Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 390-394  

Comparative study of operative treatment of mid shaft fracture of humerus by locking plate versus intramedullary interlocking nail


1 Department of Orthopedics, BMCH, Burdwan, India
2 Department of Physiology, BMCH, Burdwan, India
3 Department of Pathology, BMCH, Burdwan, India
4 Department of Orthopedics, Malda Medical College, West Bengal, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118282

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  Abstract 

Background: Treatment of humeral shaft fractures with intramedullary nailing compared with dynamic compression plating leads to comparable results. No single treatment option is superior in all circumstances for a particular fracture and each case has to be individualized . Objectives: Comparative assessment of results of plating and Intramedullary Nailing in a rural set up so that proper management techniques can be provided for better functional outcome and minimum complications. Materials and Methods: This prospective study was conducted over a period of three years on sixty patients with closed acute humeral shaft fracture requiring operative interventions. Results: Forty percent of cases were in the age group 31-40 years with males outnumbering females. Motor vehicle accidents (63.3%) were most frequent cause. Right humerus was more frequently (66.6%) involved. Maximum patients (40%) were operated within 4-6 days after injury. Out of 30 patients of plate group complications were: Infection-6.6%; delayed union-13.3%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%. Out of 30 patients of nail group complications were: Splintering of fracture end-6.6%; infection-6.6%; delayed union-26.6%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%; shoulder pain-46.6%. Maximum number of fractures (73.3% in plating group and 60% in nailing group) clinically united in the interval of 11-13 weeks. Maximum number of patients had radiological union in period of 12-16 weeks (73.3% plate group and 66.6% nail group). There was no significant difference between the two groups. On functional assessment, excellent results were obtained in 22 patients (73.3%) in locking plate group and 18 patients (60%) in locking nail group. Conclusion: For patients requiring surgical treatment of mid shaft humeral fractures, locking plating and interlocking intramedullary nailing both provide statistically comparable results but a higher rate of excellent and good results and a tendency for earlier union was seen with locking plating group in the present series.

Keywords: Humerus shaft fracture, intramedullary fracture fixation, open reduction internal fixation


How to cite this article:
Ghosh S, Halder TC, Chaudhuri A, Datta S, Dasgupta S, Mitra UK. Comparative study of operative treatment of mid shaft fracture of humerus by locking plate versus intramedullary interlocking nail. Med J DY Patil Univ 2013;6:390-4

How to cite this URL:
Ghosh S, Halder TC, Chaudhuri A, Datta S, Dasgupta S, Mitra UK. Comparative study of operative treatment of mid shaft fracture of humerus by locking plate versus intramedullary interlocking nail. Med J DY Patil Univ [serial online] 2013 [cited 2021 Jun 14];6:390-4. Available from: https://www.mjdrdypu.org/text.asp?2013/6/4/390/118282


  Introduction Top


Humeral shaft fractures account for roughly 3% of all fractures and have bimodal distribution. One group consists of mostly young males of 21 to 30 years age group and the other of older females of 60 to 80 years. The predominant causes of humeral shaft fractures in young age group are high energy traumas and in case of second group mainly simple fall or rotational injuries. [1],[2],[3],[4]

Most fractures of humeral shaft are treated non-operatively, although there are indications for primary or secondary operative treatment in some situations. The surgical indications are: Unacceptable reduction of fractures, associated vascular lesions, open fractures, radial nerve palsy, polytrauma patients, floating elbow and patients with obesity who are at risk for developing a varus angulations. [1],[2],[3],[4],[5]

Open reduction and internal fixation (ORIF) with plates and screws continues to be considered the gold standard for surgical treatment given its lower complication rate and shorter time to union over intramedullary nailing. Due to concerns about soft tissue dissection required for ORIF, a less invasive technique that allows indirect reduction and percutaneous plating of the anterior humerus has been developed. [1],[2],[3],[4] Anterior plating is a simple, safe, and effective treatment for humeral shaft nonunion. It does not require radial nerve visualization or extensive soft tissue dissection, and the healing time is similar to that of other methods used for treating humeral shaft non-union. This is an alternative approach to osteosynthesis of humeral shaft non-union, in which the plate is placed on the anterior surface of the bone. The biological benefits of less damage to the soft tissues via an approach that uses a plane between nerves certainly contributed to good results. Minimally invasive plate osteosynthesis (MIPO) is a safe approach to humeral shaft fracture management. MIPO requires intra-operative imaging and surgical experience to obtain adequate fracture alignment. Comparison of results of two methods, conventional open reduction-internal plating and MIPO, in the treatment of mid-distal humeral shaft fractures shows that MIPO offers advantages in terms of reduced incidence of iatrogenic radial nerve palsies and accelerated fracture union and a similar functional outcome with respect to shoulder and elbow function. [6],[7],[8],[9] The Polarus intramedullary nail is effective for the treatment of proximal humeral and humeral shaft fractures in elderly patients with osteoporosis because it not only enables early postoperative mobilization, but also obtains bone-union without avascular necrosis and nonunion. [5]

The results obtained in different services of trauma and orthopaedics show that plates with angular stability represents an improvement of the internal fixation of the complex periarticular fracture of the long bones and improvement of a percutaneous technique. In the future, the real time photogrammetry and triangulation techniques by top performance software will allow the trauma surgeon to obtain accurate images in order to reestablish the length, axis and rotation during minimally invasive techniques. Close cooperation between orthopedic surgeon, biomechanics and robotics specialist, and the departments of cell biology and pathology are needed for creation of the ideal internal fixator.

A MEDLINE search performed to identify all studies published from January 1995 through May 2007 and repeated from May 2007 through April 2010, suggested that treatment of acute humeral shaft fractures with intramedullary nailing (IMN) compared with dynamic compression plating leads to comparable results with respect to rates of nonunion and infection. There appeared to be an increase in risk of reoperation and iatrogenic nerve injury with IMN, which was significant when data were pooled across studies. There was conflicting evidence in regard to the mean time-to-union. [7]

The present study was conducted for comparative assessment of results of plating and IMN in a rural set up so that proper management techniques can be provided for better functional outcome and minimum complications.


  Materials and Methods Top


This prospective, comparative study of management of acute humeral shaft fractures by interlocking nail fixation and dynamic compression plating was undertaken over a period of three years, after taking Ethical clearance of Institutional committee and consent of the patient. Sixty patients with closed acute humeral shaft fracture requiring operative intervention were treated with either interlocking nailing or plating procedures. A randomization attempt was made by allocating each patient to either of the groups depending on the criteria of odd or even hospital number. The inclusion criteria were: (1) humeral shaft fractures which required operative intervention and were treated with interlocking or plating procedures, and (2) patients of age of 18 years or more. The exclusion criteria were: (1) the patient was aged less than 18 years, (2) pathological fractures, (3) segmental fractures, (4) fractures within 4 cms of proximal or distal end of humerus, 5) Vascular injury and 6) Brachial plexus injury.

All patients had appropriate clinical and radiological assessment before a decision to offer surgical intervention was made. All fractures were classified according to the AO classification. Pre-anesthetic check up was done and relevant investigations were carried.

Operative technique: Patients were operated under general anesthesia or brachial plexus block. An ante grade interlocking technique was used during intramedullary nailing and care was taken to minimize damage of the rotator cuff during nail insertion. Plating of mid shaft humeral fractures through anterolateral approach was done, reflecting the biceps medially with minimum soft tissue dissection and periosteal stripping and with utmost care for radial nerve, especially at spiral groove. Before plate fixation we routinely checked for radial nerve impingement by plate ends.

Post-operative period: All patients were advised on immediate postoperative shoulder and elbow exercises and radiographs were taken at regular intervals during follow-up. The overall rating of excellent, good, fair and poor outcomes was based on scores of shoulder and elbow movements along with pain and disability after the procedure.

Follow up: Routine follow up done at OPD with proper rehabilitation protocol with proper clinical and radiological assessment at 2 weeks,6 weeks,3 months,6 months,12 months,18 months and in between if required [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: Range of movement on follow up in case of nailing

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Figure 2: X-Ray on follow up in case of nailing

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Figure 3: Range of movement on follow up in case of plating

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Figure 4: X-Ray on follow up in case of plating

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Results were arranged in tabulated form and analyzed and chi-square test was used to compare the 2 groups.


  Results Top


Age of the patients under study varied from 22 years to 68 years. 40% of cases were in the age group 31-40 years. Male patients were more in number (63.3%) than female patients. Motor vehicle accidents (63.3%) were most frequent cause of humeral shaft fracture followed by domestic fall (30%). Right humerus was more frequently (66.6%) involved. Maximum patients (40%) were operated within 4-6 days after injury.

Most of the fractures were 12A2 (36.6%) followed by 12A1 (26.6%) [Table 1].
Table 1: Shows percentange of fractores in different according to AO fracture classification


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Out of 30 patients of plate group complications were: Infection-6.6%; delayed union-13.3%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%.

Out of 30 patients of nail group complications were: Splintering of fracture end-6.6%; infection-6.6%; delayed union-26.6%; shoulder movement restriction-13.3%; elbow movement restriction-6.6%; shoulder pain-46.6%.

Maximum number of fractures (73.3% in plating group and 60% in nailing group) clinically united in the interval of 11-13 weeks. Maximum number of patients had radiological union in period of 12-16 weeks (73.3% plate group and 66.6% nail group); mean time of union in plate group 13.7 weeks and nail 14.1 weeks. There was no significant difference between the two groups. The results were analyzed according to functional grading system of SICOT scoring. On functional assessment, excellent results were obtained in 22 patients (73.3%) in locking plate group and 18 patients (60%) in locking nail group [Table 2].
Table 2: Shows functional result analysis:


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There was no significant difference between the locking plate and locking nail group (P value 0.624).


  Discussion Top


For patients requiring surgical treatment of mid shaft humeral fractures, locking plating and interlocking intramedullary nailing both provide statistically comparable results but a higher rate of excellent and good results and a tendency for earlier union was seen with locking plating group in the present series. There are various surgical approaches mentioned in the literature for open reduction and internal fixation of mid shaft fracture of humerus, but in our study, we have done plating of mid shaft humeral fractures through anterolateral approach, reflecting the biceps medially with minimum soft tissue dissection and periosteal stripping and with utmost care for radial nerve, specially at spiral groove. In our study no post operative radial nerve palsy occurred.

Humerus nailing was done in all cases of our study through ante grade method. Rotator cuff injury was prevented as much as possible. In our study no radial nerve palsy, fracture ends splintering occurred. In our study, in spite of aseptic precaution there were 13.3% infection in plate group and 6.6% in nail group. Most of the cases of plating group radiological union were before 16 weeks (73.3%) compared to nailing group (66.6%). So healing was not a problem and cases of early healing were more in plate group. Results of our study were comparable to the study by Singisetti K et al [1] in 2010. 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. In a study by Putti et al., in 2009, [10] 34 patients with humeral shaft fractures were randomized to undergo locked ante grade intramedullary nailing. They concluded that the complication rate was higher in the IMN group, whereas functional outcomes were good with both modalities. Raghvendra S et al [11] followed up 36 patients with fractures of the shaft of the humerus in a prospective study. 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. Puri SR et al [12] suggested 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.

No differences in union rates have been found in some prospective studies whereas plate fixation shows fewer non-unions than IM nailing in others. [8],[9],[10] Bhandari et al [13] carried out a meta-analysis of prospective studies which included 155 patients but could not formulate any conclusive preference. Singisetti K et al [1] a higher rate of excellent and good results and a tendency for earlier union was seen with the plating group. Changulani M et al [9] showed no difference between the two groups in terms of the rate of union and functional outcome but a shorter union time with interlocking was suggested. No single treatment option is superior in all circumstances for a particular fracture and each case has to be individualized. [14],[15],[16]


  Conclusions Top


For patients requiring surgical treatment of mid shaft humeral fractures, locking plating and interlocking intramedullary nailing both provide statistically comparable results but a higher rate of excellent and good results and a tendency for earlier union was seen with locking plating group in the present series. Further prospective, randomized comparative study is warranted.

 
  References Top

1.Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: A prospective comparative study. Int Orthop 2010;34:571-6.  Back to cited text no. 1
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2.Livani B, Belangero W, Medina G, Pimenta C, Zogaib R, Mongon M. Anterior plating as a surgical alternative in the treatment of humeral shaft non-union. Int Orthop 2010;34:1025-31.   Back to cited text no. 2
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3.Denies E, Nijs S, Sermon A, Broos P. Operative treatment of humeral shaft fractures. Comparison of plating and intramedullary nailing. Acta Orthop Belg 2010;76:735-42.  Back to cited text no. 3
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4.Concha JM, Sandoval A, Streubel PN. Minimally invasive plate osteosynthesis for humeral shaft fractures: Are results reproducible? Int Orthop 2010;34:1297-305.   Back to cited text no. 4
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5.Hwang YS, Kim KY, Kim HC, Ahn SH, Lee DE. Polarus intramedullary nail for proximal humeral and humeral shaft fractures in elderly patients with osteoporosis. J Korean Fract Soc 2013;26:14-20.  Back to cited text no. 5
    
6.Rommens PM, Kuechle R, Bord T, Lewens T, Engelmann R, Blum J. Humeral nailing revisited.Top of Form Injury 2008;39:1319-28.  Back to cited text no. 6
    
7.Humeral-shaft fractures - Intramedullary nail compared with compression plating (UPDATE to September 2007 report). Orthop Trauma Dir 2010;5:19-29.  Back to cited text no. 7
    
8.An Z, Zeng B, He X, Chen Q, Hu S. Plating osteosynthesis of mid-distal humeral shaft fractures: Minimally invasive versus conventional open reduction technique. Int Orthop 2010;34:131-5.   Back to cited text no. 8
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9.Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomized controlled study. Int Orthop 2007;31:391-5.   Back to cited text no. 9
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10.Putti AB, Uppin RB, Putti BB. Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures. J Orthop Surg (Hong Kong) 2009;17:139-41.  Back to cited text no. 10
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11.Raghavendra S, Bhalodiya HP. Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective study. Indian J Orthop 2007;41:214-8.   Back to cited text no. 11
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12.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.  Back to cited text no. 12
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13.Bhandari M, Devereaux JP, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures a meta-analysis. Acta Orthop 2006;77:279-84.  Back to cited text no. 13
    
14.Kesemenli CC, Subasi M, Arslan H, Necmioglu S, Kapukaya A. Comparison between the results of intramedullary nailing and compression plate fixation in the treatment of humerus fractures. Acta Orthop Traumatol Turc 2003;37:120-5.  Back to cited text no. 14
    
15.Meekers FS, Broos PL. Operative treatment of humeral shaft fractures. The Leuven experience. Acta Orthop Belg 2002;68:462-70.  Back to cited text no. 15
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16.Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weight bearing on plated fractures of the humeral shaft. J Trauma 2000;49:278-80.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]


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