Management of fractures of shaft of humerus with locking compression plate: a prospective study.
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.
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).
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.
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(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.
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[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.
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|
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