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Management of fractures of shaft of humerus with locking compression plate: a prospective study.

INTRODUCTION: increasing vehicular traffic, has led to considerable increasing in the number of road traffic accidents. Speedy vehicles have high velocity injuries associated with complicated fracture. Fracture pattern is often grossly committed and often open fractures resulting in greater morbidity among the working population. The other cause of fracture are being directly below, fall from height, assault, gunshot injuries and blast victims of terrorist activities.

Fractures of shaft of humerus account for 1% to 3% of all fractures and approximately 20% of all fractures involving the bone, but little is known about their epidemiology. (1)

When operative fixation is indicated for humeral shaft fractures, plate osteosynthesis is the gold standard to which other methods must be compared. (2)

Biomechanical studies have shown that compared to other types of available implants, the locking plate is comparatively flexible and maximizes fracture stabilization by minimizing the peak stresses at the bone-implant interface. (3)

It has also been theorized that locking constructs may have a lower incidence of re-fracture because the more exuberant callus created by secondary bone healing may lead to mechanically more stable construct. (4)

This study was aimed to assess the results of plate osteosynthesis of Diaphysial fractures of humerus using locking compression plate and to assess the functional recovery with this procedure.

MATERIAL & METHODS: 60 Patients with fracture of shaft of humerus admitted in the Sri Siddhartha Medical College & Research Centre, Tumkur, during the period of October 2011-March 2013 who met the following inclusion criteria were taken up for the study after obtaining consent.

All the patients were admitted and subjected to clinical & radiological examination, necessary lab investigations are carried out for proposed surgery. Regular follow up was carried out by clinical examination and with X-rays at 6 weeks, 3 months, and 6 months. The inclusion criteria being 1) All the patients in the age group of 15 years and above, 2) All Closed and Grade 1 open fractures (Gustillo & Anderson type), 3) nonunion, 4) Polytrauma patients, 5) Associated with Radial nerve palsy and the exclusion criteria being 1) Pathological fractures, 2) Open grade 2 & 3 fractures, 3) Segmental fractures, 4) Malunion, 5) Medically unfit patient.

Though many standard approaches to humerus are available like Antero-lateral, Posterior, Modified lateral approach in this study, Antero-lateral approach was used in 36 patients, and posterior approach was used in 24 patients.

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All the cases were performed without using a tourniquet. Blood loss was minimal. Maximum blood loss found was 200 ml. Overall time taken for surgery was 35-45 minutes. In all the cases the intraoperative period was uneventful. Haemostasis was achieved using bipolar cautery in all cases. Radial nerve was visible in few cases and was secured.

The immediate postoperative period was uneventful. All the cases were put in the intensive care unit for 24hrs postoperatively. In the immediate post-operative period, care was given to the general condition and fluid balance. Parenteral cephalosporins for 3 days, parenteral salbactum for 3 days, and analgesics were given. Oral antibiotics were given for next 3-4 days. Oral analgesia was started from 2nd day till adequate pain relief was obtained. Suture removal was done after 1 week. This also helped us to mobilize the patients faster.

Post operatively shoulder range of motion and elbow movements is begun actively within the 3rd or 4th post-operative day. None of the cases were given POP immobilization postoperatively. After around 1 week, sutures were removed and patients were discharged and advised to come for follow up after 6 weeks. Patients were advised to continue exercise therapy and arm support with arm pouch for 3-4 weeks.

The first follow up was usually at 6 weeks and later on patients were followed up at 3 months and 6 months.

During the Follow up: Each case was examined for pain, functional recovery of shoulder, elbow, and hand. The course of fracture healing was documented radiologically (with minimum of 6 weeks between successive radiographs). The moment of complete healing was defined as radiologically complete bone regeneration at the fracture site., Radiological assessment of implant position, fracture reduction and healing in progress (i.e., observing whether if there is any widening of fracture line or decrease in the fracture gap).,

Evaluation of any possible loss of reduction that might have occurred, compared to immediate post of radiographs. Assessment and analysis of any complications observed. Addressing patients' problems, if any, and DASH scoring, ROMMENS et al Series Grading 56 was done. Follow up of our patients ranged from 6 weeks to 24 weeks. No patient was lost to follow up.

OBSERVATION AND RESULTS: The age group of the patients in our study ranged from 15years to 65 years. Most of the patient's belonged to 21-40 years (Table 1). Most of our patients were male, It reflected the general population, which visits our both outpatients as well as the emergency trauma section (Table 2).

In our series, 30 (50%) fractures are right sided and 30(50%) fractures are left sided, 42(70%) cases were having fracture located in middle third of shaft, in 18(30%) cases the fractures was in lower third of humeral shaft (Table 3). In our study the fracture pattern was taken into account and the figures give the general fracture pattern, which is most prevalent in humerus diaphy seal fracture.

In our study the most common fracture pattern is A3 (Transverse) in AO classification which accounts for 50% of the overall fracture pattern (Table 4) and the commonest mode of injury was road traffic accidents (55%) seen in 33 patients. Twenty seven patients had a history of falls (45%) (Table 5) 3 patients (5%) had ipsilateral fracture radius and ulna along with the fracture shaft of humerus (Table 6). All the follow up observations were summarized in Table 7.

There was improvement in the DASH scores indicating the functional recovery with this procedure (Table 8). The following results were obtained for this study using ANOVA statistical analysis; the F value: 118.77, P value: 0.001, and the Interpretation was Significant. We had 51(85%) patients with Excellent and 9(15%) patients with Good results (Table 9).

In the present study, 9 cases of superficial infection were noted. Suture removal was delayed and prolonged administration of oral antibiotics was given and eventually healed without any further complication. We had no case of any pure implant related complication like loosening screw breakage or plate failure (Table 10).

CLINICAL PHOTOGRAPHS

Pre-Operative x-rays:

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Post-Operative x-rays:

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Follow-up X-rays:

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Clinical Pictures:

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DISCUSSION: We evaluated our results and compared them with those obtained by various other studies utilizing different modalities of treatment. Our analysisis is as follows:
AGE INCIDENCE IN VARIOUS STUDIES

Series                    Year    Total no.    Average
                                 of patients     Age

McCormack R G et al (5)   2000       44          49
Wilairatana V,            2001       21          29
  Prasongchin P (6)
GongolT, Mracek D (7)     2002       32          47
Present Study             2013       60          35

SEX INCIDENCE IN VARIOUS STUDIES

Series                   Year   M: F ratio   % of males

Strong GT, Walls N,      1998    111:138        44.6
  McQueen M M (8)
Tingstad E Metal (9)     2000     44:38         53.6
Mc Cormack R Getal (5)   2000     28:16         63.6
Wilairatana V,           2001      16:5         76.2
  Prasongchin P (6)
Present Study            2013     42:18          70

SITE OF FRACTURE

MODE OF INJURY IN      MODE OF INJURY IN    MODE OF INJURY IN
VARIOUS STUDIES         VARIOUS STUDIES      VARIOUS STUDIES

Klenerman L (10)              1966                  98
Bell M J et al (11)           1985                  38
Griend R V, Tomasin           1999                  36
  J, Ward et al (12)
Strong GT, Walls N            1998                 249
  and McQueen MM (8)
Present study                 2013                  60

MODE OF INJURY IN        MODE OF INJURY IN      MODE OF INJURY IN
VARIOUS STUDIES           VARIOUS STUDIES        VARIOUS STUDIES

Klenerman L (10)            Middle third            44(44.9%)
Bell M J et al (11)    Upper third and middle       15(38.5%)
Griend R V, Tomasin         Middle third            23(63.9%)
  J, Ward et al (12)
Strong GT, Walls N          Middle third            160(64.2%)
  and McQueen MM (8)
Present study               Middle third             42 (70%)

COMMONEST TYPE OF FRACTURE IN VARIOUS STUDIES

Series                    Year    Total no.       Maximum
                                 of patients    Fracture type

Griend R V, Tomasin J,    1986       36        Transverse and
  Wardetal (12)                                 short oblique
Strong GT, Walls N,       1998       249       Transverse and
  McQueen MM (8)                                short oblique
Tingstad E Metal (9)      2000       83        Transverse and
                                                short oblique
Present study             2013       60          Transverse

Series                    No. of cases    %

Griend R V, Tomasin J,         20        55.6
  Wardetal (12)
Strong GT, Walls N,           158        63.3
  McQueen MM (8)
Tingstad E Metal (9)           53         64

Present study                  30         50

MODE OF INJURY IN VARIOUS STUDIES

Series                  Year   Total no.       Commonest
                               of patients   mode of injury

Strong GT, Walls N,     1998       249            RTA
  McQueen M M (8)
Tingstad E Metal (9)    2000       83             RTA
McCormack R Getal (5)   2000       44             RTA
Dayez J (13)            1999       36        RTA and Sports
Present study           2013       60             RTA


DASH scores were showing significant (P=0.001) improvement in the followup period indicating the functional recovery with this procedure. ANOVA statistical analysis was helpful in calculating our results. The functional results were graded into excellent, good, fair and poor.

We had 51(85%) patients with Excellent and 9(15%) patients with Good results.

SUMMARY: We studied 60 patients with fractures of diaphyseal humerus treated with locking compression plate at Sri Siddhartha Medical College Hospital, Tumkur. The study was done from October-2011 to September-2013. The age of the patient ranged from 15 years to 65. The majority of the patients were males. (M: F = 42:18).

The commonest mode of injury was road traffic accidents (55%) seen in 33 patients. Twenty seven patients had a history of falls (45%). In our series, left humerus was involved in 50% of cases, while the right was involved in the other 50% of cases. Most of the fractures in our series were transverse, Type A330 (50%) patients, and most common site of involvement is middle 1/3rd of shaft of humerus, i.e 42(70%) cases. Three cases had humerus fracture in association with ipsilateral radius & ulna fracture.

All the patients were treated by open reduction and internal fixation with locking compression plate and screws, with Antero-lateral approach in 36 patients and posterior approach in 24 patients.

Physiotherapy was started on the 3rd or 4thpost operative day, and continued for 3-4 weeks. During follow-up at 6 weeks, mild pain was noted in 18 cases, fracture line was visible in 36 cases, implant position was satisfactory in all the cases, no signs of loss of reduction in any case, superficial wound infection seen in 9 cases, and the mean DASH score was 25.55 [+ or -] 4.41.

During follow-up at 3 months, there was no pain in any case, fracture line was not visible except in 3 cases, implant position was satisfactoiy in all the cases, no complications were noted in any case, and the mean DASH score was 16.75 [+ or -] 4.07. During follow-up at 6 months, there was no pain in any case, fracture line was not visible in any case, implant position was satisfactory in all the cases, no complications were noted, and the mean DASH score was 6.05 [+ or -] 3.47.

In 51 cases, solid union was seen with no loss of range of movements and no significant complaints. In 9 cases, solid union was seen, but 10-20% loss of range of motion at the elbow and shoulder. There was statistical significance (P=0. 001) in DASH scores in the follow up period, indicating the functional recovery with this procedure. The functional results grade was excellent in 51 cases, good in 9 cases according to Rommen's grading.

CONCLUSION: This is a prospective study with age incidence varied from 21-40 years (65%) with male predominance (70%), with type A3 as the commonest fracture (50%) involving the mid shaft (70%) of humerus, underwent open reduction and internal fixation using locking compression plate. All the cases had adequate physiotherapy started on the 3rd or 4thpost operative day and continued for 3-4 weeks, which had contributed to the excellent functional recovery.

The results were assessed using the DASH score and the significant functional recovery was achieved in all the cases (P=0. 001), with Rommen's grading, excellent and good results were achieved. It is a very good procedure for fractures of shaft of humerus, however the small sample size and short duration of study were the limitations of this study.

DOI: 10.14260/jemds/2014/3203

BIBLIOGRAPHY:

(1.) Ekholm R et al, Fractures of the shaft of the humerus: The Journal Of Bone And Joint Surgery (Br)., November 2006; 88(11),.

(2.) Scolaro J, Jonas L. Matzon, Mehta S, Tips And Techniques--Surgical Fixation Of Extra-Articular Distal Humerus Fractures With A Posterolateral Locking Compression Plate(LCP)., University Of Pennsylvania Orthopaedic Journal, vol. 19.

(3.) Kenneth A. Egol et al, Early Complications In Proximal Humerus Fractures (OTA Type 11) Treated With Locked Plates; Journal Of Orthopaedic Trauma; March 2008; 22(3); 159-64.

(4.) Grant, Richard, N. William, Marc J, and David S., Can Locking Screws Allow Smaller, Low-Profile Plates To Achieve Comparable Stability To Larger, Standard Plates?; Journal of Orthopaedic Trauma; June 2011; 25(6); 347-54.

(5.) McCormack RG, Brien D, Buckley RE, McKee MD, Powell J. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. J Bone Joint Surg Br 2000; 82 (3): 336-9.

(6.) Wilairatana V, Prasongchin P. The open reduction and internal fixation of humeral diaphysis fracture treatment with a medial approach. J Med Assoc Thai 2001; 84 (1): 423-7.

(7.) Gongol T, Mracek D. Functional therapy of diaphyseal fractures of the humeral bone. Acta Chir Orthop Traumatol Cech 2002; 69 (4): 248-53.

(8.) Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg 1998; 80: 249-53.

(9.) Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weight bearing on plated fractures of the humeral shaft. J trauma 2001; 49 (2): 278-80.

(10.) Klennermann, L. Fractures of shaft of humerus. J Bone and J Surg Br 1966; 48: 105-11.

(11.) Bell MJ, Beauchamp CG, Kellan JK, Mc Mutry RY. The result of plating humeral shaft fractures in patients with multiple injuries. J Bone Joint Surg Br 1985; 67(2):293-6.

(12.) Griend RV, Tomasin J, Ward EF. Open reduction and internal fixation of humeral shaft fractures. J Bone Joint Surg Am 1986; 68A: 430-3.

(13.) DayezJ. Internal screwed plate for recent fractures of the humeral diaphysis in adults. Rev Chir Orthop Reparatrice Appar Mot 1999; 85 (3): 238-44.

(14.) Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures, the basal experience. J Trauma 1993; 35: 226-32.

AUTHORS:

[1.] Arif Mohammad Shaik

[2.] M. Mohankrishna

[3.] Diju Jacob

[4.] B. S. Jayakrishna Reddy

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Orthopaedics, Mamata Medial College & General Hospital, Khammam, Telangana.

[2.] Post Ms Student, Department of Orthopaedics, Sri Siddhartha University.

[3.] Post Ms Student, Department of Orthopaedics, Sri Siddhartha University.

[4.] Professor and HOD, Department of Orthopaedics, Sri Siddhartha Medical College & Hospital, Sri Siddhartha University, Tumkur.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Arif Mohammad Shaik, Assistant Professor, Department of Orthopedics, Mamata Medical College & General Hospital, Rotary Nagar, Khammam-507002, Telangana, India.

Email: dr.arif.ortho@gmail.com

Date of Submission: 03/07/2014.

Date of Peer Review: 04/07/2014.

Date of Acceptance: 31/07/2014.

Date of Publishing: 14/08/2014.
Table 1: Age distribution

Age group (yrs)   Frequency   Percent

<20                   9         15
21-30                18         30
31-40                21         35
>40                  12         20
Total                60         100

Table 2: Sex Distribution

Gender   No. of patients   Percentage

Male     42                70%
Female   18                30%
Total    60                100%

Table 3: Side & Site of Injury

                      Right     %    Left humerus    %
                     humerus

Upper l/3rd shaft      --                 --
Middle l/3rd shaft     24                 18
Lower 1/3rd shaft       6                 12
Total                  30      50%        30        50%

Table 4: Type of Fracture

Type of fracture   Frequency   Percent   Type of fracture

Type A1                3        5.00%        Type A1
Type A2               21       35.00%        Type A2
Type A3               30       50.00%        Type A3
Type B2                6       10.00%        Type B2
Total                 60       100.00%        Total

Table 5: Mode of Injury

Mode of injury   Frequency   Percent

RTA                 33       55.00%
Fall                27       45.00%
Total               60       100.00%

Table 6: Associated Injuries

Associated injuries    Frequency   Percent

No injury                 57       95.00%
Ipsilateral fracture       3        5.00%
  both bones-forearm
  (Radius & Ulna)

Total                     60       100.00%

Table 7: Follow-up Observations

Parameters      Overall Observations in 20 patients

                   6 weeks        3 months        6 months
                  follow up       follow up       follow up

Pain             Pain (mild)       No pain         No pain
                 was present
                 in 18 cases

Course of       Fracture line   Fracture line   Fracture line
fracture         was visible     not visible     not visible
healing,        in 36 cases,     except in 3     in all the
Radiological       Implant         cases,          cases,
assessment of     position         Implant         implant
implant         satisfactory      position        position
position,        in all the     satisfactory    satisfactory
fracture          cases, No      in all the      in all the
reduction and   signs of loss       cases           cases
healing in      of reduction
progress,        in any case
Evaluation of
any possible
loss of
reduction

Assessment &     superficial         No              No
analysis of         wound       complications   complications
any               infection
complications     seen in 9
                    cases

DASH scoring,    DASH: 25.55     DASH: 16.75    DASH: 6.05 [+
Rommens         [+ or -] 4.41   [+ or -] 4.07    or -] 3.47
grading.                                        Excellent: In
                                                  51 cases
                                                 solid union
                                                seen, no loss
                                                 of range of
                                                 movements,
                                                   and no
                                                 significant
                                                 subjective
                                                 complaints.

                                                 Good: In 9
                                                 cases solid
                                                 union seen,
                                                 10-20% loss
                                                 of range of
                                                  motion at
                                                  elbow and
                                                  shoulder.

Table 8: DASH scoring

DASH score    Mean [+ or -] SD

6 weeks      25.55 [+ or -] 4.41
3 months     16.75 [+ or -] 4.07
6 months     6.05 [+ or -] 3.47

Table 9: ROMMENS grading

Rommens Grading   Frequency   Percentage

Excellent            51         85.00%
Good                  9         15.00%

Total                60        100.00%

Table 10: Complications

Complications           Frequency   Percent

No complication            51       85.00%
Superficial infection       9       15.00%

Total                      60       100.00%

FRACTURE UNION RATE OBTAINED INVARIOUS STUDIES

Series           Total no.   Delayed      Non      Overall
                    of        union      union     results
                 patients

Klenerman L         98       8(8.2%)      --      98(100%)
  (1966) (10)
Bell M Jetai        34          --       1(3%)     33(97%)
  (1985) (11)
Griend RV,          36       5(14.6%)    1(3%)     35(97%)
  Tomasin J,
  Ward et al
  (1999) (12)
Gongol T, M         32          --      1(3.1%)   31(96.9%)
  racek D
  (2002) (17)
Present             60        3 (5%)      --      57 (95%)
  study (2013)

RANGE OF MOBILITY OF ELBOW AND SHOULDER

Study            No. of    Good range     %
                Patients   of Mobility

BellMJetall        39          38         97
  (1985) (11)
Griend R V,        36          30        85.4
  Tomasin J,
  Wardetal
  (1986) (12)
Heim Detal        127          111       87.3
  (1993) (14)
McCormack          44          44        100
  R Getal
  (2000) (5)
Gongol T, M        32          31         97
  racek D
  (2002) (7)
Present Study      60          60        100
  (2013)
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Title Annotation:ORIGINAL ARTICLE
Author:Shaik, Arif Mohammad; Mohankrishna, M.; Jacob, Diju; Reddy, B. S. Jayakrishna
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Aug 14, 2014
Words:3164
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