 patients

Fractures of the humeral shaft are relatively common injuries. Literature suggests that humeral shaft fractures represent approximately 3 % of all fractures. There are several modalities for the management of diaphyseal humeral fractures. The latest investigations emphasize the concept of minimal exposure and rigid fixation. The aim of the study is to evaluate the results of antegrade intramedullary nailing in humeral shaft fractures. A retrospective review. Patients were treated in private hospital settings by 3 orthopaedics surgeon. Between 1995 and 2003, the technique of antegrade locked intramedullary nailing with UHN in humeral shaft fractures was performed on 114 patients. Forty-two (36%) patients sustained multiple traumas, and 22 (19%) fractures were open. The outcomes were evaluated with a mean follow-up of 41 months. Ranges of results given. In 109 fractures primary union observed. In the other five patients union achieved after removal of the nail and fixation with DCP and bone grafting. The average time for union was 13 weeks (range, 10-36 weeks). One hundred-five patients had excellent or satisfactory recovery of shoulder and elbow function. Complications included impingement due to proximal locking screws in two patients and prominent nail in three patients, transient postoperative radial nerve palsy in four patients. This study shows that antegrade locked nailing in humeral shaft fractures are reliable and also effective in multiply injured patients.

Surgical management of diaphyseal humeral nonunion after intramedullary nailing: wave-plate fixation and autologous bone grafting without nail removal

Six patients with a nonunion of the humeral diaphysis after intramedullary nailing were treated with a wave plate and autologous bone graft but without removal of the intramedullary implant. The mean duration of the nonunion was 19 months (range, 6-36 months). At a mean follow-up of 12 months (range, 6-18 months), all six nonunions had healed, and patient satisfaction was high. Five patients had regained full shoulder function. One patient, who was treated for a rotator cuff tear before the humeral fracture, had a satisfactory functional outcome. Elbow motion was full in all but one patient. One patient had a postoperative radial nerve palsy, which recovered partially but did not require further surgery. This report suggests that healing of humeral nonunions can be achieved in the presence of intramedullary hardware.

Open exchange locked nailing in humeral nonunions after intramedullary nailing.

Humeral nonunions after cannulated intramedullary nailing have been difficult to reconstruct. In the current study, 23 consecutive patients were treated by open exchange locked nailing with bone grafting. There were 16 men and seven women with a mean age of 46.2 years. The nonunions followed humeral locked nailing in eight patients, Seidel nailing in 13, and Küntscher nailing in two. The average nonunion time was 14.7 months. The nonunions, located at the proximal (1/3) in four humeri, middle (1/3) in 15, and distal (1/3) in four, were antegrade nailed in 10 and retrograde nailed in 13. Nineteen had 8-mm nails and four had 7-mm nails. Supplementary wiring was used in 19 patients. The average followup was 21.4 months. With one surgery, all but one patient (96%) achieved osseous union in, on average, 16.3 weeks. One patient with chronic renal dialysis had persistent nonunion and an osteolytic supracondylar fracture. Other complications included one postoperative radial nerve palsy, one brachial artery injury, and one wire infection. At followup, all patients with solid union had excellent or satisfactory recovery of shoulder function. The average postoperative Neer score (90.7) was significantly better than the average preoperative score (68.5). Two patients had losses of elbow motion of 10 degrees and 20 degrees, respectively. This study shows that humeral nonunion after cannulated intramedullary nailing can be treated effectively by open exchange locked nailing with bone grafting. Supplementary wiring can compress the nonunion and facilitate bone healing.

Intérêt du fixateur externe dans le traitement des fractures de l'humérus : à propos de 23 fixateurs Orthofix®

From 1991 to 1998, 23 humeral fractures has been treated using the Orthofix external fixator. Average age of the patient was 42 y and average follow-up 55.5 m. Initial trauma was: 13 traffic accidents, four falls at home, two devastating farming accidents, two sports accidents, one aggression and one gun accident. AO classification was used and location of the fracture was classified using Hackethal classification modified by de la Caffinière. Majority of fractures were located at the one-third distal humerus and the majority was also comminuted. At follow-up, elbow range of motion was 130 degrees, shoulder range of motion 161 degrees, external rotation 69.5 degrees and internal rotation 92.5 degrees. Using the classification of Stewart and Hundley, eight excellent, seven good, three fair and two bad results were obtained. There were no postoperative radial nerve palsy. Two external fixators had to be removed because of pin mobility. Failures were: non union and pin mobility in one patient which has to be reoperated on; two non unions have been grafted on and plated. There were no malunion in the postoperative X-rays. This device is our favourite for this type of injury because of its rigidity and the possibility of secondary dynamization. The external fixator was removed after union: this explains the long delay of union in our series.