Musculoskelet Surg (2012) 96:67–73 DOI 10.1007/s12306-011-0166-z
ORIGINAL ARTICLE
Locked antegrade intramedullary nailing of humeral shaft fractures C. Iacobellis • T. Agro` • R. Aldegheri
Received: 29 April 2011 / Accepted: 24 August 2011 / Published online: 16 September 2011 Ó Springer-Verlag 2011
Abstract This paper reports the results of treating 35 humeral shaft fractures with antegrade nailing in patients between the ages of 25 and 92 (mean 64.5): 14 patients were aged between 25 and 59, and 21 between 66 and 92. The nail was set in place proximally with a spiral blade and distally with 1 or 2 screws. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN). The latter technique uses a guide wire which, in cases of an error in the length of the nail, is useful in that it allows another nail to be set in place. Main outcome parameters were fracture healing, shoulder discomfort, and radial nerve recovery. The DASH functional scoring system, modified according to Beaton et al. for subjective assessment was used, and range of motion was checked with the constant score. X-rays were used to assess fracture healing time and cases of malunion. Two patients developed non-union, one caused by a UHN which was too short, and the other by a nail blocked distally by a single screw. In 7 patients, consolidation was achieved, but with varus between 3 and 8 degrees (mean 5 degrees), without aesthetic or functional damage. In 33 out of 35 patients, shoulder functionality had mean DASH score results of 21.9, whereas shoulder range of motion reached a mean constant score (CS) of 26.5 (78.8%) with respect to the opposite shoulder. In 5 cases of stiffness, the UHN turned out to be insufficiently buried. Results improved with the CHN. Much better results were seen in the group of patients aged between 25 and 59 (mean age 43), but worse in older ones (66–92 years, mean age 78). Radial nerve palsy after surgery occurred in 2 cases, C. Iacobellis (&) T. Agro` R. Aldegheri Clinica Ortopedica e Traumatologica, Universita` di Padova, Via Giustiniani 2, 35128 Padova, Italy e-mail:
[email protected]
and the nerve was immediately examined. It did not appear to be trapped in the fracture in either case, and recovery was complete 6 months later. CHN appears to be a valid solution, both in younger patients, thanks to excellent results, and in older ones, who have fewer functional requirements. Keywords Antegrade humeral nail Humeral shaft fractures Radial nerve palsy
Introduction Treatment of shaft fractures of the humerus is a highly controversial topic in the literature. Some surgeons favour non-surgical treatment [1–3], but the number of those preferring surgery has increased in the last three decades, especially in patients with complex fractures or multiple injuries. However, even in the latter situation, opinions vary considerably as to the best treatment [4–7]: plating [8– 10], nailing [11–19] and, to a lesser extent, Kirschner wires [20]. In this work, we report our results with antegrade nailing which, in our experience, has some drawbacks which can be and indeed are overcome.
Materials and methods (Table 1) Our study comprises 35 patients (21 women, 14 men), operated for shaft fracture of the humerus between January 2007 and August 2009, mean age 64.5 years (range 25–92 years). Fourteen patients were aged between 25 and 59, and 21 between 66 and 92. The right shoulder was involved in 21 cases, and the left in 14. Causes were accidental falls in 25 cases, and high-energy trauma in 10.
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68 Table 1 Cases
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Patients
Gender years
Trauma AF, accidental fall RA, road accident
RX AO
Radial palsy
Traumasurgery interval (days)
1.
F57
AF
B1
No
1
70
UHN
2.
F69
AF
C1
No
3
190
UHN
3.
F84
AF
B3
Yes
3
70
UHN
4.
M70
AF
C1
No
5
70
UHN
5.
M92
AF
A2
No
1
90
UHN
6.
F75
AF
A2
No
3
120
UHN
7. 8.
F59 M66
AF RA
B1 A2
No No
1 2
170 50
UHN UHN
NAIL UHN CHN
9.
M59
AF
C3
No
1
60
UHN
10.
F71
AF
A1
No
3
120
UHN
11.
M35
RA
A2
No
1
90
UHN
12.
M76
AF
C1
No
4
120
UHN
13.
F56
AF
A2
No
1
60
UHN
14.
M55
AF
B2
No
1
60
UHN
15.
F82
AF
C2
No
4
110
CHN
16.
F70
AF
B2
No
1
70
CHN
17.
M32
RA
B1
No
3
180
CHN
18.
F76
RA
A1
No
3
70
CHN
19.
M25
RA
A3
No
2
130
CHN
20.
F80
RA
C2
No
2
170
CHN
21.
M72
AF
C3
No
1
130
CHN
22. 23.
M32 F79
RA AF
C2 B2
No No
1 1
150 120
CHN CHN
24.
F89
AF
B1
No
2
60
CHN
25.
F77
AF
C2
No
2
60
CHN
26.
M25
AF
A1
No
1
70
CHN
27.
M48
RA
A2
No
1
130
CHN
28.
F88
AF
B1
No
2
60
CHN
29.
F85
RA
A2
Yes
1
60
CHN
30.
M36
RA
A2
No
1
110
CHN
31.
F84
AF
A2
No
1
60
CHN
32.
F52
AF
A1
No
2
60
CHN
33.
F47
AF
B2
No
1
70
CHN
34.
F73
AF
B1
No
3
70
CHN
35.
F84
AF
C3
No
2
90
CHN
The level of fracture was at least 3 centimetres distal to the surgical neck of the humerus and 5 cm proximal to the olecranon fossa. The fractures, classified according to AO, were 14 (40%) of type A (4 cases of A1, 9 of A2, 1 A3), 11 (31%) of type B (6 B1, 4 B2, 1 B3), and 10 (29%) of type C (3 C1, 4 C2, 3 C3). In 28 patients, traction with a transolecranic wire was applied; in 7 patients, all over 80, the upper limb was immobilised with a sling. Surgery generally took place 2 days after trauma (range 1–4 days). Nailing was not carried out in patients with radial nerve palsy. In these cases, we preferred to expose the fracture to isolate the nerve, in some cases found trapped in the
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Operation time (min)
fracture but intact, and to proceed with an LCP plate. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN), which allows the insertion of a guide wire which is useful if, due to an error in measuring the nail, another of more suitable size has to be set in place (Fig. 1). Surgical technique General anaesthesia was given, enabling the surgeon to reassess any radial nerve palsy after surgery, since palsy may remain masked for a few hours after local–regional
Musculoskelet Surg (2012) 96:67–73
Fig. 1 A.R., male, aged 72, case 21: a, b pre-operative X-ray; c, d follow-up 2 years later. Malunion with 5° varus without aesthetic or functional damage
anaesthesia. If palsy was noted after nailing, we explored the fracture site to ascertain that the radial nerve was not trapped. The operation begins with the patient supine. The radiotransparent operating table is positioned so that the patient’s proximal humerus can be viewed in two planes by fluoroscopy. An incision of about 3 cm is made anterior to the acromion, the fibres of the deltoid are separated, and the tendon of the rotator cuff is exposed. Arthrotomy is limited to 1 cm, to avoid cutting the point of insertion of the cuff, and the guide wire is inserted in cases of CHN. The entry hole is prepared with an awl and checked with the fluoroscope. The hole is made in the groove between the articular surface and greater tuberosity and laterally, at half the distance between the anterior and posterior margins of the tuberosity. The nail, previously measured carefully, is inserted with gentle rotatory movements, without reaming. The diameter of the nails we used was always 7 mm, the smallest available, in order to avoid further fractures. The nail is buried slightly in the humeral head to avoid subacromial friction. Distally, it must reach to within a few mm of the olecranon fossa. It is blocked proximally with a spiral blade which is positioned, in the two projections, in the centre of the humeral head and fixed to the nail with a locking screw. The spiral blade gives a broader support in the humeral head. This blade is locked in the nail itself through an end cap giving pressure on the blade. As well as the spiral blade, the nail also allows an oblique proximal screw to be introduced, but we did not use it after the first 6 cases of proximal humeral nail (PHN [21]), because its hold was mediocre. One or two screws are inserted distally, according to the characteristics of the fracture and the length of the distal end. We prefer to use an antero-posterior screw for distal interlocking, since it is safer, as shown by studies on cadavers [22]. If a second lateromedial screw is necessary, we lengthen the incision by
69
2 cm to make the hole, exposing the bone (under visual control). The incision is sutured with two stitches in the tendon of the rotator cuff. Patients were examined by X-ray (AP and LL projections) 3 months after surgery. In cases of delayed union, we carried out further checks after 4 and if necessary 5 months. A final check was made during this study. Clinical assessment of the patient focused on shoulder functionality by means of the DASH functional scoring system, modified according to Beaton et al. [23] for subjective assessments. We considered scores between 0 and 20 as Excellent, between 21 and 40 Satisfactory, and between 41 and 100 Poor. Range of motion was checked with the constant score [24] and a score of 40 was given for normal shoulders. The score was also calculated for the other shoulder, and the degree of functionality in the operated shoulder was compared with the opposite one. We have adopt only the range of motion part of the constant score rather than the entire system because for our study is more significant the DASH score, completed by the analysis of the movement. X-ray examination enabled us to assess time to consolidation, cases of malunion, and ossification near the point of insertion of the nail. Our criteria for union were the formation of a bridging callus on radiographs and the absence of pain at the fracture site.
Results (Table 2) Average follow-up was 24 months (range 12–38). In 33/35 cases, union occurred over an average period of 3.8 months (range 3–5). In 2 patients (cases 11 and 22), non-union was caused by too short a nail in an A2 fracture, which evolved to B2 when the screw was inserted (case 11), and one nail blocked distally by a single screw. Both cases were resolved with LCP plates and autologous grafts. In 7 patients (cases 2, 3, 14, 21, 24, 33 and 34), the X-ray check revealed malunion with varus between 3° and 8° (mean 5°), without aesthetic or functional damage (Fig. 1). No case of infection occurred, nor was ossification seen near the point of insertion of the nail. Shoulder functionality was observed in 33/35 cases of union, with a mean DASH score of 21.9 (range 0–85). Shoulder range of motion on the operated side reached a mean, assessed by the constant score (CS) of 26.5 (range 14–40) or 78.8% with respect to the other shoulder (range 30–100%). In 5 cases of shoulder stiffness, the nail turned out not to be properly buried (Fig. 2). After nail removal in cases with protrusion, shoulder functionality after union clearly improved in one patient aged 66 (case 33), was partially improved in 2 patients of 57 and 59 (cases 1 and 7) but was poor in 2 patients aged 69 and 84 (cases 2 and 3).
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70 Table 2 Results
Musculoskelet Surg (2012) 96:67–73
Patients
Follow-up (months)
DASH
Range of motion (0–40) constant
Controlateral shoulder
1.
38
35
20
40
2.
36
55
12
40
3.
36
50
12
4.
35
22.5
5.
34
6. 7.
Time to union (months)
Varusvalgus angulation (degrees)
Nail removal PP, proximal protrusion
50
3
No
Yes (PP)
30
3
5° Varus
Yes (PP)
38
31.6
4
8° Varus
Yes (PP)
28
40
70
5
No
No
46.8
12
20
60
3
No
No
34
13.8
18
36
50
3
No
No
34
85
22
38
59
5
No
Yes (PP)
8.
33
10
14
14
100
3
No
Yes (PP)
9.
33
17.5
22
22
100
5
No
No
10.
32
0
40
40
100
5
No
No
11.
Non-union
–
–
–
–
–
–
–
12.
30
34
34
100
4
No
No
13.
28
6.8
38
38
100
3
No
No
14. 15.
28 27
9 0
20 40
20 40
100 100
4 5
3° Varus No
No No
16.
26
70
16
36
44
4
No
No
17.
25
9.9
40
40
100
4
No
Yes
18.
25
5.5
34
38
89
3
No
No
19.
24
13.6
38
40
95
3
No
Yes
20.
24
85
6
18
33
3
No
No
21.
22
52.5
20
34
59
5
5° Varus
No
22.
Non-union
–
–
–
–
–
–
–
23.
20
15
30
36
83
5
No
No
24.
20
0
24
24
100
3
5° Varus
No
25.
18
0
38
38
100
5
No
No
26.
16
9.9
38
40
95
3
No
No
27.
16
20
38
40
95
3
No
No
28.
14
16.6
20
24
83
5
No
No
29. 30.
14 14
20 0
8 40
14 40
57 100
3 3
No No
No No
31.
13
14
8
18
44
5
No
No
32.
13
2.5
38
40
95
3
No
No
33.
12
13.6
36
40
90
3
5° Varus
No
34.
12
0
34
36
94
4
5° Varus
No
35.
12
5
38
40
95
5
No
No
20
When the means were calculated without the 5 cases of nail protrusion, the mean DASH score became 17.5 (range 0–52.5) and range of motion according to the CS of 83.25% with respect to the other shoulder (range 33–100%). Separating the 33 patients into 2 groups according to age (group A: 25–59 years group B 66–92), we found significant differences. The younger group A, composed of 12/33 cases, had a mean DASH score of 22.28 (range 0–85), and range of motion had a mean CS value of
123
Difference (%)
32.5, or 89.9% with respect to the opposite shoulder (range 50–100%). When the means were calculated without the 2 cases of nail protrusion, the mean DASH score was 10.28 (range 0–17.5) and range of motion had a CS value of 34.8 (97% with respect to the other shoulder, range 90–100%). The older group B (21/33 cases) had a mean DASH score of 23.8 (range 0–85) and range of motion a mean CS of 22.4 (72.5% with respect to the other shoulder; range 30–100%). When the means were calculated without the 3
Musculoskelet Surg (2012) 96:67–73
Fig. 2 C.L., female, aged 69, case 2: a, b pre-operative X-ray; c, d follow-up 6 months later. Shoulder stiffness. After nail removal, shoulder functionality was poor
cases of nail protrusion, the mean DASH score was 21.5 (range 0–85) and a CS of 24.1 (75.6% with respect to the other shoulder; range 33–100%). Radial nerve palsy after surgery occurred in 2 patients (cases 3 and 29). The nerve was immediately examined, and was not found to be trapped in the fracture in either case. Recovery was complete 6 months later.
Discussion and conclusions Non-surgical treatment of shaft fractures of the humerus can allow consolidation, as maintained by several authors even relatively recently [1–3]. The good vascularisation of the humerus [25] guarantees acceptable consolidation, even with moderate axial deformity and shortening of a few centimetres, especially in elderly patients, as long as there is no torsional deformity. The literature in the last 30 years has clearly been oriented towards surgical treatment, mainly by those who prefer LCP plating [8–10] and intramedullary nailing [11–19]. The former report precision of the fracture reduction, the right approach towards the radial nerve, and a good range of shoulder motion even soon after surgery. The latter, in favour of nailing, emphasise the minimal invasiveness, rarity of non-union, and better treatment of elderly patients with osteoporosis which weakens screw hold in plating. This study, based on a group of 35 patients receiving locked antegrade intramedullary nailing, aims at completing a previous work [21] on 80 cases treated with PHN which, like the humeral nails applied in the cases presented
71
here, involves proximal locking entrusted to a spiral blade. In our experience with 115 patients in the two groups (14 UHN, 21 CHN, and 80 PHN), loss of screw hold hardly ever occurred. In the first cases of PHN implants, which we treated with proximal locking with a spiral blade, we had 3 cases of loss of hold of the blade, of which two were technical errors due to insufficient locking. In humeral nailing with proximal stability entrusted to several screws, the antero-posterior position of some screws may cause damage to some branches of the axillary nerve [26]. In addition, screw hold in an osteoporotic head is poor [27], as we found in 6 cases treated with PHN in which, as well as the spiral blade, we also inserted a proximal screw, which then moved. Spiral blades offer a greater contact surface in cases of porotic bone and guarantee good hold, as we found, as long as they are constrained to the nail by the locking screw. In any case, as shown by biomechanical studies [28], it must be borne in mind that spiral blades may lose their hold in bone during rotatory movements. It is essential to measure the length of the blade very carefully: if it is too short, hold is reduced; if it is too long, it will perforate the articular surface. The technique therefore requires great care. It is important to insert the blade in an axial position in the centre of the humeral head, and we believe that the patient’s supine position makes axial fluoroscopy easier. Shoulder functionality is often compromised, as several authors, both in the past [17, 27, 29] and more recently [6, 30, 31] have reported. Stiffness due to nail protrusion and subacromial impingement should be distinguished from stiffness without nail protrusion. In the former case, the cause is a technical error at the moment of surgery, or poor proximal hold of screws in osteoporotic bone, with later upward movement of the nail [17, 27]. We never found loss of blade hold in any of our 35 cases. We believe that secondary migration of the nail with this type of proximal locking can always be avoided. Conversely, we found 5/35 cases (14.2%) of nail protrusion with stiffness in patients with UHN, due to technical errors, i.e. the nails were too long. Technical errors, in the first group of patients, were due to the fact that we began by using uncannulated nails, and the surgeon underestimated the damage caused by nail protrusion. One over-long nail was left too long, and a nail of more suitable length was not inserted, in order to avoid further reduction manoeuvres. This error, which caused the nail to protrude, was later easily solved with CHN, which involves a guide wire and thus easy replacement with another shorter nail if necessary. Shoulder stiffness without nail protrusion has been hypothesised by some authors [27, 29, 31] as due to cuff damage at the moment of nail insertion. None of our patients suffered subacromial impingement, and excellent results were obtained in patients aged between 25 and
123
72
59 years (mean age 43), but less good in those aged between 66 and 92 (mean age 78) with fewer functional requirements. If these older patients with osteoporotic bone had been treated with a LCP plate, the risk of non-union would be higher. Damage to the cuff due to nail insertion was insignificant in young patients and acceptable in elderly ones, as already reported by several authors [18, 29, 32], as we had already seen in our 80 cases treated with PHN. This type of damage can be avoided [19, 32] if the entry hole is carefully made in the groove between the greater tuberosity and the lateral extremity of the humeral head. If the nail is inserted correctly, the cuff will not be significantly damaged. Non-union, which occurred in 2 of our 35 cases, was due to the fact that the nail was too short. We believe that this complication can easily be avoided with a guide wire, because a short nail can be replaced quickly and easily. Another potential cause of non-union, which has also been demonstrated in a laboratory study [33], is over-early rotatory movement: our patients were warned not to rotate the arm for 1 month. Radial nerve palsy may be the weak point of this method with respect to plate synthesis which, in expert hands, does not expose the nerve to neurotmesis, although it may stretch it, with consequent axonotmesis. With nailing, the risk of axonotmesis, which occurred in 2 of our cases, is certainly higher, because the manoeuvres required for closed reduction are longer than in open treatment. In addition, the nerve may be trapped at the site of fracture, or be cut as the nail passes. In their epidemiological study, Ekholm et al. [34] report 33 out of 401 fractures (8%) of radial nerve palsy. In a statistical study involving searches for web-based databases, Shao et al. [35] found 532 cases out of 4,517 fractures (11.8%) of radial nerve palsy. In a work based on 6,097 humeral fractures, Grassmann et al. [36] report trapped nerves in 19% of cases, nerve cutting in 7% and, in cases of neurorrhaphy, partial or total recovery in 87%. We agree with surgeons who prefer to explore the nerve [37] if the patient is already hospitalised for radial palsy, and believe that in such cases it is essential to open the fracture site and carry out plate synthesis. In addition, in all cases of nailing which lead to radial nerve palsy after surgery, we expose the fracture to exclude the possibility of nerve trapping. This is why we prefer general anaesthesia, which means that re-operation, if necessary, can be carried out in the same operating session. We do not believe it is preferable to wait without verifying whether the nerve has been trapped or not [36]. As regards malunion, we did not find any functional problems, nor did any patient complain of aesthetic damage, which is in any case certainly less than that produced by plate synthesis. To conclude, we believe that shaft fractures of the humerus which are distally more than 5 cm from the
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Musculoskelet Surg (2012) 96:67–73
olecranon fossa and without radial nerve deficit, should be treated by antegrade cannulated nailing, rather than LCP plates. However, nailing does require a learning curve which should not be underestimated. Conflict of interest
None.
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