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Nonunion of the lateral humeral condyle in 6 children was treated by open reduction, internal fixation and bone grafting. All cases united. All patients had relief of pain. There were no complications.
Antegrade intramedullary nailing with four different implants was used in 126 humeral shaft fractures. There were 74 acute fractures, 17 pathologic fractures, 16 fractures malaligned in a hanging cast or brace, 15 fractures with delayed union and 4 fractures that were nailed after failed open reduction and internal fixation. The nonunion rate was 21/95 after primary operation, and after reoperations 14/95. Distraction of the fracture was a significant cause of nonunion, but not type of fracture, localization, implant, and delay between injury and surgery. Shoulder joint function was significantly impaired in 25/67 patients. The patients regarded the result as good or satisfactory in 41/67 of the cases who were followed mean 3 (0.5-10) years. We conclude that antegrade intramedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. It can be recommended as primary treatment only when nonoperative treatment is likely to fail.
This study involves 65 patients with severe war injuries to the extremities where all conventional and available lines of treatment have failed or a decision of amputation has been made. Twelve humeri, 45 tibiae and eight femura were studied. The sliding system was used on 39 patients and the compressor system on 26 patients. In the sliding system, gaps ranged from 2 cm to 12 cm. In the compressor system established nonunion, failed bone graft operations, infected pseudarthrosis and gaps less than 2 cm were studied. Salah Eddin external fixation systems, both sliding and compressor, were found to be efficient, biomechanically adequate, easy to apply and remove and able to replace considerable gaps with no risks of open surgery.
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Indications for use of the intramedullary interlocked humeral nail are: pathologic fractures, including those with severe osteopenia alone; nonunions, especially those with bone atrophy and/or marked osteopenia; and humeral shaft fractures with comminution, bone loss, or other causes of instability not controlled by conventional treatment methods. In this series, eight patients were treated by intramedullary interlocked humeral nail. Follow up ranged up to 30 months, with an average of 12 months. Five of six patients in this series who had the potential to unite their fractures did so. The remaining patient had a painless fibrous union. While the two patients with pathologic fractures of the humeral shaft caused by malignant tumors did not unite their fractures, the pain relief, functional recovery, and lack of postoperative morbidity justified the operative procedure.
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We reviewed 38 fractures of the humeral shaft which had been treated non-operatively to identify factors prognostic of nonunion. Of these, 23 healed uneventfully and 15 progressed to nonunion. Factors prognostic of nonunion included long oblique fracture pattern, alcohol abuse, and obesity. In patients with these risk factors, lack of clinical and radiographic evidence of healing 8 to 10 weeks post-injury suggests an impending nonunion, and operative intervention should be considered.
From May 1993 to January 1997, a total of 130 humeral fractures and nonunions were treated using an "elastic" unreamed nail. The elastic nail consists of a cylindrical proximal component tapered for the application of the impactor-extractor, distally containing the proximal ends of four or five secondary nails preloaded to diverge and held together by a retaining system. The surgical approach is through the olecranic fossa apex. Once introduced, the proximal end of the nail locks automatically by diverging the secondary nails in the proximal humeral epiphysis. Distally, the elastic nail is locked with a crossbolt. The elastic nail enables stable fixation of fractures or nonunions and allows early rehabilitation.
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Functional bracing is an effective therapeutic modality in the management of selected fractures of the tibia, humerus, and ulna, particularly low-energy injuries. In the case of tibial fractures, it is applicable only to reduced transverse fractures and to axially unstable fractures with an acceptable degree of shortening. The rate of union of tibial fractures after functional bracing is approximately 97%. The initial shortening noted with closed tibial fractures rarely increases with weight bearing. Shortening has been reported to be as little as 12 mm in 95% of patients, with angulation of 8 degrees in 90%. Such minimal shortening and angulation do not affect functional results. In closed and type I open diaphyseal humeral fractures treated with functional braces, the nonunion rate is approximately 3%. Most of the reported residual angular deformities have been functionally and cosmetically acceptable. For isolated ulnar fractures, the nonunion rate is approximately 2%. Functional fracture bracing is predicated on the premise that motion at the fracture site encourages osteogenesis. The method is applicable only to selected fractures, and it is necessary to have a clear understanding of its rationale, indications, and technique.
Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.
Fractures below proximal humeral prostheses are rare and their successful management presents technical difficulties. Closed treatment usually results in nonunion. A case illustrating this disabling complication is reported and a literature review is presented that summarizes the classification, treatment options, and complications of these uncommon fractures.
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PURPOSE: This study was designed to evaluate the complication rate of a novel intramedullary pinning technique described in 1988. After 10 years of clinical experience, it was possible to establish a significant difference in terms of healing delay compared with other fixation methods or conservative treatment. MATERIALS AND METHODS: During a 10-year period, a total of 82 fractures, mostly isolated, unstable fractures, were treated. Retrograde intramedullary pinning (RIMP) was used for proximal and midshaft fractures and antegrade pinning (AIMP) for distal fractures. Statistical analysis was used to investigate the role of all parameters that may influence healing delay. RESULTS: 92.7% of the fractures healed in an average time of 9 weeks. Neither location nor fracture type, nor even an intrefragmental gap had any significant influence on healing delay. There were 7 primary axial deviations of more than 10 degrees in which union was achieved and 6 nonunions. These nonunions were mostly proximal fractures and inappropriate fixation. No radial nerve injury, no infection, and no deterioration of the fracture site was observed. There were 27 pin migrations, mainly towards the shoulder, which dit not affect the final anatomic and functional outcome. Functional result was good in 88% of cases. Four algodystrophy syndromes and 6 nonunions induced stiffness, mainly in the shoulder. DISCUSSION: Intramedullary pinning using this technique did not induce any severe iatrogenic condition. Healing delay compares favorably with better results of conservative treatment. Improving surgical technique should further minimize disadvantages of this method. CONCLUSION: Humeral intramedullary pinning technique has a low complication rate. It is a good compromise between conservative treatment and conventional osteosynthesis. It causes little trauma to the patients, allows stabilization of any fracture site, and delay to bone union is similar to that with conservative treatment.
From January 1984 to November 1997, the boiling xenogenic bone (porcine and bovine bone) was applied in 65 patients. The xenogenic bone was used to promote bone healing in 24 cases, intramedullary bone graft in 37 and osteomyelitis in 4. All of the patients were followed up for 2 to 35 months. The results showed that in five cases there was infection after operation, and all other the wounds had primary healing. The xenogenic bone seemed to induce rejection in vivo. In the sevious cases immunosuppressive treatment was often needed. The volume of the bone grafted and the extent of the periosteum being stripped seemed to be important whether xenogenic bone graft would be successful or. There were lots of problem needed investigation.
A series of 42 patients operated on due to humeral shaft fracture and 67 patients with forearm bones shaft fracture were analyzed clinically and statistically. The type of fracture was related to the time span between injury and surgery and number of complications. Complications were divided into two groups--early ones (skin necrosis, infection) and late ones (fixation failure, delayed union, pseudoarthrosis). Injury to surgery time span was divided into for sections: less than 10 h, 10-24 h, 24 h-10 d and above 10 days. Early and late complications prevailed in patients operated within 24 hours from injury (87% of all complications). Eleven patients with humeral fracture had fair or poor result; 8 of them were operated within 24 hours from injury. Among 18 patients with fair and poor results after forearm fracture 13 were operated on within 24 hours from injury.