|Year : 2013 | Volume
| Issue : 1 | Page : 49-54
Operative management of fracture of shaft humerus by dynamic compression plate versus interlocking intramedullary nailing: A comparative prospective study of 30 cases
Subhash R Puri, Samar K Biswas, Anil Salgia, Sahil Sanghi, Tushar Aggarwal, Ashish Kohli
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||14-Mar-2013|
Subhash R Puri
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Background: Uncomplicated diaphyseal fractures of the humerus successfully healed in over 90% of cases when treated
conservatively by reduction and immobilization. Open reduction with internal fixation, is preferred for open, segmental and pathological fractures. Objective: To compare functional outcomes, union and complication rates in patients treated with locked intramedullary nailing or dynamic compression plating for humeral shaft fractures. Materials and Methods: We randomized prospectively 30 patients with fractures of the shaft of the humerus were treated by open reduction and internal fixation by dynamic compression plate (DCP) in 15 cases and closed reduction and internal fixation with interlocking intramedullary nail in 15 cases. Patients were followed up for a minimum of six months. Result: There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. In our study, complications in DCP and IMN groups common were radial nerve injury and shoulder impingement. We had to perform secondary surgery on four patients in the IMN group, but on only one in the DCP group. Conclusion: Our findings suggest that open reduction and internal fixation with a DCP remains a better treatment option for fractures of the shaft humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.
Keywords: Closed intra medullary locking nail, dynamic compression plate, fracture shaft humerus
|How to cite this article:|
Puri SR, Biswas SK, Salgia A, Sanghi S, Aggarwal T, Kohli A. Operative management of fracture of shaft humerus by dynamic compression plate versus interlocking intramedullary nailing: A comparative prospective study of 30 cases. Med J DY Patil Univ 2013;6:49-54
|How to cite this URL:|
Puri SR, Biswas SK, Salgia A, Sanghi S, Aggarwal T, Kohli A. Operative management of fracture of shaft humerus by dynamic compression plate versus interlocking intramedullary nailing: A comparative prospective study of 30 cases. Med J DY Patil Univ [serial online] 2013 [cited 2018 Nov 20];6:49-54. Available from: http://www.mjdrdypu.org/text.asp?2013/6/1/49/108641
| Introduction|| |
Uncomplicated diaphyseal fractures of the humerus successfully healed in over 90% of cases when treated conservatively by reduction and immobilization. ,,, Open reduction with internal fixation is preferred for open, segmental and pathological fractures. Surgical stabilization is considered to be better treatment for bilateral fractures of the humerus and ipsilateral fractures of the humerus and forearm, as well as in cases of polytrauma, progressive neurological deficit, vascular injury and failed conservative treatment. ,,, Usually, fixation is achieved by a dynamic compression plate (DCP), and it is generally accepted and gives satisfactory results. ,, Use of plate, however, requires extensive dissection and is complicated by risk of radial nerve palsy and mechanical failure in osteopenic bone. There is growing interest in the use of the humeral intramedullary nail (IMN) as a result of recent technical advances. ,, Browner et al.  and Rockwood and Green  recommend fixation of diaphyseal fractures of the humerus by an IMN which can be inserted into the humerus antegrade, from the shoulder, or retrograde, from the elbow. In theory, fixation by an IMN requires less invasive surgery, and reaming can yield autograft material. The biomechanics are improved, with higher moments of inertia and load-sharing capabilities.
| Materials and Methods|| |
Between 2008 and 2011, 30 patients with a fracture of thehumeral shaft requiring surgical stabilization were prospectively randomized to undergo fixation by either a DCP or locked IMN by alternate selection. [Table 1] gives details of gender, age.
Surgeons involved were all experienced in both procedures.Inclusive criteria: The fractures which are located from 5 cm distal to the surgical neck to 5 cm proximal to the olecranon fossa, age 18 or more and both sexes, open fractures grade I and II, polytrauma, instability of fracture and early failure of conservative treatment with full skeletal maturity. Exclusion criteria were previous fractures of the humerus, pathological fractures, grade-III open fractures, un- cooperative patient in the assessment of function because of head injuries or children. Most of the patients (12 in the DCP and 13 in the IMN fixation group) sustained their injuries in motor-vehicle accidents, followed by fall which was second most common cause of injury with 3 patients in the DCP and 2 in the IMN fixation group. There were 2 open fractures (grade II) in the DCP group and 4 (grade II) in the IMN group. Plating was done through posterior approach [Figure 1], length of the plate and the necessity for autogenous bone grafting were dependent on pattern of the fracture and comminution. Antegrade unreamed locked humeral IMNs were used [Figure 2]. Reaming of canal done in 5 cases having canal diameter less than 7mm.
|Figure 1: Intraoperative picture of posterior approach with fracture site exposed|
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Post-operatively patient was given shoulder arm pouch with immobilizer. Pendulum exercises were started on 7 th post-operative day. Sutures were removed on 12 th post-operative day. On discharge, patient was advised to continue shoulder arm pouch, not to lift heavy weight and to follow-up regularly on outpatient basis. Immediate post-operative X-ray was taken and follow-up X-rays were taken after 6 and 12 weeks Post-operatively to check fracture healing. Patient was gradually encouraged shoulder exercises as tolerated by patient. We also recorded the time taken to union and concentrated more on union of fracture clinically and radiologically checking for any evidence of alteration in progress of union requiring surgical intervention. The primary outcomes measured were pain and function. Function was assessed by using American Shoulder and Elbow Surgeons' (ASES) shoulder score for 13 activities of daily living  requiring full shoulder and elbow movement [Table 2]. The maximum possible score is 52 points.
|Table 2: Details of american shoulder and elbow surgeons (ases) score (4 = normal, 3 = mild compromise, 2 = diffi culty, 1 = with aid, 0 = unable; NA = not available|
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| Result|| |
There were 15 patients in the DCP as well as in IMN group. Routine follow-up examinations, including clinical and radiological assessments, were carried out for a mean of 12.3 months (6 to 31). Minimum follow-up of six months was taken because healing of the fracture would normally have taken place and functional improvement would be starting to level off by that time.
Pain was quantified by using visual analogue scales, with zero being no pain and 10 as extreme pain. Secondary outcomes of the study were the incidence of complications [Table 3].
All fractures healed with < 7° of angulatory or rotatory deformity and < 1.5 cm of shortening. Blood loss in view of nailing was insignificant [Table 4] and results of both groups are in [Table 4].
[Figure 3] shows pre -op and post -op X-ray of a patient treated with IM Nailing. None of the patients sustained iatrogenic injury to the radial nerve. Eight months after surgery, one patient sustained a fracture after fall from bike. Because of nonunion, we substituted DCP for IMN fixation in two patients. After 6 weeks there was no improvement of range of movement in 5 cases, abduction was restricted. Local infiltration of depo-medrol and xylocaine was infiltrated and abduction exercises us0 heat was given. In 3 cases, there was improvement in rom0 after 2 months but in 2 cases it persisted after 1½ years, for which implant removal was done and abduction improved after implant removal. After six months, one patient with adhesivecapsulitis needed manipulation under anesthesia. At follow-up at one and half year, this patient still had restricted movement. In two patients, iatrogenic comminution occurred during insertion of the IMN, but this did not affect the outcome and was given shoulder arm pouch with immobilizer post-operatively for 4 weeks. there were two patients in which nonunion occurred which required revision surgery.
[Figure 4] shows pre-op and post-op X-ray of a patient treated with open reduction and DCP plate. There was one nonunion which required revision of the plate fixation and bone grafting at one year. One patient had minimal loss of fixation, with plate pulling away from bone for which patient was given shoulder arm pouch and immobilizer for another 4 weeks and was given ostocalcium for fracture healing and fracture got united in 14-16 weeks. Another patient had intraoperative comminution with slight displaced fracture at distal end of the plate. All 3 patients were treated conservativelyand the complications did not affect the outcome. It was not necessary to remove hardware from any patient in the DCP group except in 1 case for revision osteosynthesis. Two patients suffered from iatrogenic radial nerve palsy, one recovered in 4 months and another in 6 month.
Only one secondary surgical procedure was necessary in the DCP group, but 5 patients treated with an IMN required secondary surgery.
[Table 5], compares the complications and problems between nailing and DCP fixation
|Table 5: Details of complications and problem in nailing and dcp fixation|
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| Discussion|| |
In previous reports of DCP fixation, the incidence of nonunion has ranged from 2% to 10%, of infection from 2% to 4%, and of iatrogenic palsy of the radial nerve from 2% to 5%. ,, With few exceptions, patients regained a full range of pain-free movement of both shoulder and elbow of operated limb. ,, In our DCP group, there was one nonunion (6.7%), and iatrogenic palsy of the radial nerve or decrease in the range of movement of the shoulder or elbow was not seen.
Retrospective studies of locked IMN fixation quote incidences of nonunion ranging from 0% to 8%, and reports of the function of the shoulder and elbow differ widely. ,,,,, In a study of 50 fractures of the humeral shaft, which included pathological fractures, Hems and Bhullar  found that 30% of the non-pathological fractures had failed to unite after eight months and that a similar percentage of their patients had poor or unsatisfactory function. In fivepatients, (10%) comminution of the fracture occurred oninsertion of the IMN which required removal of the nail in three. They had one case of deep infection and two of intraoperative palsy of the radial nerve in both of which there was complete recovery. They concluded that IMNs should be used cautiously in treating acute non-pathological fractures.
Jinn  collected data on 48 acute humeral shaft fractures in 48 conservative patients treated with humeral locked nails and compared with retrospective data on 25 fractures in 25 other patients treated with dynamic compression plates. They concluded that humeral locked nailing offered a less invasive surgical technique and more favorable treatment results than did plate fixation. Correct nailing direction, precise surgical techniques, less bulky hardware, and stable transfixing screws are the keys to a successful treatment and further prospective, randomized comparative study is warranted.
McCormack et al. in 2000  performed a prospective randomized study of 44 patients with fracture shaft humerus fixed with dynamic compression plate and intramedullary interlock nailing. Patients were followed up for a minimum of six months. They concluded that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications. Our results were comparable with this study and we also found plating was better than nailing for fracture shaft humerus.
Kesemenli and Subasi et al., in 2003  studied 60 patients with fractures of the shaft of humerus, 33 fixed with interlock nailing and 27 with dynamic compression plating. They showed that healing did not differ in both the groups, but non-union rate was higher with interlock nailing. Similar results were obtained in our study with higher complications in nailing than plating.
S Raghvendra and Bhalodiya  followed up 36 patients with fractures of the shaft of the humerus in a prospective study. Eighteen patients each underwent open reduction and internal fixation with compression plating and antegrade interlock nailing. Though there was no significant difference between plating or nailing in terms of time to union, compression plating is the preferred method in the majority of fractures of the shaft of the humerus with better preservation of joint function and lesser need for secondary bone grafting for union. Our study also concluded that plating was better than nailing in terms of infection, range of motion at joint, and rate of secondary bone grafting.
In a study by Putti et al., in 2009,  34 patients with humeral shaft fractures were randomized to undergo locked antegrade intramedullary nailing (n = 18). All patients were followed up for a minimum of 24 months. In the respective IMN and DCP groups, the mean ASES scores were 45.2 and 45.1 (P = 0.69), the complication rates were 50% and 17% (P = 0.038) they concluded that the complication rate was higher in the IMN group, whereas functional outcomes were good with both modalities. ASES score in our study was 48 for plating and 47 for nailing which was comparable.
Functional results of our study were comparable to the study by Singisetti and Ambedkar.  In 2010 in a prospective, comparative study of management of acute humeral shaft fractures treated by antegrade interlocking nail fixation and dynamic compression plating over a period of 3 years, 20 patients were operated with interlocking nailing and 16 patients with plating. A higher rate of excellent and good results and a tendency for earlier union was seen with the plating group in their series.
Rommens et al.,  retrospectively reviewed DCP fixation of the humerus and then prospectively reviewed IMN fixation. They achieved better results with a retrograde IMN than with an antegrade IMN or DCP fixation; they recorded that 90% of their patients regained excellentfunction in the shoulder and elbow, and found that only 5% required secondary surgery. Unfortunately, their functional assessments were qualitative and their indications for primary surgery broader than is generally accepted. Despite the higher rate of complications and need for secondary operations in our IMN group, there was no significant difference in pain and function scores between the two groups.
Despite theoretical concerns about stress risers at the end of the plates, our experience is consistent with the findings of McKee et al.  that such problems may be greater at the distal locking screws and tip of the IMN, possibly because they are in diaphyseal cortical bone. As observed by Riemer et al., The benefits of IMN fixation in the femur and tibia do not seem to apply to the humerus, probably because of problems associated with reaming. 
The two cases of nonunion in the IMN group occured after nailing, only one of which was reamed.
Hems and Bhullar  suggest that nailing adversely affects healing by distracting the fracture and the soft tissues. In our study 5 cases of impingement occurred in our IMN group. Our study confirms that IM nail insertion can lead to problems with shoulder function and range of movement, probablybecause of damage to the rotator cuff. ,,, A rate of injury to the radial nerve of 5% has been reported with DCP fixation.  In the 24 acute fractures treated by this method, iatrogenic injury to the radial nerve was not seen but three patients in the IMN group had this complication.
We are aware that by inserting IMNs using variable degrees of reaming, we introduced variables which weakened direct comparison with DCP fixation. The small numbers limit comparison between the groups, but in our study there were more complications with the IM nailing than with the open reduction and internal fixation by a DCP. Fractures of the humeral shaft account for approximately 5% of all fractures; most of which are treated conservatively, and our inclusion/exclusion criteria were strictly applied. Complications in the IMN group were more common, more severe and needed more secondary surgery.
In specific situations, such as pathological or segmental fractures, IMN fixation may be better than DCP fixation, ,, but we did not study the former. We suggest that DCP fixation should continue to be regarded as the better treatment for fractures of the humeral shaft which require surgical stabilization.
| Conclusion|| |
Our findings suggest that open reduction and internal fixation with a DCP remains a better treatment option for fractures of the shaft humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.
Thus, dynamic compression plating remains the management of choice for the closed fractures of shaft of humerus.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]