Summary
INTRODUCTION
Trauma is the leading cause of morbidity and mortality in the present age.
The victim of bony injury may face prolonged immobilisation and loss of wages and
it’s a tough time for the entire family. Besides, the patient often may have to live with
the sequelae and functional disability.
Fractures of the shaft of humerus have been treated conservatively since ages,
with good results. Sir John Charnley in his treatise “ The closed treatment of
common fractures “ even states “ it is perhaps one of the easiest major long bone
fractures to treat by conservative methods.” 1
However conservative treatment cannot be recommended in every case.
Conservative treatment requires prolonged immobilisation of the fractured limb that
leads to disuse of the involved limb, repeated hospital visits, disturbances in daily
routine activities , troublesome in his or her professional duties and complications due
to prolonged immobilisation such as stiffness of joint leading to prolonged recovery
time.
Moreover if unstable fractures, comminuted fractures, fractures associated
with nerve or vascular injuries are treated conservatively leads to complications like
Non-union, Mal Union so these fractures need fixation.
Many options were available to treat fractures conservatively but taking into
consideration pitfalls of it, an era of Fixation evolved. Aim of it was early restoration
of joint motion and return to normal physiologic function and minimal morbidity.
Many modalities were also developed for fixations, intramedullary devices
like Locking nail and plate osteosynthesis system. Fracture of humerus causes
functional limitation of the arm.
Page 94
Summary
Humeral shaft fractures account for 5% of all fractures. These fractures are
mainly due to high energy trauma such as Road traffic accidents (RTA) and fall from
height2. These fractures were treated by Functional bracing, Hanging cast, U splints
which gave excellent results for healing of fractures with no or very less acceptable
deformity as published by Sarmiento et all3 but required prolonged immobilisation
leads to hampering of social and daily activities of person.
In the last two decades several operative procedures has been developed for
treatment of humeral fractures such as intramedullary locking nail, plate fixation,
intramdedullary rush wires, external fixation.
The present study attempts to highlight comparison in functional outcome and
time of union in fracture shaft of humerus treated either by intramedullary nailing or
by a plate osteosynthesis.
AIM AND OBJECTIVES
AIM –
To perform comparative study of use of Intrmedullary nail and Dynamic Compression
Plate to treat Diphyseal fracture of Humerus at A.V.B.R.H
OBJECTIVES –

To evaluate and compare the adaptability and acceptability.
Page 95
Summary

To evaluate and compare the functional outcome.

To evaluate and compare pattern of callus formation and time of union.

To evaluate and compare emerging complications

To review the literature
REVIEW OF LITARATURE
Through all the changes in medical and surgical knowledge and in technique
in the history of medicine, there are some subjects, such as fractures, in which,
because of their nature, there has been very little change.
It is, therefore, easier to trace the history of fracture treatment back through
many centuries than find what was known or done a hundred years ago about some of
the "modern " diseases.
Because the mechanical factors in fractures were the same in the first century
as they are in the twentieth century, the methods of treatment in ancient times are
found to be similar, not only in principle but in practice, to those of our own day.4
In the earliest known surgical text, The Edwin Smith Papyrus, three cases of
humeral fractures appear.5
Page 96
Summary
The papyrus contains 48 cases of wounds and fractures topographically
ordered from the skull to the chest and upper arm. The papyrus is incomplete and
fractures of the humerus are the only limb fractures dealt with.
They have treated these fractures of humerus according to their way and with
the substances they were having with them like follows –
‘‘A broken upper arm,’’ deals with the diagnosis, reduction, and bandaging of
a fracture of the humerus. The prognosis of the injury is considered to be favourable.
Reduction by traction is recommended: ‘‘Then you lay him out, with something
folded between his shoulder blades. You have to pull his arms to lengthen his upper
arms, until that break falls into its place’’.
A broken upper arm with a wound,’’ deals with a compound fracture of the
humerus. Two kinds of injuries are distinguished according to the depth of the lesion.
The examination of the injury is done with the fingers in the wound. The case
introduces the technical term nekhebkheb referring to a movement of the fracture
under the fingers of the physician, which has been translated to ‘‘wiggling’’ or
‘‘crepitating’’. If the wound is only superficial, two strips of cloth with alum, oil, and
honey are applied. If bone penetrates the soft tissue and blood is issuing from the
wound, the prognosis is considered hopeless and no treatment can be provided.
Then arrived era of The Hippocratic corpus( crica 440-340 BC).
The Hippocratic method of reduction of glenohumeral dislocations is known
to most physicians. However, the Hippocratic approach to fractures of the humerus in
De Fracturis (written circa 415 BC) has not been studied since the early nineteenth
Page 97
Summary
century. The author distinguishes prognostically between proximal and distal fractures
of the humerus:
He developed his own method of reduction of humeral fractures –
The Hippocratic mode of reduction for fractures of the humerus (De Fracturis,
VIII) has been interpreted and illustrated in later surgical texts Fig.: The patient is
seated on a high stool with a hanging rod in the armpit so he can hardly sit. The
patient’s elbow is flexed with a scarf with heavy weights under the forearm extending
the upper arm. The physician then reduces the fracture manually. After reduction,
bandages of linen are applied with the head of the bandages on the fracture. The
bandages are soaked in cerate, an ointment of oil or fat mixed with wax or resin. The
bandages should be changed every third day and replaced with increasing pressure.
Stable fixation of the fracture may have been maintained by the bandages soaked in
cerate. On the seventh or ninth day, the bandage is removed and the upper arm is
washed in hot water. The bandage is reapplied and splints are added.
He said that humerus is naturally convex outwards, and is therefore apt to get
distorted in this direction when improperly treated’’ because he was aware of the risk
of varus displacement. In such cases he told that the humerus should be fixed with
bands to the chest in valgus position after applying many-folded compresses under the
elbow.
Page 98
Summary
Fig No - 1
Fig. Interpretations of the Hippocratic mode of reduction for fractures of the humerus
(De Fracturis, VIII) [10] are shown. (Reprinted from (A) Primatice (1504–1570) [23],
with permission from Bibliothe`que national de France, Paris, France), and (B)
Joannis Scultetus (1595–1645)
Celsus distinguished between shaft fractures, proximal fractures, and distal
fractures according to prognosis and treatment recommendations: ‘‘…there is least
danger when the middle of the bone is fractured. The nearer the fracture is to either
the upper or the lower end the worse it is; for they are at once more painful and more
difficult to treat’’
Celsus described various fracture configurations, including transverse-,
oblique-, and multifragmented fractures. He mentioned displacement of oblique
Page 99
Summary
fractures with abbreviation and described the sensation of crepitus: ‘‘If the fragments
are in contact, they make a sound when moved and produce a stabbing sensation…’’5
According to Celsus, fractures of the humerus should be reduced immediately
to prevent inflammation. The reduction is successful if the pain disappears and the
arms become equal in length. The Hippocratic method of reduction is followed except
for the use of bandage loops for extension (De Medicina, VIII, 10). As in Corpus
Hippocraticum, Celsus prescribed successive application of bandages at the seventh
or ninth day followed by splinting. When the proximal part of the humerus is broken,
the bandages should be longer than if the shaft or distal part is broken. If the fracture
is close to the shoulder, the skin should be fomented with hot water and wine and oil
should be dropped on it. To prevent gangrene, Celsus recommended making the turns
of the bandage numerous rather than tight. If the fracture is not in position, it could be
reduced again on the seventh or ninth day. The splints should be tightened every third
day and used for 2.3 of the time of healing (40 days in total). Celsus differed from
Hippocrates in using six bandages instead of three; he applied larger pieces of linen
and soaked it with wine and oil instead of cerate.
.
Page 100
Summary
Fig No - 2
An illustration of Oribasius’ mode of reduction for humeral fractures and
glenohumeral dislocation using the Hippocratic bench, scamnum, is shown.
(Reprinted from Vidius [29] and Brockbank W.
The man who was Vidius.
An accurate description of the humerus is found in Galen’s De ossibus ad
tirones (circa AD 180):
‘‘The humerus, the largest bone except for the femur, articulates at both ends.
At the shoulder end it has an epiphysis with a very large head on a small neck. A
broad fossa in the front divides the entire head into two condyles… the humerus is
bowed, yet not sharply and even not uniformly; because it is convex anteriorly and
outwardly and concave in the reverse’’
Page 101
Summary
Hippocrate gave directions to treat fracture humerus in 460-377 B.C like follows –
having got a piece of wood a cubit or somewhat less in length, like the handles of
spades, suspend it by means of a chain fastened to its extremities at, both ends; and
having seated the man on some high object, the arm is to be brought over, so that the
armpit may rest on the piece of wood, and the man can scarcely touch the seat, being
almost suspended; then having brought another seat, and placed one or more leather
pillows under the arm, so as to keep it a moderate height while it is bent at a right
angle, the best plan is to put round the arm a broad and soft skin, or broad shawl, and
to hang some great weight to it, so as to produce moderate extension.
"He used a fracture table called the Scamnum which he describes as follows:
"But the best thing is, for any physician who practices in a large city, to have prepared
a proper wooden machine, with all the mechanical powers . . . either for making
extension, or acting as a lever."
GUY DE CHAULIAC (1300-1370) emphasized the use of ointments and salves in
the treatment of fractures.4
For compound fractures he advised the extraction of "foreign substances such
as arrows or pieces of bone", then "the separated parts of the bone should be brought
together and the flesh wound deeply sutured and closed firmly ". The limb was then
bandaged "in such a way that the wound can be attended to . . . without undoing all
the bandages and supports".
In 1822 A.D. SIR ASTLEY COOPER published his textbook on fractures &
dislocations.5
Page 102
Summary
GIOVANNI DI VIGO ( 1460-1520) Placed Much stress on the healing of
fractures by external application of various ointments and concoctions.4
In 1940, Caldwell proposed his technique of treating humeral shaft fractures
relying on gravity to achieve proper position of the fracture.6
In this method, the arm is immobilised in a long arm plaster cast Known
as Hanging Cast.
The cast is then suspended by a strap around the neck, which is connected to
loops incorporated into the cast at the level of the forearm. Fracture alignment can be
adjusted by adjusting the position at which the straps connect to the loops.
Sarmiento reported in 1977 about his results in humeral shaft fractures treated
with an orthosis allowing for complete motion in shoulder and elbow joint.3,7
The basic design is a rigid light-weight plastic brace composed of an anterior
and posterior shell joined by Velcro straps.
The hanging cast is applied as a circular plaster bandage which encases the
upper extremity from its upper third to the wrist; it holds the elbow in 90 degree
flexion, and is suspended from the neck by a sling. The plaster bandage is applied
with the patient either sitting or recumbent as convenient or as condition of the patient
permits, the elbow flexed to a right angle, with the forearm held in midpronation. An
adequate length of stockinette is pulled over the arm, and a strip of saddlers' felt, one
inch in width, is made to encircle the wrist just above the ulnar styloid. The plaster
bandage is applied either with no other padding or with a few turns of flannel
bandage. Fractures were treated by using functional braces also.
Page 103
Summary
In 1855 A.D. the functional cast brace was introduced which was the fore
runner in the treatment of Humeral shaft fractures.3,8-10
In 1852 A.D. ANTONNINE METHIJSEN devised the method of using
bandage impregnated with plaster of Paris for reduction maintenance.11
In 1860 A.D. BUCK used skin traction to treat fractures.12
HUGH OWEN THOMAS (1831-1891) stressed the importance of
uninterrupted & prolonged immobilization in fracture treatment.13
In 1880 the plaster of Paris came into common use for external
immobilization.12
After invention of X-rays by ROENTGEN in 1895 science of bone including
fracture treatment has advanced tremendously.14
The principles of gutter splint & plaster 'U' slabs were described by MC
MURRY in 1939 & ROWLEY in 1942 respectively.15
Schittko stated in 2004 that nowadays operative treatment is the gold standard
because of the development of new intramedullary and rotational stable implants.16
Open reduction & wire sutures fixation was attempted by ROGERS as early as
1827, this method did not receive wide acceptance in surgery due to sepsis.17
Curling was the first to report basic sequences of fracture healing in 1836
A.D.18
In 1894 Sir William Lane introduced the idea of metallic internal fixation in
fracture treatment.16
Page 104
Summary
The “beginnings” of intramedullary fixation go back into the 16th century.
The conquistadors in America described how the Indians used wooden wedges to treat
bone fractures.4
In 1897 Nicolaysen described the principles of medullary fixation for
fractured bones, He & Delbet in 1906 published details of intramedullary fixation of
bones.19
By the end of the 19th century, first experimental intramedullary fixations
were performed in Europe. The pioneers were Bircher, König, von Langenbeck,
Cheyne and Lane.4
Metallic pin traction was used by Codvilla & Steinman in 1907.12
In 1907 Lane introduced light plates.20
In 1907 Lambotte developed & promoted internal fixation methods.20
Alvin Lambotte of Belgium was the first surgeon to device an external
fixation in 1907. Since then it has been improved by ROGER ANDERSON (1934),
OTTO STADER (1937), HOFFMAN (1939) & ILLIZAROV (1950) in the following
years. The external fixators are particularly helpful in open fractures of the
Humerus.21
In 1912, Plate fixation for diaphyseal fracture was introduced by Beckmann.14
In 1912, Sherman introduced Vanadium steel bone plates & self tapping
screws.20
Page 105
Summary
Hey Grooves in 1914 was the first to declare that some fractures do require
open reduction while there are many fractures which do well with skilful closed
treatment & should not be operated upon.22
Robert Jones believed in early reduction of fresh fractures under anaesthesia
in 1914.21
In 1914, Maclean introduced oval hole modified lane plate for compression
after resorption at the fracture ends.20
In 1935, Pauwel's concept of tension band fixation applied to bone.20
In 1937 L.V.Rush & H.L.Rush reported use of steinmann pin in the
medullary canal of Humerus & other long bones.23
In the beginning of the 20th century, Ernest Hey Groves (England) already
used specially designed three- or four-edged intramedullary nails for the fixation of
diaphyseal long bone fractures.22
In 1940 Kuntschner of Germany presented convincing evidence concerning
the value of intramedullary fixation devices which simply fitted the entire length of
the bone.24,25
In 1940, Lambrinudi suggested the placement of strong wires and thin metal
sticks through the medullary canal.19
In 1943 Townsend & Gilfillan designed a plate with slots to allow the
surgeon to coapt the fragments manually just before tightening the screws. It was thin
& flexible, when greater strength was needed, two or more of these plates were
stacked one on top of the other.21
Page 106
Summary
None of the above authors made any reference to compression of bone. These
plates were used to fix the fracture fragments, represented an extension of the old
principle of splintage.
In 1948 Egger's & associates studied the effect of compression on healing of
experimental fractures in animals & concluded that compression forces applied to
healing bone fragments could influence the rate of healing. He designed the sliding
compression caused necrosis & suggested muscle action provides the physiological
amount of compression forces. But in the actual sense he just coapted the fragments &
not compressed it.26
In 1949 Robert Danis (1880-1962) was the first surgeon to use a true
compression plate in the treatment of acute diaphyseal fractures of long bones. He
was a Belgium surgeon, graduated at Brussels. Initially he was interested in thoracic
surgery, vascular surgery, anaesthesiology & on breast cancer & orthopaedics also.
He was unhappy with the implants & instrumentation of fracture treatment & hence
he devoted later part of his life on metallurgical properties of bone implants & its
design & published the technique of osteosynthesis in 1932 & in 1949 " Theories &
practice of Osteosynthesis".27
In 1950 Rush brothers treated fracture shaft of humerus with rush nailing with
100% good results.23
In 1950 Collison All the above mentioned plates, were compressed by a flat
head screw. He modified his plate with a beveled slots, which were designed to
accommodate chamfered screw head and compression.
Page 107
Summary
In 1951 Venable, He modified Danis plate where the compression screw was
oriented obliquely to make it more accessible, but this change made the junction
between the compression screw and the threads of the anchoring screw insecure.
Stewart.M.J. & Hundley.J.H. in 1955 studied 223 humeral shaft fracture
treated by conservative methods & formulated a grading for analyzing the final
results.28
Dr. Whitson in 1954 demonstrated that, radial nerve does not pass in the
spiral groove, instead it is separated by about 1-5 cm thick muscles, usually medial
head of triceps & only near the inferior lip of the groove it is in direct contact with the
humerus where it pierces lateral intramuscular septum.29
P.G.Laing in 1956 studied the blood supply of adult humerus by injecting a
radio opaque dye into the brachial artery of cadavers & according to his study the
main nutrient artery arises in 2/3rd of cases from the brachial artery & in the
remaining from the profunda brachii artery.30
In 1958 M.E.Muller assembled a group oh friends, general & orthopaedic
surgeons to discuss the poor results obtained with both non-operative methods of
fracture treatment in the country. This nucleus in the same year developed into the
group called A.S.I.F.( Association for the Study of Internal Fixation) or A.O. (
Arbeints gemein schaft fur osteosynthese fragen).26
Four principles were accepted during the meeting:1) Anatomical reduction.
2) Rigid Internal fixation.
Page 108
Summary
3) Atraumatic technique on soft tissue as well as bone to preserve blood supply.
4) Early pain free active mobilization of muscles & joints adjacent to the fracture.
To prove or disprove these principles they started working in 3 different directions:1) Animal experimentation on the pathophysiology of bone repair under various
biomechanical conditions with or without internal fixation.
2) Creation of compression armamentarium taking advantage of modern technology.
3) Careful clinical follow up in patients treated for fresh fractures, non-union &
malignant conditions.
They took the help of Robert Mathys, a manufacturer, FRITX
STRAUMMAN a metallurgist & developed over 1400 items for use in the surgery of
fractures.
Dr. Arthur Holstein & Gwilyn Lewis of California in 1963 described
"Humeral fracture syndrome" in which they said, in case of fractures of distal third
humerus, which are usually spiral, the distal bone fragment had always displaced
proximally with its proximal end deviated radialwards, the radial nerve was caught in
the fracture site & if there was a comminuted fragment, that damages the nerve. If
there was no displacement, the radial nerve was spared.31
Johansson studied complications associated with antegrade & retrograde Knailing for fractures of the humerus. L.KLENERMAN of Middlesex in 1966,
described a series of 98 patients with humeral shaft fracture treated with conservative
methods with good results. S.E.CARROL, University of Ontario, Canada, studied the
Page 109
Summary
blood supply of humerus & according to his study, 2/3rd of humerus has single
nutrient artery.11,32
In 1982 Perren.s.m. & Klauge devised a BIOLOGICAL (FIXATION)
PLATE. The screw slots are inclined even on the undersurface of the slots & hence
the high degree of inclination of screws, upto 40 degrees. It is made up of Titanium
which is more flexible & hence less stress protection. Lag screws applied through the
plate is twice as effective as that of conventional lag screws. The slots are
symmetrical & there is no gap in the mid section of the plate which makes it more
versatile for the use in any type of fractures.33
In 1989 Seidal developed locking nail for the humerus. Closed nail techniques
have reduced blood loss, infection rates & length of stay in the hospitals, With locking
nails, the fixation is rigid, no rotational instability & external splintage is not
required.34
In 1989 LIMITED CONTACT DYNAMIC COMPRESSION PLATE was
devised by PERREN.S.M. It stands for a new concept of biological plating HUBER,
KEESELER.H.W. & REHM.K.E. in 1996 recommended the use of flexible
intramedullary nails in fractures of long bones in children. They concluded that to
correct angulation & to avoid plaster immobilization in diaphyseal fractures in
childhood closed nailing with flexible intramedullary nails is an easy & safe
method.33
R.G.Mccormack, D.Brien et. al. in 2000 compared the fixation of fractures
of shaft of Humerus by Dynamic Compression Plate or Intramedullary nail &
suggested that open reduction & internal fixation with DCP remains the best treatment
for unstable fractures of the shaft of the humerus.35
Page 110
Summary
....And the options goes on increasing for fixation of humeral shaft fractures
from simple pinning , intramedullary nailing to locking intramedullary nailing.
Fixation of fractures with plate also evolved from simple light plate and from
compression plate to modern locking plate.
ANATOMY 36
Arm comprises important role in the upper extremity. It is the major weight
bearing portion of upper extremity. The arm (Brachium) Extends From the shoulder
to the Elbow(Cubitus).The bone of the upper arm is Humerus , its upper end meets
with the scapula and forms shoulder joint , its lower end articulate with radius and
ulna to form elbow joint.
SURFACE LANDMARKS OF THE ARM –
1. Greater tubercle of the humerus is the most lateral bony point in the shoulder
region. It can be felt just below the acromian, deep to deltoid when the arm is
by the side of trunk.
2. The shaft of the Humerus is felt only indistinctly because it is surrounded by
muscles in its upper half , the humerus is covered anteriorly by the biceps and
brachialis and posteriorly by triceps.
3. The medial epicondyle of the humerus is a prominent bony projection on the
medial side of elbow.
4. The lateral epicondyle of humerus is less prominant bony projection than
medial. It can be felt in the upper part of depression on the posterolateral
aspect of the elbow in the extended position of the forearm.
Page 111
Summary
OSTEOLOGY OF ARM –
HUMERUS
It is the longest bone of the upper limb.
It has an upper end , a shaft and a lower end....
UPPER END –
1. Head is directed medially , superiorly and posteriorly. It articulates with glenoid
cavity of the scapula to form a shoulder joint. The head forms about one third of
sphere and is much larger than the glenoid cavity.
2. The line separating head from rest of the upper end is called Anatomical neck.
3. The lesser tubercle is an elevation of anterior aspect of upper end.
4. The greater tubercle is an elevation that forms the lateral part of an upper end. Its
posterior aspect is formed by three impressions upper, middle and lower for
insertions of muscles of Rotator cuff.
5. The intertubercular sulcus or bacipital groove separates the lesser tubercle from
greater tubercle. The sulcus has medial and lateral lips that represents downward
prolongations of the lesser and greater tubercles.
THE SHAFT –
The shaft is rounded in its upper half and triangular in the lower half. It has
three borders and three surfaces.
BORDERS –
Page 112
Summary
1. The upper one third of anterior border forms the lateral lip of the intertubercular
sulcus. In its middle part , it forms an anterior margin of the deltoid tuberosity.
The lower half of an anterior border is smooth and rounded.
2. The lateral border is prominent only at the lower end where it forms the lateral
supracondylar ridge. In the upper part, it is barely traceable upto the posterior
border of greater tubercle. In the middle part, it is interrupted by the radial or
spiral groove.
3. The upper part of medial border forms the medial lip of the intertubercular sulcus.
About the middle it presents a rough strip. It is continuous below with the medial
supracondylar ridge.
SURFACES –
1. The anterolateral surface lies between the anterior and lateral borders. The upper
half of this surface is covered by the deltoid. A little above the middle it is marked
by a V shaped deltoid tuberosity. Behind the deltoid tuberosity the radial groove
runs downwards and forwards across the surface.
2. The anteromedial surface lies between the anterior and medial borders. Its upper
one third is narrow and forms the floor of the intertubercular sulcus. A nutrient
foramen is seen on this surface near its middle, near the medial border.
3. The posterior surface lies between the medial and lateral borders, its upper part is
marked by an oblique ridge. The middle one third is crossed by the radial groove.
LOWER END –
Page 113
Summary
The lower end of humerus forms the condyle which is expanded from side to
side, and has articular and non-articular parts. The articular part includes the
following.
1. The capitulum is a rounded projection which articulates with the head of
radius.
2. The trochlea is a pully shaped surface. It articulates with the trochlear notch of
the ulna. The medial edge of the trochlea projects downwards down 6mm
more than the lateral edge, his results in the formation of carrying angle.
The non-articular part includes the following –
1. The medial epicondyle is a prominent bony projection on the medial side of the
lower end. It is subcutaneous and is easily felt on the medial side of elbow.
2. The lateral epicondyle is smaller than the medial epicondyle. Its anterolateral part
has a muscular impression.
3. The sharp lateral margin just above the lower end is called as lateral
supracondylar ridge.
4. The medial supracondylar ridge is a similar ridge on medial side.
5. The coronoid fossa is a depression just above the anterior aspect of the capitulum.
It accommodates the head of radius when the elbow is flexed.
6. The olecrenon fossa lies just above the posterior aspect of the trochlea. It
accommodates the olecrenon process of the ulna when elbow is extended.
OSSIFICATION –
The humerus ossifies from one primary centre and 7 secondary centres. The
primary centre appears in the middle of the diaphysis
during the 8th week of
development.
The upper end ossifies from 3 secondary centres –
Page 114
Summary
-
One for the head in the first year
-
One for greater tubercle in the second year
-
One for lesser tubercle in the fifth year
The three centres fuses during 6th year to form one epiphysis which fuses with
the shaft during 20th year. The epiphyseal line encircles the bone at the level of the
lowest margin of the head. This is the growing end of the bone.
The lower end ossifies from 4 centres which form 2 epiphyses. The centre
include - --
One for capitulum and lateral flange of trochlea in the first year,
-
One for medial flange of trochlea in the 9th year,
-
One for the lateral epicondyle in the 12th year
All the three fuses during 14th year to form one epiphysis which fuses which
the shaft at about 16th years.
The centre for medial epicondyle appears during 4-6 years , forms a separate
epiphysis, and fuses with the shaft during the 20th years.
Page 115
Summary
Fig.No.3
Page 116
Summary
Fig.No.4
Fig.No.5
Page 117
Summary
Arterial supply of the Adult Humerus:- 26 , 30
Healing of the fracture like any other wound, depends upon blood supply
(Johnson-1927). P.G.Laing(3) from the surgical & pathological services, department
of veterans service hospital, Lancaster, studied the blood supply of adult humerus by
injecting radio opaque contrast medium into the brachial artery of cadavers & taking
radiographs. The largest artery supplying the humerus is termed as the main nutrient
artery.
According to his study, the main nutrient artery arises in 2/3 cases from the
brachial artery & in the remaining cases from the profunda brachii artery. The point of
entry of the main nutrient artery to the humerus is a restricted area, beginning on the
medial side of the distal third & spiraling upwards & medially to the dorsal surface of
the middle third of the shaft. This was proved by dissection in cadavers undertaken by
S.E.Carroll in the university of Ontario, Canada. CARROL’s study also revealed that
2/3 of the humerus had single nutrient foramen & the mean position is distal to the
midpoint of the humerus & distal to the insertion of the deltoid. ¾ of the foramen are
found in the medial border or the anteromedial border or the anteromedial surface.
The main nutrient artery on or before entering the bone divides into ascending
& descending branches. The ascending branch travels up the medullary canal &
anastamoses with accessory nutrient arteries & with periosteal vessels through
transcortical vessels. In most cases, a peculiar coiled arrangement of the beginning of
the ascending branch was noted in the study of P.G.Laing. Descending branches are
usually smaller, divides immediately into branches to reach supracondylar region.
Accessory nutrient arteries vary from 1-4 in number & may arise from anterior
circumflex humeral artery or profunda brachii artery. These arteries enter the bone
either in the spiral groove or in the anterolateral surface, mostly in the upper third of
Page 118
Summary
the shaft. No accessory nutrient artery was found between the site of the main nutrient
artery & the epicondylar region.
Practical importance of blood supply:- 26,30
Healing of fracture depends upon the blood supply (Johnson 1927). Injury to
nutrient artery at the time of trauma or during manipulation or during surgery, may be
a significant predisposing factor for non-union (Steward 1955, Watson Jones 1955,
Kennedy 1957,Mercer 1959,Turek1959). If surgeons could avoid the area of cortex of
the humerus containing the nutrient artery foramen during open reduction an
improvement in the result might be expected (S.E.Carroll).The danger of damaging
the blood supply during operation is maximum in open reduction of fractures at the
junction of middle & lower third. In such cases upper end of lower fragment will
depend on epicondylar vessels & periosteal stripping of the lower fragment should be
avoided. Because of the intremedullary course of the nutrient artery, it may get
damaged during intramedullary nailing & at the same time periosteum is stripped
extensively, blood supply will be jeopardized unduly.
MUSCULAR ANATOMY OF THE ARM – 36
Arm is composed of two compartments Anterior and Posterior. The anterior
compartment of the arm contains three muscles-the coracobrachialis, brachialis, and
biceps brachii muscles-which are innervated predominantly by the musculocutaneous
nerve.
The posterior compartment contains one muscle-the triceps brachii musclewhich is innervated by the radial nerve.
Page 119
Summary
ANTERIOR COMPARTMENT –
Corachobrachialis –
The coracobrachialis extends from the tip of coracoids process of the scapula
to the medial side of the midshaft of the humerus.
It passes through the Axilla and is penetrated and innervated by the
musculocutaneous nerve.
The coracobrachialis flexes the arm at the glenohumeral joint.
Biceps brachii –
The biceps brachii muscles has got two heads –

The short head of it originates from coracoids process in conjunction with
coracobrachialis.

The long head originates from supraglenoid tubercle of scapula.
The tendon of long head of biceps passes through the glenohumeral joint
superior to the head of humerus , then passes through the intertubercular sulcus and
enters the arm. In the arm the tendon joins with its muscle belly and together with the
muscle belly of the short head , overlies the brachialis muscle.
The long head and short head converges to form a tendon which inserts on a
radial tuberosity.
As the tendon enters the forearm , a flat sheet of connective tissue (bacipital
apponeurosis) fans out from the medial side of the tendon to blend with the deep
fascia covering the anterior compartment of the forearm.
The biceps brachii muscle is a powerful flexor of the forearm at the elbow , it
is also the most powerful supinator of the forearm when elbow is flexed. Because the
two heads crosses the glenohumeral joint , the muscle also flexes the arm.
The biceps brachii muscle is innervated by the musculocutaneous nerve.
Page 120
Summary
A tap on the tendon of biceps brachii at the elbow tests predominantly spinal cord
segment C6.
Brachialis –
The brachialis muscle originates from the distal half of the anterior aspect of
the humerus and from adjacent parts of the intermuscular septa, particularly on the
medial side. It lies beneath the biceps brachii muscle, is flattened dorsoventrally, and
converges to form a tendon , which attaches to the tuberosity of ulna.
The brachialis muscle flexes the forearm at the elbow joint.
Innervations of brachialis muscle is predominantly by the musculocutaneous
nerve. A small component of the lateral part is innervated by the radial nerve.
POSTERIOR COMPARTMENT –
Triceps brachii –
It is the only muscle of the posterior compartment of the arm. It has got three heads –
 The long head originates from the infraglenoid tubercle of the scapula.
 The medial head originates from the extensive area on the shaft of the
humerus inferior to the radial groove.
 The lateral head originates from a linear roughening superior to the radial
groove of the humerus.
The three head converge to form a large tendon , which inserts on the superior
surface of the olecrenon of the ulna.
The triceps brachii muscle extends the forearm at the elbow joint.
Innervations of triceps brachii is by branches of the radial nerve.
A tap on the tendon of triceps tests predominantly spinal cord segment of C7.
Page 121
Summary
Fig.No.6
Page 122
Summary
Fig.No.7
Page 123
Summary
Arteries of the Arm:- 36
Brachial artery:It is the continuation of axillary artery. It extends from the lower border of
teres major muscle to the neck of the radius where it divides into ulnar & radial
arteries. It is superficial throughout its course, anteriorly, it is related to medial
cutaneous nerve of the arm & the median nerve in the upper & lower halves
respectively. Medially, it is related to ulnar & median nerve in the upper & lower
parts respectively. Laterally, it is related to biceps, coracobrachialis & median nerve.
Branches:1) Profunda brachii artery leaves through the lower triangular space, runs in the
spiral groove with the radial nerve. Apart from the muscular branches it supplies
the following arteries, nutrient artery, deltoid branch, middle collateral & radial
collateral vessels. The deltoid branch ascends between the lateral & long head of
triceps & anastamoses with the descending branch of posterior circumflex
humeral artery. The middle collateral branch ascends in the substance of the
medial head of triceps to the elbow where it anastamoses with the interosseous
recurrent artery behind the lateral epicondyle. The radial collateral artery
accompanies the radial nerve through the lateral intermuscular septum & then
descends between the brachialis & the brachioradialis to the front of the lateral
epicondyle where it anastamoses with the radial recurrent artery.
2) Superior ulnar collateral artery arises little below the middle of the arm &
accompanies the ulnar nerve & ends deep to flexor carpi ulnaris by anastamoizing
with posterior ulnar recurrent artery.
Page 124
Summary
3) Inferior ulnar collateral arteries ( supra trochlear) starts about 5 cms above the
elbow & ends by anastamoizing with anterior ulnar recurrent artery.
4) Nutrient artery to humerus sometimes arises from the profunda brachii artery in
the radial sulcus.
Veins of the Arm –
Paired brachial veins pass along the medial and lateral sides of the brachial
artery, receiving tributaries that accompany branches of the artery.
In addition to these deep veins, two large subcutaneous veins, the basilica vein
and the cephalic vein are located in the arm.
The basilic vein passes vertically in the distal half of the arm , penetrates the
deep fascia to assume a position medial to the brachial artery , and then becomes the
axillary vein at the lower border of the teres major muscle.
The brachial vein join the basilic or axillay vein.
The cephalic vein passes superiorly on the anterolateral aspect of the arm and
through the anterior wall of axilla to reach the axillary vein.
Page 125
Summary
Fig.No.8
Page 126
Summary
Fig.No.9
Page 127
Summary
Fig.No.10
Page 128
Summary
NERVES - 36
Musculocutaneous nerve
The musculocutaneous nerve leaves the axilla and enters the arm by passing
through the coracobrachialis muscle. It passes diagonally down the arm in the plane
between the biceps brachii and brachialis muscles. After giving rise to motor branches
in the arm, it emerges laterally to the tendon of the biceps brachii muscle at the elbow,
penetrates deep fascia, and continues as the lateral cutaneous nerve of forearm.
The musculocutaneous nerve provides:

motor innervation to all muscles in the anterior compartment of the arm; and

sensory innervation to skin on the lateral surface of the forearm.
Median nerve
The median nerve enters the arm from the axilla at the inferior margin of the teres
major muscle. It passes vertically down the medial side of the arm in the anterior
compartment and is related to the brachial artery throughout its course:

in proximal regions, the median nerve is immediately lateral to the brachial
artery; in more distal regions, the median nerve crosses to the medial side of
the brachial artery and lies anterior to the elbow joint.
The median nerve has no major branches in the arm, but a branch to one of the
muscles of the forearm, the pronator teres muscle, may originate from the nerve
immediately proximal to the elbow joint.
Page 129
Summary
Ulnar nerve
The ulnar nerve enters the arm with the median nerve and axillary artery .It
passes through proximal regions medial to the axillary artery. In the middle of the
arm, the ulnar nerve penetrates the medial intermuscular septum and enters the
posterior compartment where it lies anterior to the medial head of the triceps brachii
muscle. It passes posterior to the medial epicondyle of the humerus and then into the
anterior compartment of the forearm.
The ulnar nerve has no major branches in the arm.
Radial nerve
The radial nerve originates from the posterior cord of the brachial plexus
and enters the arm by crossing the inferior margin of the teres major muscle. As it
enters the arm, it lies posterior to the brachial artery. Accompanied by the profunda
brachii artery, the radial nerve enters the posterior compartment of the arm by passing
through the triangular interval.
As the radial nerve passes diagonally, from medial to lateral, through the
posterior compartment, it lies in the radial groove directly on bone. On the lateral side
of the arm, it passes anteriorly through the lateral intermuscular septum and enters the
anterior compartment where it lies between the brachialis muscle and a muscle of the
posterior compartment of the forearm-the brachioradialis muscle, which attaches to
the lateral supraepicondylar ridge of the humerus. The radial nerve enters the forearm
anterior to the lateral epicondyle of the humerus, just deep to the brachioradialis
muscle.
Page 130
Summary
In the arm, the radial nerve has muscular and cutaneous branches

Muscular branches include those to the triceps brachii, brachioradialis, and
extensor carpi radialis longus muscles. In addition, the radial nerve contributes to
the innervation of the lateral part of the brachialis muscle. One of the branches to
the medial head of the triceps brachii muscle arises before the radial nerve's
entrance into the posterior compartment and passes vertically down the arm in
association with the ulnar nerve.
Page 131
Summary
Surgical Anatomy of Humerus:-26
Humerus is not a weight bearing bone & therefore compression forces are not a factor
& shortening does not significantly worsen the end results. The freely movable
scapulohumeral articulation minimizes tortional stresses.
Humerus is the most easily reducible of all the long bones which can easily be
accomplished under sedation. Malunion up to 20 degrees of anterior angulation & 30
degrees
of
varus
is
tolerated
without
compromising
function
of
appearance.13Transverse fractures of the middle third of humerus heals slowly
because of small fracture surface area. Distraction & angulations may occur due to
long lever arm which is difficult to immobilize. Proper rotation is also a problem
during healing as the forearm is usually is brought in front of the chest causing the
distal fragment to rotate internally while the proximal fragment is in neutral rotation.
The critical zone is at the junction of the middle third & lower third of the shaft. Here
lies the radial nerve and it is close to the bone as it penetrates the lateral intermuscular
septum. Here too main nutrient artery enters the shaft medially near the insertion of
the coracobrachialis tendon. The blood supply to the shaft is limited compared to
metaphysis. Middle third shaft fracture may damage the nutrient artery, thus
contributing to delayed & non-unions.
Page 132
Summary
MECHANISM OF INJURY 11,13
Humeral shaft fractures result from direct & indirect trauma. In majority of
cases, they are the result of direct injury such as in road traffic accident(RTA) and fall
from height. It may also result from indirect trauma such as fracture due to extreme
muscle contractions in cases of seizure disorder.
Compressive forces result in fracture in proximal or distal end of humerus.
Bending forces, however, typically result in transverse fractures of the humerus shaft.
Torsional forces result in spiral fracture patterns. The combination of bending
& torsion usually results in an oblique fractures, often with an associated butterfly
fragment. Greater amounts of comminution & soft tissue injury results from high
energy injuries.
The muscle forces that act on the humeral shaft produce characteristic
deformities. A fracture proximal to the pectoralis major insertion results in abduction
& internal rotation of the proximal fragments secondary to the pull of rotator cuff,
while the distal fragment is displaced medially by pectoralis major. If the fracture is
distal to the pectoralis major insertion & proximal to the deltoid insertion, the distal
fragment is laterally displaced by the deltoid, while the pectoralis major, latissimus
dorsi & teres major displace the proximal fracture medially. When the fracture is
distal to deltoid insertion, the proximal fragment is abducted & flexed while the distal
fragment is proximally displaced.
Patient with humeral shaft fracture presents with history of trauma, arm pain,
swelling & deformity. The arm is shortened with local tenderness & crepitus on gentle
Page 133
Summary
manipulation. Neurovascular status of the extremity must be assessed. Associated
injuries should be examined and life threatening injuries must be managed first.
The standard X-ray views include anteroposterior & lateral views. The
shoulder & elbow joint should be included in each view.
Fig No - 11
Biomechanics of Fracture
CLASSIFICATION
According to Rockwood & Green26, fractures of the humeral shaft may be
conveniently classified on the basis of various factors. Several categories are used for
full descriptive classification of individual fractures.
1) Communication with external environment.
a) Open.
b) Closed.
Page 134
Summary
2) Location of fracture.
a) Above the pectoralis major insertion.
b) Below the pectoralis major insertion but above the deltoid insertion.
c) Below the deltoid insertion.
3) Degree of fracture.
b) Incomplete.
c) Complete.
4) Direction & character of fracture line.
a) Longitudinal.
b) Transverse.
c) Oblique.
d) Spiral.
e) Segmental.
f) Comminuted.
5) Associated injury.
a) Nerve
i. Radial.
ii. Median.
iii. Ulnar.
Page 135
Summary
b) Blood vessels.
i) Brachial artery.
ii) Veins.
6) Intrinsic condition of bone.
a) Normal.
b) Pathological.
i) Due to local pathology.
ii) Bone atrophy.
iii) Inflammatory process.
iv) Neoplasia.
7) Disorders affecting entire skeleton.
i) Congenital abnormalities.
ii) Metabolic bone disease.
iii) Disseminated bone disorders of unknown etiology.
II. According to L. Klenerman(1966) of London, fractures of the shaft of humerus
were classified depending on the level of fracture.
1) Fractures of upper third.
2) Fractures at the junction of upper & middle third.
3) Fractures of middle third.
Page 136
Summary
4) Fractures at the junction of middle & distal third.
5) Fractures of the lower third.
III. According to A.O.Classification26,
Muller, M.E. Allgower, Willenegger, classified fractures of the humeral shaft
based on the morphologic characteristics & the location of the fracture. Depending on
the fracture it is classified into simple- A, Wedge- B & Complex-C. Further Spiral
fractures of the Humerus are given the number 1, Oblique fractures of the Humerus
are given the number 2 and Transverse fractures of the Humerus are given the number
3.. Each subgroup is divided into A1, A2, A3, B1,B2,B3 and C1,C2,C3. & each group
is further subdivided into 3 subgroups denoted by a number .1, .2, .3 & finally there
are 27 subgroups. A1 indicates the simplest fracture with best prognosis & C3 the
most difficult fracture with worst prognosis.
A- Simple fracture.
A1 Simple fracture, Spiral.
A1.1 Proximal zone.
A1.2 Middle zone.
A1.3 Distal Zone.
A2 Simple fracture, oblique.(greater than or equal to 30 degrees)
A2.1 Proximal zone.
A2.2 Middle zone.
A2.3 Distal zone.
Page 137
Summary
A3 Simple fracture, transverse.(less than 30 degrees)
A3.1 Proximal zone.
A3.2 Middle zone.
A3.3 Distal zone.
B- Wedge fracture.
B1 Wedge fracture, spiral wedge.
B1.1 Proximal zone.
B1.2 Middle zone.
B1.3 Distal zone.
B2 Wedge fracture, bending wedge.
B2.1 Proximal zone.
B2.2 Middle zone.
B2.3 Distal zone.
B3 Wedge fracture, fragmented wedge.
B3.1 Proximal zone.
B3.2 Middle zone.
B3.3 Distal zone.
Page 138
Summary
C- Complex fracture.
C1 Complex fracture, spiral.
C1.1 with two intermediate fragments.
C1.2 with three intermediate fragments.
C1.3 with more than three intermediate fragments.
C2 Complex fracture, segmental.
C2.1 with one intermediate segmental fragment.
C2.2 with one intermediate segmental &additional wedge fragment(s).
C2.3 with two intermediate segmental fragments.
C3 Complex fracture, irregular.
C3.1 with two or three intermediate fragments.
C3.2 with limited shattering (<4cms).
C3.3 with extensive shattering (>4cms).
Page 139
Summary
Fig No – 12: Classification Of Fracture
MANAGEMENT
Many methods have been described for the treatment of humeral shaft
fractures. Good to excellent results have been reported in most series of humeral shaft
fractures treated by non-operative or by open reduction & internal fixation. But nonoperative methods are associated with a significant risk of non-union, malunion,
fracture disease. Open reduction & internal fixation is required in unstable fracture,
comminuted fracture even though it is associated with relatively high incidence of
delayed union, non-union, risk of infection and the risk of radial nerve injury.
Page 140
Summary
The numerous methods available today allow considerable individuality in the
selection of the technique. The type & level of fracture, the patient’s age & cooperation of the patient, the degree of fracture displacement & presence of associated
injuries are factors that influence the choice of treatment.
NON-OPERATIVE TREATMENT:HANGING ARM CAST:37,38
It is a traction method introduced by Caldwell in 1933, which uses
dependency traction provided by the weight of the cast to effect fracture reduction.
This dependency traction may cause fracture distraction resulting in delayed union or
nonunion.
The indications include displaced midshaft fractures with shortening,
particularly those fractures with an oblique or spiral pattern. It is useful when certain
principles are followed.
i)
The arm must always be in dependent position and it is considered to cause
fracture distraction.
ii) It should be of light weight and extend from at least 2 cms proximal to the
fracture site to the wrist joint distally, with the elbow in 90 degree flexion and
forearm in neutral rotation.
iii) The sling must be securely fixed at the wrist by a loop of POP, to correct lateral
angulation place the loop on the dorsum of the wrist and to correct the medial
Page 141
Summary
angulation placed on the volar side. Lengthening the sling corrects posterior
angulation while shortening corrects anterior angulation.
iv) Check X-ray has to be done weekly.
v)
Shoulder and hand range of motion exercises are instituted as pain subsides.
COAPTATION SPLINT:39
A molded plaster slab (U shaped brachial splint) is placed around the medial
and lateral aspects of the arm, extending around the elbow and over the deltoid and
acromion with a cuff and collar introduced by Rowly in 1942. It does not cause
hanging effect at the fracture site as in the hanging cast. It has distinct advantage of
allowing exercises of elbow, wrist, hand & to some extent the shoulder during the
entire period of immobilization.
ABDUCTION HUMERAL SPLINT:28
Stewart has advocated the use of humeral abductional splint in humeral shaft
fractures. Closed and continued observation is required. It increases level of comfort
as well as it eliminates effect of gravity.
SHOULDER SPICA CAST ( THORACO HUMERAL SPICA CAST):26
It is recommended in the early healing stage of the unstable fractures where
delayed or non-union appears imminent. It usually replaced by a simpler form of
Page 142
Summary
treatment following reduction for maintenance. Patient non compliance is the main
disadvantage, more so in hot and humid climates, old, obese patients and in patients
with significant pulmonary problems.
OPEN VELPEAU METHOD:40
Gilchrist has described the open velpeau type cast for undisplaced or
minimally displaced fractures in active and unmanageable children or for some
elderly patients unable to tolerate hanging cast. The desired degree of abduction and
forward flexion at shoulder is maintained by axillary & forearm pads. In these cases
patient comfort, not fracture reduction is the critical consideration. Early humeral
fracture brace application is considered as well.
FUNCTIONAL BRACING:15,41,42,43
The humeral functional brace was first described by Sarmiento in 1977. A
functional brace is an orthosis that effects fracture reduction through soft tissue
compression. Use of this device maximizes shoulder and elbow motion. This brace
initially was custom-made and designed as a wrap around sleeve. Now a days these
braces comes prefabricated. It consists of an anterior shell (contoured for the biceps
tendon distally) and a posterior shell. These shells are circularized with velcro straps,
which can be tightened as swelling decreases. The proximal aspect of the brace
approaches the acromion laterally and encircles the arm underneath the axilla
medially. Distally, the sleeve fashioned to avoid the medial and lateral epicondyles
permitting free elbow motion.
Page 143
Summary
Contra indications include :i) Massive soft tissue injury or bone loss
ii) Unreliable or uncooperative patient
iii) Inability to obtain or maintain acceptable fracture alignment.
The fracture brace can be applied acutely or 1-2 weeks after application of a
hanging arm cast or coaptation splint. If the brace is applied acutely, the patient
should be re-evaluated to assess the extremity`s neurovascular status and amount of
arm or forearm oedema. The patient instructed to keep the arm hanging free of the
body, use of a sling may result in varus angulation. The patient is followed at weekly
intervals for the first 3-4 weeks to assess fracture alignment & is instructed to do
pendulum exercises and range of motion of the shoulder, elbow, wrist and hand. The
patient is encouraged to remain upright to allow gravity assisting fracture reduction.
When patient comfort permits, the brace removed for hygiene. The brace is worn for a
minimum of 8 weeks post reduction.
Fig No - 13
Page 144
Summary
OPERATIVE TREATMENT:
INTRAMEDULLARY NAILS:
There are two types
1. Flexible intramedullary nails-23
Include Ender nails, Hackenthal nails and Rush nails. They can be used
retrograde from the distal humerus or antegrade near the rotator cuff. These nails do
not provide rigid fixation or prevent shortening or rotational control. Use of a
functional brace should be considered for additional stability.
2. Interlocking nails like Seidal nails, Russel Taylor nails.44,45
These nails usually rely on proximal screw or distal screw or pin fixation to
provide stability. They maintain alignment of unstable fracture preventing fracture
shortening and rotation. They can be used to stabilize fractures from 2 cms distal to
the surgical neck to 3 cms proximal to the olecranon fossa. These nails can be inserted
antegrade through the rotator cuff/ greater tuberosity or retrograde proximal to the
olecranon fossa with or without prior reaming.
PLATES & SCREWS:35,46
Plates and screws are devices which are fastened to bone for the purpose of
fixation.
They are principally differentiated by their function asi.
Neutralization plate
Page 145
Summary
ii.
Buttress plate
iii.
Compression plate
iv.
Tension band plate
Plates and screws fixation undergone continual design modification and
improvements. Some of them are
a. Regular ASIF with ordinary round holes
b. Semi-tubular plate
c. Round holes with key holes at the end of the plate for facilitating the Muller`s
compression device.
d. Dynamic compression plate (DCP)
e. Limited contact-DCP (LC-DCP)
Plates offer the benefits of anatomical reduction, stable fixation without
violation of the rotator cuff and early function of the muscle-tendon units and joints.
Disadvantages of plate fixation include opening up of the fracture site causing
soft tissue trauma, evacuation of the fracture haematoma, risk of bone refracture after
plate removal, plate irritation and rarely an immunologic reaction.
Basic designs of plating are:
a. Careful handling of implant
b. Correct plate contouring before application
c. Drill diameter slightly smaller than screw diameter
Page 146
Summary
d. Measurement of screw holes with depth gauge
e. Proper orientation of screw heads in the plate
f. Final tightening of all screws and assessing the fracture stability before closure.
Plates used are must be of appropriate length and screw fixation should be
adequate.
Over torquing of the screws should be avoided during insertion. Minimal soft
tissue stripping must be performed; butterfly fragments must not be devitalized.
Severe comminuted fragments require cancellous bone grafts.
A 4.5 mm broad DCP is usually used for shaft fractures in average to large
sized patients. In smaller patients, a 4.5 mm narrow DCP may be used. If the fracture
permits, the plate should be applied in compression with lag screw insertion whenever
possible. These plates are fixed to bone with the help of 4.5mm cortical screws.
COMPLICATIONS AND ITS MANAGEMENT
The complications of fractures of the humeral shaft are:
1. Nerve injury
a. Radial nerve
b. Ulnar nerve
c. Median nerve
Page 147
Summary
2. Vascular injury
3. Non-union
4. Mal union
Radial nerve injury:47,48,49
This is the most common complication. It could occur at the time of injury or
following manipulative reduction or operative treatment or rarely due to callus. Up to
18% of humeral shaft fractures have an associated radial nerve injury. Although the
Holstein-Lewis fracture (oblique, distal third) is the best known for its association
with neurologic injury, radial nerve palsy is most commonly associated with middle
third fractures. Most nerve injuries represent a neurapraxia or axonotmesis; 90% will
resolve in 3-4 months. Electromyography and nerve conduction studies can aid in
determining the degree of nerve injury and monitor the rate of nerve degeneration.
Early exploration is indicated for radial nerve palsy associated with open
fractures. Penetrating injuries develop after fracture manipulation are due to trapping
of nerve ends between fractured fragments. Radial nerve palsies that occur at the time
of closed humeral fracture should be observed and radial nerve exploration is
preferred at 6 to 12 months after injury if there is lack of neurologic improvement.
Other Nerves:
Ulnar nerve <1% cases.
Median nerve <2% cases usually associated with open fractures.
Page 148
Summary
Vascular injury:26
Although uncommon, injury or laceration of the brachial artery may occur due
to gun shot wounds, stab wounds, vessel entrapment between the fracture fragments
and occlusion secondary to haematoma or swelling in tight facial compartments. The
brachial artery is at the greatest risk of injury in the proximal and distal third of the
arm. Fractures complicated by vascular injury constitute an orthopaedic emergency.
Primary control of haemorrhage can usually be accomplished by direct pressure
followed by vessel exploration, its repair and fracture stabilization. If limb viability is
not in jeopardy, bony stabilization can be performed before vascular repair. If there is
significant ischaemic time without distal limb perfusion, the vascular surgeon should
place a temporary intraluminal vascular shunt before the fracture is stabilized.
Stabilization of the fracture is mandatory to protect the vascular repair and
minimize additional soft tissue injury. The technique for definitive arterial repair is
determined by the type and location of the vascular injury. Clean lacerations
involving short segments of arterial wall can often be managed by direct repair.
Jagged injuries and gun shot wounds may require excision of segments of artery
followed by an end to end anastomosis or vein graft.
Non-union:34 , 50-56
The incidence of non-union of the humeral shaft has ranged from 0 to 13% in
large series of patients. The proximal and the distal third of the humerus are at
increased risk of non-union.
Page 149
Summary
Factors associated with non-union are:
1. Mid shaft location
2. Transverse and short oblique fractures
3. Comminuted fractures
4. Open fractures
5. Infection
6. Distraction of the fracture fragments
7. Extensive soft tissue damage
8. Soft tissue interposition
9. Unstable surgical fixation.
Compression plating with bone grafting and reamed intramedullary nailing are
probably the most effective methods for the treatment of established non-unions. The
illizarov method of internal bone transplant also can be used for humeral nonunions
with bone loss.
Mal Union:26
Conservative treatment usually results in mal union of the humerus. Malunion
in adults should not be treated surgically unless angulation and overlapping are
pronounced and disability is severe. When severe deformity is pronounced, surgical
intervention i.e. osteotomy at the fracture site, accurate reduction and fixation with
Dynamic Compression Plate is necessary..
Page 150
Summary
MATERIAL AND METHODS
The present study entitled “A Comparative Study Of Surgical Outcome of
Intramedullary Nailing Versus Plate Osteosynthesis In Diphyseal Humerus
Fractures” is carried out in the department of Orthopaedics Jawaharlal Nehru
Medical College DMIMS [Deemed University] and Acharya Vinoba Bhave Rural
Hospital, Sawangi, Wardha during the period from May 2009 to December 2010.
The patients admitted in Departmentof Orthopedics of Acharya Vinoba Bhave
Rural Hospital, diagnosed as a case of Fracture Shaft Of Humerus were included in
the study.
Inclusion criteria:
•
Patients with age above 18 yrs
•
Humeral shaft fractures which requires surgical fixation.
•
Fractures situated 3cm distal to surgical neck of humerus and 3cm proximal to
olecrenon fossa
•
Less than 2weeks old fractures.
•
Grade I & Grade II compound fractures.
•
Consent for undergoing surgery and for the study.
Exclusion criteria:

Any patient who has not given consent for operation.

Patient of age less than 18yrs

Fracture not situated in area 1 2 according to A.O classification.

Refracture ,pathological fracture,fractures failed due to conservative
management.
Page 151
Summary

More than 2wks old fractures.

Compound Grade III fractures.

Fracture associated with major systemic illness
TYPE OF STUDY- The present study is prospective randomized study.
METHOD:
22 patients of Humeral shaft Fractures visited our hospital from May 2009Dec 2010 were included in the study.
Out of 22 cases 2 had associated Wrist Drop, one patient came with gross
oedema over the arm and forearm but fortunately patient was not in compartment
syndrome. We waited for 3 days till oedema reduced. We have kept limb elevated for
3 days and then fracture was fixed with plate after regression of oedema , 1 patient
had ipsilateral isolated ulna fracture and 1 had ipsilateral ulna fracture with Distal End
radius fracture. 1 Patient had olecrenon fracture and 1 was with ipsilateral both bone
forearm.
All patients were haemodymanically stabilised first and were immobilised in
U plaster splint.
Patient and their relatives were explained and counselled about the injury and
the prognosis. The need of treatment and options were explained to the patients. Pros
and cons of various modalities of treatment were explained to the patient. Written
informed consent was taken from the patients and relatives.
Page 152
Summary
Detail neurological examination of the patients was done preoperatively to
rule out associated nerve injury . Radiological examination of the patient was done
consisting of plain radiograph AP and lateral view and if necessary additional views.
All the co-morbidities were ruled out and proper fitness was taken from
Anaesthetist before surgical intervention. ASA Grade was done pre-operatively.
Fracture associated with radial nerve injury and with compartment syndrome was
fixed in an emergency.
Out of 11 patients from plate group 5 were having simple transverse fracture
and remaining were with communited fractures.
Out of 22 patient 4 patients had compound grade I fracture which was fixed by
primary intramedullary loking nail.
Post Operative Protocol:
Intravenous Antibiotics were given for 5 days and followed by oral Antibiotics
for next 7 days. Patients were operated with Plate Fixation was inserted with negative
suction drain.
Check dressing of wound was done on 2rd Post-op day and drain was removed
at the same time. If condition of wound found to be good then next check dressing
was done on the day of suture removal. Suture removal of the all cases were done on
day 12.
Patients treated with nailing was immediately mobilised as soon as patient was
comfortable symptomatically.(apprx. From day-2).
Page 153
Summary
Patients treated with palting for simple transverse fracture was mobilised after
drain removal i.e from day 3. Patients with communited fracture , doubtfull fixation
was given U plaster slab for 3 weeks and started with mobilisation after 3 weeks.
Patient was followed up regularly on 1st ,2nd ,3rd , 4th and 8th on 12th month.
Patient was assisted for radiological time for union , functional activity and for
complication on each follow-up.
Functional assessment was done by using ASES Score.
SURGICAL EXPOSURE
1. POSTERIOR APPROACH 57
POSITION OF PATIENT –
1. Prone
2. Lateral
In the prone position the arm will be abducted 90 degree, a sandbag should be
placed under the shoulder of the side to be operated on , and the elbow should be
allowed to bend and the forearm to hang over the side of the table. A tourniquet
should not be used because it will get in the way.
Page 154
Summary
LANDMARKS AND INCISION –
LANDMARKS –
The acromian is a rectangular bony prominance that forms summit of the
shoulder.
The olecrenon fossa should be palpated at the distal end of posterior aspect of
arm. Precise palpation is difficult , because the fossa is filled with fat and covered by
a portion of the triceps muscle and aponeurosis. The fossa is filled by an olecrenon
when the elbow is extended.
INCISION –
Make a longitudinal incision in the midline of the posterior aspect of the arm ,
from 8cm below the acromian to the olecrenon fossa.
INTERNERVOUS PLANE –
There is no true internervous plane , dissection involves separating the head of
triceps brachii muscle , all of which is supplied by radial nerve. Because the nerve
branches enter the muscle head relatively near their origin and run down the arm in
the muscle’s substance , splitting the muscle longitudinally does not denervate any
part of it. In addition the medial head (which is the deepest head) has got the dual
nerve supply consisting of radial and ulnar nerve , splitting the medial head
longitudinally does not denervate either half.
SUPERFICIAL SURGICAL DISSECTION Incise the deep fascia of the arm in the line with the skin incision. The triceps
muscles has two layers , the outer layer consists of two heads , lateral head arises from
Page 155
Summary
lateral lip of spiral groove , and long head arises from infraglenoid tubercle of the
scapula. The inner layer consists of the third head , the medial head (deep head)
which arises from whole width of posterior aspect of humerus below the spiral groove
all the way down to the distal fourth of the bone. The spiral groove contains the radial
nerve , thus the radial nerve actually separates the origins of the lateral and medial
heads.
To identify the gap between the lateral and long heads , begin proximally ,
above the point at which the two heads fuse to form a common tendon. Proximally ,
develop this interval between the heads by a blunt dissection , retracting the lateral
head laterally and the medial head medially. Distally the muscle will need to be
divided by sharp dissection along the line of the skin incision. Many small blood
vessels cross the muscle at this level, these need to be coagulated individually.
DEEP SURGICAL DISSECTION –
The medial head of triceps muscle lies below the other two heads , the radial
nerve runs just proximal to it in the spiral groove. Incise the medial head in the
midline, continuing the dissection down to the periosteum of the humerus. Then strip
the muscle off the bone by subperiosteal dissection. The plane of operation must
remain in a subperiosteal location to avoid damaging the ulnar nerve , which pierce
the medial intermuscular septum as it passes in an anterior to posterior direction in the
lower third of the arm. Detach as little soft tissue as possible to preserve blood supply
to the zone of injury.
Page 156
Summary
Fig No - 14
A–D. The posterior surgical approach to the humeral shaft. If necessary, the approach
can be extended distally by reflecting the triceps from the olecranon, providing
exposure of both medial and lateral columns. The triceps is then reattached through
drill holes in the olecranon
Page 157
Summary
2. ANTEROLATERAL APPROACH 57
The anterolateral approach to the shoulder offers excellent exposure of the
acromioclavicular
joint
and
the
underlying
coracoacromial
ligament
and
supraspinatus tendon .Its uses include the following :1. Anterior decompression of the shoulder
2. Repair of the rotator cuff
3. Repair or stabilization of the long head of biceps tendon
4. Excision of osteophytes from the acromioclavicular joint
The use of arthroscopic subacromial decompression has reduced the use of
this approaching the treatment of impingement syndrome and for some cases of
rotator cuff repair. The approach , however ,remains clinically relevant in large
number of cases involving extensive degenerative disease of the rotator cuff.
POSITION OFTHE PATIENTPlace the patient in the supine position on the operating table , with a sandbag
under the spine and medial border of scapula to push the affected side forward
.Elevate the head of the table 45 degrees. Apply surgical drapes in such a way that the
limb can be moved easily during the operation. This allows different structures to be
brought into view.
Page 158
Summary
LANDMARKS AND INCISION –
LANDMARKS –
Coracoid Process. Palpate the coracoids process 1 in from the anterior end of
the clavicle just inferior to the deepest point of the clavicular concavity.
Acromion . Palpate the acromion at the shoulder summit.
Incision. Make a transverse incision that begins at the anterolateral corner of
the acromion and ends just lateral to the coracoids process .
INTERNERVOUS PLANENo internervous plane is available for use. The deltoid muscle is detached at a
point well proximal to its nerve supply, which, therefore is not in danger.
SUPERFICIAL SURGICAL DISSECTIONDeepen the incision through the subcutaneous fat to the deep fascia. Numerous
small vessels will be divided. Coagulate these meticulously to ensure adequate
visualisation of the deeper structures. Incise the deep fascia in the line of skin
incision. If the approach is to be used for subacromial decompression and access to
the rotator cuff is not required, detach the fibres of the acromion that arise from the
acromioclavicular joint and continue this detachment by sharp dissection laterally to
expose 1 cm of the anterior aspect of the acromion. Bleeding will be encountered
during this dissection as a result
of the division of the acromial branch of
coracoacromial artery. This must be coagulated. Do not detach more of the deltoid
than is necessary because reattachment is difficult and excessive stripping of the
deltoid from the acromion may be associated with poor long-term results of surgery.
Page 159
Summary
If the approach is to be used for repairs of the rotator cuff, split the deltoid
muscle in the line of its fibres starting at the acromioclavicular joint. Extend this split
5 cm down from the acromioclavicular joint Insert stay sutures in the apex of the split
to prevent the muscle from splitting inadvertently further down during retraction and
damaging the axillary nerve. Continue the operation as for the subacromial
decompression by detaching the fibres of the deltoid that arise from the
acromioclavicular joint ,and, as before, continue this detachment by sharp dissection
laterally to expose 1 cm of the anterior aspect of the acromion. Retract the split edges
of the deltoid muscle to reveal the underlying coracoacromial ligament.
DEEP SURGICAL DISSECTION –
Detach the coracoacromial ligament from the acromion, either by sharp
dissection or by removing it with a block of bone from undersurface of the acromion.
Detach the medial end of coracoacromial ligament just proximal to the coracoid
process and excise the ligament. The supraspinatus tendon with its overlying
subacromial bursa now is revealed. Rotate the head of the humerus to expose different
portions of the rotator cuff. Full external rotation will reveal the long head of biceps
tendon in its groove.
Page 160
Summary
Fig No - 15
Page 161
Summary
Fig No – 16
A. The radial nerve lies close to the humeral shaft as it exits from posterior to the
shaft to anterior, and is in danger of being entrapped underneath the distal,
lateral corner of a compression plate applied through the anterolateral
approach. B. During plate application the nerve and associated soft tissue is
retracted laterally, and the corner of the plate should be checked prior to wound
closure.
Page 162
Summary
TECHNIQUE OF INTRAMEDULLARY FIXATION58-61
1. Positioning of patient In supine position ,the head was turned to the opposite side to increase
exposure of the shoulder. A cloth roll or ring pillow was placed under the scapula so
as to achieve 30° extension of the shoulder, & the image intensifier was placed on the
opposite side of the table and positioned perpendicular to the table.
2. Patient Preparation Preoperative scrubbing and Draping was done with sterile sheets.
3. Incision and entry point A longitudinal skin incision was made from the most lateral point of the
acromion and extended 5 cms distally, centering over the tip of the greater tuberosity.
The entry portal was made at a point just medial to the tip of greater tuberosity and
0.5 cms posterior to the bacipital groove using a small curved bone awl & its position
was confirmed to be in the centre of the canal on image intensifier.
4. Insertion of guide rod and intraoperative assessment of nail length
A guide rod of 500 mm was used in every case, after withdrawing the curved
awl, the 2.4 mm nonbeaded (all cases were done without reaming) guide rod was
inserted and advanced down the canal, after achieving reduction until the tip was 2
cms proximal to the olecranon fossa, confirmed on the image intensifier. The nail
length was estimated by overlapping a second guide rod of same length, proximally
from the humeral entry point and subtracting the calculated length of overlapping
from 500 mm to determine the precise nail length.
5. Nail insertion Cannulated nails were passed over the guide rod. Non connulated nails were
inserted only after removing the guide rod. The jig was held pointing away from the
Page 163
Summary
patient (laterally) so the apex of the proximal bend in the nail faced medially. The nail
was then gently passed across the fracture to avoid comminution and advanced
distally after confirming nail position in the distal canal in both AP and lateral views
under the image intensifier. The distal limit of the was confirmed under the image
intensifier to be 2cms proximal to the olecranon fossa and proximally the nail was
confirmed to be flush with the entry portal or countersink.
6. Proximal locking :
The drill barrel was passed through the proximal drill guide along with the
trocar and where the skin was dimpled by the trocar, a small 8 mm incision was made
and the trocar passed upto bone.
The trocar was exchanged for a drill sleeve and using 2.7 or 3.5 mm drill bits
respectively, the proximal screw hole was drilled from lateral to medial cortex, while
keeping the arm abducted to avoid damage to the brachial artery. The screw depth
guage was then inserted through the drill barrel and the required bolt length estimated.
The appropriate sized bolt was selected and inserted using the hexagonal screw driver.
A washer was used in osteoporotic bone to prevent the screw from being countesink.
7. Distal interlocking :
Two techniques were used :
1. The free hand technique (used in 22 cases )
2. Using a distal jig/aiming device (used in 4 cases)
Page 164
Summary
Fig No -17 Interlocking Nails
Fig No -18 Instrument set
Page 165
Summary
DYNAMIC COMPRESSION PLATE –
The Dynamic compression plate (DCP) is a self compressing plate due to the
special geometry of the screw hole that makes it possible to achieve axial
compression without the use of a tension device, & the screws can be angled in any
direction. The plate is adaptable to many different internal fixation situation & can be
used as static compression plate, a neutralization plate & butter's plate. Both the
narrow & broad DCP's are considerably stronger than the semitubular plates & plate
failure have become rare.
Fig No - 19
Page 166
Summary
Fig No - 20
OBSERVATIONS AND RESULTS
Table 1: Age wise distribution of patients in both the groups
Age Group(yrs)
Nail Group
Plate Group
‫ﭏ‬2-value
Page 167
Summary
20-30
4(36.36%)
6(54.55%)
31-40
4(36.36%)
3(27.27%)
41-50
1(9.09%)
1(9.09%)
0.87
>50
2(18.18%)
1(9.09%)
p-value=0.83
Total
11(100.00%)
11(100.00%)
NS,p>0.05
Mean Age
39.00
32.18
SD
13.42
14.89
Graph 1: Age wise distribution of patients in both the groups
100%
9.09%
20%
18.18%
30%
9.09%
40%
9.09%
50%
27.27%
60%
36.36%
70%
36.36%
% of patients
80%
54.54%
90%
10%
0%
20-30
31-40
41-50
>50
Age Group(yrs)
Nail Group
Plate Group
The age varies from 20-60 yrs in both groups. The mean age in group I is 39 yrs and in
group II is 33 yrs. Maximum patients were from age 20-40 yrs in group I (36%) and from 2030 yrs in group II.(54%).
There was no statistical difference in age amongst two groups.
Page 168
Summary
Table 2: Gender wise distribution of patients in both the groups
Gender
Nail Group
Plate Group
‫ﭏ‬2-value
Male
10(90.91%)
10(90.91%)
0.00
Female
1(9.09%)
1(9.09%)
p-value=1.00
Total
11(100.00%)
11(100.00%)
NS,p>0.05
Graph 2: Gender wise distribution of patients in both the groups
% of patients
90.91% 90.91%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
9.09%
Male
9.09%
Female
Gender
Nail Group
Plate Group
There was higher incidence for male patients in both groups. (90%)
Page 169
Summary
Page 170
Summary
Table 3: Distribution of patients according to classification of fracture in both the groups
Classification of
fracture
A
Nail Group
Plate Group
5(45.45%)
2(18.18%)
‫ﭏ‬2-value
2.06
B
4(36.36%)
5(45.45%)
p-value=0.35
C
2(18.18%)
4(36.36%)
Total
11(100.00%)
11(100.00%)
NS,p>0.05
Graph 3: Distribution of patients according to classification
of fracture in both the groups
100%
90%
% of patients
80%
70%
60%
45.45%
50%
45.45%
36.36%
36.36%
40%
30%
18.18%
18.18%
20%
10%
0%
A
B
C
Classification of fracture
Nail Group
Plate Group
Page 171
Summary
In group I type A fracture were commonest (45%) in group II type B fracture were
commonest (36%)
Page 172
Summary
Table 4: Distribution of patients according to mode of Injury in both the groups
‫ﭏ‬2-value
Mode of injury
Nail Group
Plate Group
RTA
5(45.45%)
7(63.64%)
Fall from height
4(36.36%)
3(27.27%)
0.80
Trivial Trauma
2(18.18%)
1(9.09%)
p-value=0.66
Assault
0(0.00%)
0(0.00%)
NS,p>0.05
Total
11(100.00%)
11(100.00%)
Graph 4: Distribution of patients according to mode of Injury in both the groups
20%
10%
0.00%
30%
0.00%
40%
9.09%
50%
18.18%
60%
27.27%
70%
45.45%
% of patients
80%
36.36%
90%
63.64%
100%
0%
RTA
Fall from height
Trivial Trauma
Assault
Mode of injury
Nail Group
Plate Group
Page 173
Summary
RTA was the most common mode of injury in both groups of patients as in group I 5
patients (45%) were injured due to this and 7 patients in Group II (64%) were injured due to
this. History of fall was the second commonest mode.
Table 5: Distribution of patients according to anatomical level in the humerus in both the
groups
Anatomical Level
Nail Group
Plate Group
Lower 1/3rd
1(9.09%)
2(18.18%)
Middle-lower 1/3rd
1(9.09%)
5(45.45%)
‫ﭏ‬2-value
5.81
Middle 1/3
rd
7(63.64%)
4(36.36%)
p-value=0.21
Middle-upper 1/3
rd
1(9.09%)
0(0.00%)
NS,p>0.05
Upper 1/3
Total
rd
1(9.09%)
0(0.00%)
11(100.00%)
11(100.00%)
Graph 5: Distribution of patients according to anatomical level in the humerus in both the
groups
Page 174
0%
9.09%
20%
10%
9.09%
9.09%
40%
30%
9.09%
50%
18.18%
% of patients
70%
60%
0%
45.45%
80%
36.36%
100%
90%
63.64%
Summary
0%
Low er
1/3rd
MiddleMiddle 1/3rd
MiddleUpper 1/3rd
low er 1/3rd
upper 1/3rd
Anatomical Level
Nail Group
Plate Group
The most common site in arm was affected was middle 1/3rd in group I (63%) and
middle-lower 1/3rd in second group (45%).
The difference between two was not statistically significant.
Table 6: Distribution of patients according to associated Injuries in both the groups
Associated conditions
Nail Group
Plate Group
# B.B Forearm
1(9.09%)
0(0.00%)
# Olecrenone
1(9.09%)
0(0.00%)
0(0.00%)
1(9.09%)
# D/E Radius with #
Ulna
‫ﭏ‬2-value
8.81
p-value=0.18
Gross Oedema
0(0.00%)
1(9.09%)
Wrist drop
0(0.00%)
2(18.18%)
Ipsilateral # Ulna
0(0.00%)
1(9.09%)
NS,p>0.05
Page 175
Summary
None
9(81.82%)
4(36.36%)
Total
11(100.00%)
11(100.00%)
81.82%
36.36%
0%
9.09%
18.18%
0%
0%
9.09%
0%
9.09%
9.09%
0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
9.09%
0%
% of patients
Graph 6: Distribution of patients according to associated Injuries in both the groups
e
a
a
ln
m
rm
ne
ln
op
U
U
ro
dr
no
ea
d
r
#
#
t
e
l
yn
cr
Fo
ri s
ith
ra
le
w
W
tS
te
.B
O
n
a
s
B
l
e
#
iu
si
#
tm
Ip
ad
ar
R
p
/E
om
D
C
#
N
e
on
Associated Injuries
Nail Group
Plate Group
9 patients (82%) from group I and 6 patients from group II (54%) got isolated
fracture shaft humerus.
Table 7: Distribution of patients according to ASA grading in both the groups
ASA Grading
Nail Group
Plate Group
‫ﭏ‬2-value
I
9(81.82%)
10(90.91%)
0.38
II
2(18.18%)
1(9.09%)
p-value=0.53
Page 176
Summary
Total
11(100.00%)
11(100.00%)
NS,p>0.05
Graph 7: Distribution of patients according to ASA grading in both the groups
90.91%
100%
81.82%
90%
% of patients
80%
70%
60%
50%
40%
18.18%
30%
9.09%
20%
10%
0%
I
II
ASA Grading
Nail Group
Plate Group
Maximum patients in both groups were not having any major systemic illness as 9 patients
(82%) from group I and 10 patients (91%) from group II was under ASA Grade I. remaining
patients were under grade II. No patients were under grade III , IV and V.
Page 177
Summary
Table 8: Distribution of patients according to time of
Union in both the groups
Time of union(wks)
Nail Group
Plate Group
t-value
Mean
18.72
13.27
5.30
p-value=0.000
SD
2.41
2.41
S,p<0.05
Graph 8: Distribution of patients according to time of
Union in both the groups
25
MEan Time of union(weeks)
18.72
20
13.27
15
10
5
0
Nail Group
Plate Group
Group
Page 178
Summary
Mean time for union in group I was 19 weeks and in group II was 14 weeks. The time taken
for union in group II was less than in group I.
There was statistical difference between two groups. (p˂0.005)
Table 9: Distribution of patients according to ASES score in both the groups
ASES Score
Nail Group
Plate Group
z-value
Mean
44.36
48.18
3.16
p-value=0.002
SD
2.15
2.08
S,p<0.05
Graph 9: Distribution of patients according to ASES score
in both the groups
Page 179
Summary
51
48.18
50
Mean ASES Score
49
48
44.36
47
46
45
44
43
42
41
Nail Group
Plate Group
Group
The mean ASES score in group I was 44.36 and in group II was 48.18. score was
higher in group II suggestive of better functional outcome as compared with group I.
There was significant statistical difference between two groups. (p>0.005)
Table 10: Distribution of patients according to complications
in both the groups
Complications
Nail Group
Plate Group
Shoulder stiffness
2(18.18%)
0(0.00%)
Superficial Infection
0(0.00%)
1(9.09%)
Impingement
syndrome
Iatrogenic Radial
‫ﭏ‬2-value
4.22
p-value=0.23
1(9.09%)
0(0.00%)
NS,p>0.05
0(0.00%)
0(0.00%)
Page 180
Summary
Nerve Palsy
None
8(72.73%)
10(90.91%)
Total
11(100.00%)
11(100.00%)
Graph 10: Distribution of patients according to complications
% of patients
in both the groups
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90.91%
72.73%
18.18%
9.09%
0%
Shoulder
stiffness
0%
Superficial
Infection
9.09%
0%
0% 0%
Impugement
syndrome
Iatrogenic
Radial Nerve
Palsy
None
Complications
Nail Group
Plate Group
Complication rate of 27% found in group I as 3 patients out of 11 had complications.
In second group this rate was pretty good of 9% as only one patient had complication.
There was no statistical difference between two groups.
Table 11: Distribution of patients according to radial nerve injury
Radial nerve injury
On admission
After fixation
Total
Page 181
Summary
No. of patients
2
0
2
Percentage(%)
18.18%
0.00%
18.18%
Graph 11: Distribution of patients according to radial nerve injury
20%
18.18%
18.18%
18%
% of patients
16%
14%
12%
10%
8%
6%
4%
0.00%
2%
0%
On admission
After fixation
Total
Radial Nerve Injury
Two patients had associated radial nerve injury along with humeral shaft fracture.
(18.18%). No iatrogenic radial nerve palsy was found.
DISCUSSION
Page 182
Summary
The arm serves an important role in upper extremity. It articulates or perhaps
participates to form two major joints of upper limb shoulder and elbow which
required vitally in life to perform major activities of life.
To achieve satisfactory functional results diphyseal fractures of humerus needs
near anatomical reduction.
Majority of patients of our institute are from rural areas so affordability is a
major factor. Patient wants a low cost fixation to his fracture. In such a senario plate
fixation can be preferred over locked nailing as the cost of nailing is higher than that
of plating. The need for low cost biological fixation method lead us to do this
comparative study.
The variables of this study were compared in two groups and with some other
related studies.
1. Age –
In a comparative study done by T.MULIER and D.SELINGSON on 55
patients they found age of patients ranges between 30-40yrs. R.G Mccormak et all in
his prospective study of 44 patients found that such fractures were common in age
group of 35-45 yrs. F.S.L Meekars et all noted mean age for fracture shaft of humerus
is 38 yrs. M.Changulani and U.K. Jain reported commonest age range of 30-50 yrs for
fracture shaft of humerus. Mohit Bhandari and Michael D. Mckee in his metaanalysis of 215 patients found commonest age range of 25-50 yrs and mean age was
35yrs. Another study of 401 fractures done by R.Ekholm , J.Adami and they have
noted mean age of 40 yrs. Kiran Singisetti et all reported mean age of 45 yrs. Amit B
Putti , Rajendra Uppin recorded mean age of 32 yrs in their comparative study. In
Page 183
Summary
recent comparative studies done are recorded mean age of 39 yrs ranges from 2060yrs. A comparative study done by S.Raghvendra and Haresh Bhalodiya , they found
mean age of 40 yrs. In our study mean age is of 36 yrs ranges from 20-60 yrs which
co-relates with other studies.
2. Gender distributionMohit Bhandari and Michael D. Mckee found in his meta-analysis of 215
patients that the fracture was male predominated. R.Ekholm and J.Adami found in his
study of 401 fractures that male was on high predominance than female. S.
Raghavendra and Haresh Bhalodiya found that male was predominated. Other all
studies highlight male predominance for this fractures. Male predominance than
female for this fracture due to high exposure of males to high energy trauma than
females.
3. Classification of fractures –
Rockwood classified fractures simply into three types – A , B , C
A – Simple Fracture
B – Wedge fracture
C – Complex fracture
Each fractures has its subclasses. Many studies done on treatment of humeral
shaft fractures includes their inclusive fractures classified according to this gross
classification. It will be also easy to plan a management according to it.
In an study of 401 patients done by R.Ekholam et all (2006) he found that
simple fractures were by far the most common and all were treated by nailing.
Page 184
Summary
In many mentioned studies simple fractures were treated by nailing and some
of wedge fractures too. Many of wedge fractures were treated by plate fixation.
Complex fractures were exclusively treated by plate fixation as some of them required
bone grafting.
In our study simple fractures and some of wedge fractures were treated by an
intramedullary nail fixation and all other wedge fractures and complex fractures were
fixed with plate.
4. Mode Of Injury T. Mulier et all recorded the commonest cause to cause this type of fracture is
high energy trauma such as due to road traffic accident and secondly due to fall from
height .R.G Mccormack reported road traffic accident is the commonest cause for
such type of injury.
Mohit Bhandari and Michael D. Mckee in his meta analysis of 215 patients
reported that R.T.A being the commonest cause for such type of injury.
All other articles are in favour that such type of injuries are commonly occur
due to R.T.A. this is because this fracture is common in young age group which
exposes to road traffic accidents very oftenly.
In our study the commonest mode of injury is R.T.A and 2nd is the fall from
height which is in conjunction with other studies.
5. Fracture Anatomy -
Page 185
Summary
F.S.L Meekers et all in his study noted that majority of fractures were treated
was at middle 1/3rd of shaft. Fractures associated in 5 cm of surgical neck and in 5cm
of olecrenon fossa were excluded.
R.Ekholam et all (2006) in his meta-analysis of 401 patients found that
fracture of shaft of humerus were commonest in middle 1/3rd and of spiral type.
M.Changulani and U.K jain found that majority of fractures were located in
the middle 1/3rd of shaft.
Amit B Putti and Rajendra Uppin reported maximum fractures at middle 1/3 rd
level and some fractures at lower 1/3rd level.
S.Raghvendra et all in his studies noted that fracture is common at middle
1/3rd of shaft. He recorded 20 cases out of 36 cases fractured at mid shaft of humerus.
In our study majority of fractures were in middle 1/3rd of shaft which is in support
with others.
6. Associted Injury –
T Mulier et all reported 15% of associated injuries along with fracture shaft of
humerus which was operated on the same day of shaft of humerus. Mohit bhandari
and Micheal D Mckee found 40% associated injuries. Amit B Putti and Babu B Putti
recorded 50% of associated injuries.
In our study we came across associated injuries like compartment syndrome ,
fracture of both bones of forearm , fracture of ulna and olecrenon , fracture of D/E
radius. These fractures were managed according to their need of emergency.
7. Follow-up Page 186
Summary
In a study done by R.G Maccormak et all (1999) the mean follow-up was of
12 months (6-33 months). In a prospective comparative study done by Kiran
Singisetti et all (2009) he followed up the patient for 12 months (range 10-24
months). In a study done by M.Changulani et all (2006) follow-up time was of 14
months.
In our study the follow up time was of 12 months.
8. Time of union –
T. MULIER et all (1997) found mean time of union of 16 weeks and range
from 8weeks to 65 weeks. He found that union time was less in case of plate fixation
than nail fixation. R.G Mccormak et all (1999) found less time of union in patients
treated with plate osteosynthesis. Some of their patients treated with nailing went into
non-union and was underwent second surgery. A study done by F.S.L Meeker’s et all
(2002) they found that time of union in patients treated with nailing was significantly
longer than in patients treated with plating. M.Changulani et all (2006) reported in
their study that time of union was similar in both groups. In a meta-analysis done by
Mohit Bhandari et all (2006) they found less time required for union in plating group
than nailing group and delayed union and non union was higher in nailing group. In a
study done by Amit Putti et all (1999) he reported mean time of healing of 18 weeks
in patients treated with nailing group and of 16 weeks in patients with plating. A
comparative study done by S.Raghvendra et all (2010) he reported mean time of
healing was 25.9 weeks in patients treated with plating and 34.6 weeks in patients
treated with nailing group.
Page 187
Summary
In our study we found that mean time of union in patients treated with nailing
was 18.72 weeks and for the patients treated with plate osteosynthesis was 13.72
weeks which is lower than nailing which co-relates with other mentioned studies.
9. ASES Score –
To asses patients functionally American shoulder and Elbow surgeons
developed a score. This score based on the performance of the patient while doing 13
included daily routine activities. These were arranged as normal, with mild
compromise, difficult and great difficult. Grades were given according to score as
poor, good and excellent and total score was of 52 points.
R.G Maccormak et all (1999) reported mean ASIS score in a patients treated
with nailing was 46 and in patients treated with plate fixation was of 49 . In a study
done by M.Changulani et all (2006) he used ASES score to asses the patient postoperatively for functional outcome and he found that mean ASES score in patients
treated with nailing was 44 and that of patients treated with plate fixation was 45 yrs.
A study done by Kiarn Singisetti et all (2009) he reported the mean ASES score was
of 46 in patients treated with nail fixation and 49 in patients treated with plate
fixation.
10. Complications –
T. Mulier et all (1997) found non-union rate of 30% in patients treated with
nailing and 20% in patients treated with plating. They have also found functional
restrictions after nailing. F.S.L Meeker et all (2002) in his comparative study in 232
patients found that non-union rate was significantly high in patients treated with
nailing as 14.8% for which they were reoperated. In a meta-analysis done by Mohit
Page 188
Summary
Bhandari et all (2006) they reported high rate of shoulder impingement in
patients treated with nailing. A study done by R.Ekholm in 401 patients of fracture
shaft of hunerus (2006) they reported functional restrictions in patients treated with
nailing rather than plating and high rate of non-union in patients treated by nailing.
Amit Putti et all(2009) reported complication rate of 50% in patients treated with
nailing and of 17% in patients treated with plating. S.Raghwendra et all (2010) in his
study found that significant restrictions of movements were present in patients treated
with nailing group.
In our study we have not found any non-union or delayed union. No one
patient from our study group required re-operation but we have complication rate of
29% in patients treated with nailing rather than of 9% rate in patients treated with
plating. Complications were in the form of restriction of movements , shoulder
stiffness and impingement syndrome.
11. Results –
All the above mentioned studies were reported highest rate of union, less time
required for union , excellent functional outcome and less complications. So all the
above mentioned studies done by T.Mulier et all (1997), F.S.L Meeker (2002), Mohit
Bhandari et all (2002) , R.Ekholam et all (2006), Amit Putti et all (2009) and
S.Raghvendra et all (2010) found less complications and excellent outcome in patients
treated with plate fixation rather than nailing.
In out study we found 100% union in patients treated either nailing or plating
with excellent functional amount in patient treated with plating (ASES Score 49) than
nailing (ASES Score 45) with very less rate of complications (9%) than of nailing
Page 189
Summary
(30%) with faster healing of fracture (Mean Time of union 14 weeks) than in patients
treated with nailing (Mean time of union 19 weeks).
SUMMARY
The study is a prospective randomized comparative study of 22 patients of
fracture shaft of humerus in adults treated by compression plating and closed nailing.
The subjects were divided into 2 groups, Group I patients (n=11) were treated by
open reduction and dynamic compression plating and Group II patients (n=11) were
treated by closed reduction and intramedullary nailing. The patients were followed up
for assessment of radiological and functional results.
In brief -
1)
All patients coming to A.V.B.R.H satisfying the inclusion criterion were
included in the study.
2)
The age group of the patients varied from the 20 to 60 yrs the average being
35 yrs. the maximum no of patients being in the 28 – 38 age group.
3)
The series revealed a male preponderance with a Male:Female ratio of 4:1.
4)
Both limbs were equally affected.
5)
RTA was the most common mechanism of injury.
6)
The patients mostly (60%) belonged to occupations requiring heavy labour.
Page 190
Summary
7)
Most common level of bones affected was middle third. Fractures of the upper
third were uncommon.
8)
Open fractures(27%) were uncommon and were treated immediately with
definitive management.
9)
Acute injuries presenting within 2 weeks were included and the average
injury to surgery interval was 5 days.
10)
In group I, patients with comminuted fracture , with doubtful fixation were
given postoperative immobilization in the form of U slab for 3 weeks and
then he was mobilised. Rest patients from group I were mobilised from day 3.
Patients from group II were mobilised from day 2.
11)
The union time was, 13.27 wks in group I and 18.72 wks in group II.
12)
There were few complication and superficial infection in group I,
shoulder stiffness, functional restrictions, impingement syndrome were
found in group II.
13)
Functional results were assessed by ASES Score. The score was 45 in
group II and 49 in group I.
Page 191
Summary
CONCLUSION

Plating required extensive soft tissue exposure, more duration of surgery and
blood loss , more chances of injury to radial nerve. It also gives comparatively
bigger post-operative scar and delayed mobilisation.

Interlock Nailing needs proper technique , minimal invasive exposure , small
incisions , minimal blood loss , less soft tissue exposure, less surgical time and
early mobilisation.

But functional restrictions are higher in nailing , non union , delayed union are
also higher in nailing ,also one cant asses radial nerve intraoperatively, time
required to heal the fracture is longer render ultimately prolonged functional
recovery.

Plating was cost-effective than nailing.

Taking into consideration all the above mentioned points; Plating is the
treatment of choice to treat diphyseal fractures of humerus.
BIBLIOGRAPHY
1) Charnaley J - The closed treatment of the common fractures - 3rd ed:1961, Pg 99.
2) L. Klenerman, london, England - fractures of the shaft of the humerus
3) A.Sarmiento, J.B.Zagorski, G.A. Zych, L.L.Latta & C.A. Capps- Functional Bracing
for the Treatment of fractures of the Humeral Diaphysis. J.B.J.S.vol-82A
April
2000, No.4, 478-486.
Page 192
Summary
4) William Arthur Clark - History of fracture treatment up to the sixteenth century, J
Bone Joint Surg Am. 1937;19:47-63.
5) Stig Brorson MD, PhD , Management of Fractures of the Humerus in Ancient Egypt,
Greece, and Rome An Historical Review
6) Caldwell J - Treatment of fracture shaft humerus by hanging cast, surh,Gynaec and
Obst. 70:421 - 423 , 1940.
7) Augusto Sarmiento, Alan Horowitch, Albert Aboulafia, C. Thoma Vangsness. Jr.
functional bracing for Comminuted Extra-Articular fractures of distal Third of the
Humerus. J.B.J.S vol-72B No.-2, March 1990, 283-287.
8) Sarmieto A et al - Functional bracing of fracture of the shaft of humerus. JBJS 1977 ;
59A : 596-601.
9) Sarmiento A, Latta LL - Functional fracture bracing J. AAOS 1999 Jan ; 7(1) : 66-75.
10) Sarmiento A, Jagorski JB, Zych GA - Functional bracing for the treat ment of the
fractures of humeral diaphysis. JBJS Am. 2000; 82 : 478-486.
11) Klenerman. L. – Fractures of shaft of the Humerus. J.B.J.S. vol-48B, 1966, 105-111.
12) Stewart - Traction and its Appliances.
13) Mast. J. W., Spiegel. P. G., Harvey. J. P., Harrison. C. – Fractures of the Humeral
shaft. Clin. Orthop, vol-12, 1975, 960-970.
14) P. V. A. Mohandas, S. Ravindran, Management of fresh fractures of the shaft of the
humerus by Internal Fixation. Indian Journal of Orthopaedics, vol-16, 1982, 44-51.
15) Rowly - A simple method of reducing fracture shaft humerus. Br Med. Journal
1934;2
16) T. De Baere Cliniques Universitaires St-Luc, Brussel - conservative treatment of
humeral shaft fractures : literature review.
Page 193
Summary
17) Hey- Groves EW - Methods and results of transplantation of bone in the repair of
defects caused by injury or disease. Br. J Surg. 1918; 5 : 185-242.
18) Instructional Course Lectures.
19) Jochen Blum1, René Engelmann2, Raphael Küchle2, Matthias Hansen1, Pol M.
Rommens2 - Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures.
20) A.J Thakur – Textbook of Elements Of Fixation.
21) Watson Jones- Fracture & Joint Injuries.
22) Hey- Groves EW - Methods and results of transplantation of bone in the repair of
defects caused by injury or disease. Br. J Surg. 1918; 5 : 185-242.
23) Rush LV - Atlas of Rush pin techniques. Meridian Beribon Co. 1976, pg 243.
24) Kuntscher G - The Kuntscher method of intramedullary fixation. JBJS 1958 ; 40A :
17-26.
25) Kuntscher G - Intramedullary surgical technique and its place in ortho paedic surgery
- My present concept. JBJS 1965 ; 47A : 809 – 818.
26) Rockwood And Green – Textbook Of Fractures of Adult
27) Dijkstra S, Staper J, Boxma H, Wiggers T - Treatment of pathological fractures of the
humeral shaft due to bone matastases - a comparision of intramedullary locking nail
and palte osteosynthesis with adjunctive bone cement - J Surg. Oncology 1996, Dec ;
22(6) : 621-6.
28) Stewart MJ, Hundley JM - Fracture of the humerus - a comparative study In methods
of treatment. JBJS 1955; 37A : 681-92.
29) Whitson. R. O.- Relation of radial nerve to the shaft of the Humerus. J.B.J.S. vol36A, 1954, 85-91.
30) Laing. P. G. – The Arterial supply of the adult Humerus. J.B.J.S. VOL-38A, 1956,
1105-1116.
Page 194
Summary
31) Arthur Holstein & G. B. Lewis – Fractures of the Humerus with Radial nerve
paralysis. J.B.J.S. vol-45A, 1963, 1382-1388.
32) Carrol. S. E.- A study of the nutrient foramina of the humeral Diaphysis, J.B.J.S. vol45B, 1963, 176-181.
33) S. M. Perren – Physical & Biological Aspects of Fracture Healing with Special
reference to Internal Fixation. C.O.R.R. No.138, Jan 1979, 175-196.
34) Wu.C.C., & shih.C.H. - Treatment for Nonunion of the shaft of the humerus:
Comparison of plates & Seidel interlocking nails. Can.j.surg., vol-35, 1992, 661-665.
35) R.G. Mc Cormack, D.Brien, R.E.Buckley, M.D. McKee, J. Powell, E.H. Schemitsch Fixation of fractures of the shaft of the Humerus by Dynamic compression plate or
Intramedullary nail J.B.J.S. vol-82B, 2000, 336-339.
36) Gray’s Anatomy – 31st Edition
37) Caldwell J - Treatment of fracture shaft humerus by hanging cast, surh, Gynaec and
Obst. 70:421 - 423 , 1940.
38) A. D. Laferte1, m.d., and p. David nutter, m.d. detroit, mich. - the treatment of
fractures of the humerus by means of a hanging plaster case "hanging cast".
39) Shantaram SS - Modified coaptation splint for humeral shaft fractures Orthopaedic
review. J CORR Nov. 1991; 20(11) : 1033-39.
40) Gilchrist DK - A stockinette- velpeau for immobilisation of the shoulder gridle. JBJS
1967; 49A : 750-51.
41) Rockwood CA, Green DP, Bucholz RW - Fractures in adults, 4th ed, 1994, pg 10281029.
42) Rommens PM, Verbruggen J, Broos P - Retrograde interlock nailing of fracture of
the humeral shaft - a clinical study. Unfallchirurg 1995 Mar ; 98(3) :133-8.
Page 195
Summary
43) R. Bhalla, T.S.Narang & L.H.Lobo- Functional Brace Treatment of the fracture of the
Shaft of the Humerus. Indian Journal of Orthopaedics vol-16, No.1, 1982, 9-3.
44) Tom EJ, Carsi D, Garcia C, Marco F - Treatment of pathologic frac tures of the
humerus with Seidel nailing. Clin. Orthop. 1998 May 350:51-5.
45) Russel TA, Taylor JC - Surgical technique manual - Russel Taylor humeral
interlocking naik system, Smith and nephew Richards.
46) Naiman.P. T., Schein.A.J., & Siffert.R.S.- Use of ASIF compression plates in selected
shaft fractures of upper extremity: A preliminary report. Clinical orthop vol-71, 1970,
208-211.
47) JayendraKumar. J. Shah & Nazir Ahmad Bhatti- Radial Nerve Paralysis Associated
with Fractures of the Humerus. C.O.R.R.1983, 172-176.
48) Dabezies. E. J., Banta. C.J. Murphy. C. P. D’Ambrosia. R. D. – Plate fixation of the
Humeral shaft for acute fractures with & without Radial nerve injuries. J Orthop
Trauma vol-6, 1992, 10-13.
49) Calos. M. Olarte, Michael Darowish, Bruce. H. Ziran - Radial nerve Transposition
with humeral fracture fixation: preliminary results. C.O.R.R. vol-413, 2003; 170-174.
50) Jesse. B. J. – Complex Non-union of the Humeral Diaphysis. J.B.J.S. vol-72A, 1990,
701-703.
51) Robert. J. Foster, George. L. Dixon Jr, Allan. W. Bach, Ross. W. Appleyard, Thomas.
M. Green – Internal Fixation of Fractures & Non-Union of the Humeral Shaft. J.B.J.S.
vol-67A, No.6, July 1985, 857-864.
52) Ivan. F. Rubel, Peter Kloen, Deirdre Campbell, Meng, Mark Schwartz, Alan Liew,
Elizabeth Myers & David L. Helfet – Open Reduction & Internal Fixation of Humeral
Nonunions. J.B.J.S. vol-84A, No.8, Aug 2002, 1315- 1322.
Page 196
Summary
53) John. L. Esterhai, Jr, Carl. T. Brighton, R. Bruce Heppenstall, & Albert Thrower –
Nonunion of the Humerus. C.O.R.R. No. 211, Oct 1986, 228-234.
54) D. Ring, J.B. Jupiter, J. Quintero, R.A.Sanders, R.K. Marti- Atrophic Ununited
Diaphyseal fractures of the Humerus with a bony defect. J.B.J.S. vol-82B, No.6, Aug
2000, 867-871.
55) Tzu-Liang Hsu, Fang-Yao Chiu, Chuan-Mu Chen, Tain- Hsiung Chen – Treatment of
Nonunion of Humeral Shaft Fracture with Dynamic Compression Plate & Cancellous
Bone Graft J Chin Med Assoc, Vol-68, Feb 2005, No.-2, 73-76.
56) William. H., George. M. W. – Non-union of the Humeral shaft. C.O.R.R. vol-219,
1987, 206-212.
57) Stanley Hoppenfeld & Peit deBoer. M. A.- Surgical exposures in Orthopaedics. Third
edition, 2003, 79-84.
58) Ruf W, Pauly E - Interlocking nailing of the humerus. Unfallchirurg Jun e 1993 ;
96(6) : 323-8.
59) Jensen C. H., Hansen D. & Jorgensen U.- Humeral shaft fractures treated by
interlocking nail, A preliminary report on 16 patients. Injury 23(4) – 1992: 234-236.
60) Heim. D., Herkert. F., Hess. P., Regazzoni. P. – Surgical treatment of Humeral shaft
fractures: the Basel experience. J Trauma, , vol-35, 1993, 226-232.
61) James P. Stannard, Howard W. Harris, Gerald McGwin, Jr., David A. Volgas and
Jorge E. Alonso - Intramedullary Nailing of Humeral Shaft Fractures with a Locking
Flexible Nail , J Bone Joint Surg Am. 2003;85:2103-2110.
62) T. Mulier , D.Selgison , W.Sioen , J. Van Den Berg – Operative treatment of humeral
shaft fractures.
Page 197
Summary
63) R. G. McCormack, D. Brien, R. E. Buckley, M. D. McKee, J. Powell, E. H.
Schemitsch - Fixation of fractures of the shaft of the humerus by dynamic
compression plate or intramedullary nail.
64) F. S. L. Meekers, p. L. O. Broos - operative treatment of humeral shaft fractures the
leuven experience.
65) M. Changulani & U. K. Jain & Tulsi Keswani - Comparison of the use of the humerus
intramedullary nail and dynamic compression plate for the management of diaphyseal
fractures of the humerus. A randomised controlled study.
66) Mohit Bhandari, Michael Mckee – Compression Plating Versus Intramedullary
Nailing of humeral shaft fractures – a meta analysis.
67) R Ekholm, J Adami, J Tidermark , K. Hansson – An epidemiological study of fracture
of shaft of the humerus.
68) Kiran Singsetti , M.Ambedkar – Nailing versus plating in humerus shaft fractures,a
prospective comparative study.
69) Amit Putti , Rajendra Uppin – Locked Intramedullary nailing versus dynamic
compression plating for humeral shaft fractures.
70) Lori A. Michener, PhD, PT, ATC,a Philip W. McClure, PhD, PT,b and Brian J.
Sennett, MD,c Richmond, Va, andGlenside and Philadelphia, Pa - American Shoulder
and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report
section: Reliability, validity, and responsiveness.
Page 198
Summary
Page 199