Transcript
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Closed reduction and internal
fixation of # shaft of humerus with
ender nails
By
Dr. Rakesh KumarM.S. Ortho (std.)
Co authors: Dr. (Prof) Arjun Singh
Prof & Head
Dr. Ajoy Kumar Manav
Asst. Professor
Deptt. Of Orthopaedics
Patna Medical College & Hospital
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INTRODUCTION
Fracture shaft of humerus with or
without neurovascular complications is
a common entity.
It constitutes approximately 3-5% of allfractures.
With the growing mechanization and
increasing road traffic accidents, it
often presents in a bizarre way and
becomes difficult to manage, especially
at the ends.
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EPIDEMIOLOGY
It has a bimodal distribution.
In younger age group: males >females.
In older age group: females> males.
High energy trauma (especially motor
vehicle accidents) is more common inthe young males
Low energy trauma ( trivial fall at home)
is more common in the elderly female.
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AGE AND GENDER SPECIFIC
INCIDENCE OF SHAFT OF
HUMERUS FRACTURE
http://www.google.co.in/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=Uv39Oeo7Y6onVM&tbnid=dXy9DVC5DCSV7M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.msdlatinamerica.com%2Febooks%2FRockwoodGreensFracturesinAdults%2Fsid835419.html&ei=VVJEUpz7ApCnrAe9q4DYBw&bvm=bv.53217764,d.dGI&psig=AFQjCNEa2LYjgIVJUMc4GIs9dLfAoEBg7g&ust=13802956207388128/12/2019 Ender nailing in humerus
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There is no universal consensus on themost appropriate method formanagement.
Conservative management is a rational
option for the treatment of isolatedhumeral shaft fractures with no orminimal displacement.
Sir John Charnley in his treatise Theclosed treatment of commonFractures states that it is one of theeasiest major long bone fractures to
treat by conservative methods.
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However conservative management
has its own demerits: It requires a long period of
immobilization, which carries a risk
of prolonged shoulder joint stiffness.
Nonunion after conservativetreatment does occur in
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Surgical management is a better choice
in case of :
Polytraumatised patients
Unstable fracture (spiral/long oblique)
Comminuted fractures
Segmental fractures
Pathological fractures
Open fractures &
Fractures associated with radial nerveinjury and major vascular injury
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For the shaft portion i.e. leaving
about 5 cm form above and 5cm from below, plate is the
unanimous choice.
A variety of these plates are in
use today such as DCP,LC-
DCP, locking plate and others.
There has been a sea change
in the technique also i.e. from
open reduction to MIPO.
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In adults, interlocking intramedullary
nails are also in use.
However, injury to the rotator cuff
has restricted its use to a greatextent.
Problems such as iatrogenic fracture
comminution (especially in small
diameter canals), and nonunion
(and significant difficulty in its
salvage) have also been reported.
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Ender nails
Enders nails are flexible nail which
can be molded to any shape and
angled to most of the long bones.
It works on the principal of three
point fixation and achieve stability
by stacking.
It has been mostly used for tibia
and femur fractures, especially in
children.
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Review of Literature
Hall RF Jr, Pankovich AM.1987
found that
Average time to clinical union = 7.2
weeks. 1 out of 86 cases developed non
union.
No infection or malunion. 1 nail backed out.
http://www.ncbi.nlm.nih.gov/pubmed?term=Hall%20RF%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Pankovich%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Pankovich%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=3571315http://www.ncbi.nlm.nih.gov/pubmed?term=Hall%20RF%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=35713158/12/2019 Ender nailing in humerus
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Chenet alin 2000 conducted a
retrospective study of 118 cases
and found
Average operative blood loss = 105
cc
Average operation time = 57 min.
Average hospital stay =6.5 days
http://www.injuryjournal.com/article/S0020-1383%2800%2900081-4/abstracthttp://www.injuryjournal.com/article/S0020-1383%2800%2900081-4/abstract8/12/2019 Ender nailing in humerus
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Average time to union =10.5 weeks
Post operative complications
included:
Superficial infections = 3/118
Iatrogenic radial nerve palsy
=1/118 Nail backouts = 8/118
Non union =8/118
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M.S. Moon et al, in 2002 performed
ender nailing in 67 patients. Theyused 1 nail in 18 cases, 2 nails in 48
cases and 3 nails in 3 cases.
Radiological visible bridging callus
was observed at 6.8 weeks on
average (5-15 wks)
Average clinical union time was 9.3weeks.
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In 6 cases, the long nail distracted
the fracture gap, and resulted in
delayed union.
In cases of proximal nail migration,
shoulder pain and partial stiffness
were complicated, which
disappeared after nail removal.
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AIM OF STUDY
To study the functional outcomes of
Ender nails in management of
humerus fractures by closed
technique.
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MATERIAL AND METHODS
This prospective study was carried
out at the Patna Medical College
Hospital, Patna, India, between
January 2008 and December 2012. 50 patients admitted from emergency
department of our hospital, with a
humeral shaft fracture suitable for
Ender nailing were included in thestudy.
Informed consent was obtained from
the patients participating in the study.
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Approval from the ethical committee
was taken.
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Fracture Side
28, 56%
22, 44%
Right Left
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15
22
10
3
0
5
10
15
20
25
10-20 21-30 31-30 41-50
Age distribution
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2225
3
0
5
10
15
20
25
Low Middle High
Socio Economic Group
Socio economic group:
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AO CLASSIFICATION
Fractures were classified according
to the AO system
1HUMERUS
2--- DIAPHYSISASPIRAL 1-PROXIMAL ZONE
2- MIDDLE ZONE
3- DISTAL ZONE
B- OBLIQUEC- TRANSVERSE
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3
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A3
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SURGICAL TECHNIQUE
The nails were introduced through a
small stab incision 1.5 cm in length on
the anterolateral aspect of the head of
the humerus lateral to the greatertubercle.
The deltoid muscle was split to
visualize the insertion of rotator cuff.
Nails were inserted through holes made
distal to the rotator cuff.
Most often only two nails were used.
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Post operative management
Patients were given arm slings and
pendulum and elbow movements were
allowed as the pain subsided.
An initial follow-up was done at 10 daysfor wound review.
At 3 weeks, patients were encouraged
to start active shoulder exercises.
Patients were further followed up at
6,12, 20, 28 weeks.
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Plain radiographs were taken to
evaluate union.
Radiographic union was defined as
observation of an osseous bridge inboth AP and lateral radiographs.
Clinical union was defined as absence
of motion or tenderness on movement
or manipulation of the arm.
We defined non union as no evidence
of union after 24 weeks.
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Shoulder function was evaluated using the
constant score, which assigns a maximum
of 100 points according to different
parameters:
Presence of residual pain
Impairment in daily functions
Recreational activities or sports, and
Limitation in active movements or in the
shoulders strength.
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Sex Ratio
32, 64%
18, 36%
Male Female
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In our study:
Average time for union: 12-20
weeks
Mean time: 12.8 weeks
Average blood loss : 10-20 ml Average exposure time for x-rays : 1
min
Primary union was achieved in - 45cases (90%)
Bone graft was required in - 5
cases.
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Time of union
Within 12 weeks- 40 cases (80%)
Within 20 weeks- 5 cases (10%)
No union upto 24 weeks- 5 cases(10%)
Revision surgery was done withbone grafting
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Case 2
Pre-operative Post-operative
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After 10 weeks
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Case 3
Pre-operative
Post operative
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Functional outcome:
Full range of shoulder and elbow
movement was achieved in40
cases (80%) within 16 weeks.
In rest of the cases, abduction was
limited to 900.
Rest 5 cases (i.e. 10%) required
vigorous physiotherapy, then
improved.
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Case 1
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External rotation Internal rotation
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Case 2 - Abduction restricted to 900
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Complications:
Superficial stitch infection- 3 cases
(managed by intravenous
antibiotics)
Proximal migration of nails- 2 cases
(realignment surgery was done)
Shoulder stiffness- 5 cases
(required vigorous physiotherapy)
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Our series did not have any post
operative nerve injuries or deep
infections.
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Comparison between different
modalities of treatment
Conservative
literature
suggests that
average time tounion ranges
from 6.2 to 9.4
weeks.
Union rates>90% due to
the excellent
blood supply of
Ender nailing
literature
suggests that
average time tounion ranges
from 7.2 to 9.3
weeks
Similar unionrates i.e. > 90
% due to
preservation of
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the bony
fragments
provided by the
surrounding softtissue and
muscle
envelopes
soft tissues
during insertion
and periosteum
and fracturehematoma at #
site.
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Ender nailing vs interlocking nail
Ender nails
Ender nails does
not require
reaming andthus relatively
preserve the
endosteal blood
supply. Ender nailing
relies on
configuration.
Interlocking nails Reaming of
interlocking nailsdestroys the
residualendosteal bloodsupply and hasdeleteriouseffects on fracture
union. With reamed
interlocking nails,locking screws
are
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and spatialorientation ofthe nails toachieve
rotationalstability.
They canachieve goodfixation inosteopenicbones
used to providerotationalstability.
They rely onbone qualityand henceachieve poorfixation inosteopenicbones
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Discussion
The use of ender nail in
management of # shaft of humerus
is not a common practice.
But in our part, where economy &time is prime concern it gives good
results.
The results are comparable with
plate and interlocking nail.
The technique is simple and require
minimum instrumentation (except
IITV).
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Overall stability of the construct
depends on the number and size of
implants and their spatial distribution
with adequate flushing in themedullary canal.
Meticulous preoperative planning
and intra-operative execution is thekey to this operation.
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The use of Ender nails in elderly
patients having multiple injuries or
pathological fractures has been
shown to be minimally invasive and
safe, and to produce excellentfunctional and cosmetic result.
This technique gives minimal x ray
exposure, short operative time and
causes less soft tissue insult. This decreases the overall morbidity
in elderly and poly traumatised
patients
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Conclusion
Ender nailing for # shaft of humerus
is a cost effective, time saving and a
technique with minimal blood loss.
Although plate osteosynthesis is
considered the gold standard, ender
nails have many benefits, with good
results attainable and comparablewith those seen with conservative
modalities.
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