Midshaft Humerus Fracture: Operate or Treat Conservatively

Today, we will talk about when to Midshaft Humerus Fractures- when & how you decide to operate or not!

Clinical Presentation

• 44 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over right arm
• Paresthesia in distribution of radial nerve; no motor loss
• Co-morbidities – post traumatic neurogenic bladder (Old trauma)

Conservative treatment- When/How/Where to avoid?

Indications

Criteria for acceptable alignment include: 

< 20° anterior angulation

< 30° varus/valgus angulation

< 3 cm shortening

Resulting shortening and varus angulation is well adjusted in upper limb and without cosmetic issues.

Method- reduction in GA and cast application/ Coaptation splints

Absolute contraindications

• Brachial plexus injury
• Vascular injury requiring repair
• Severe soft tissue injury or bone loss

Relative contraindications

• Associated ipsilateral forearm fracture/lower extremity fracture 
• Pathologic fractures
• Soft tissue injury that hinders bracing
• Iatrogenic nerve injury while attempted reduction
• Bilateral humeral fracture
• Obese patient- difficult to reduce and maintain reduction; compliance issue with brace
• Fracture characteristics
  • Distraction at fracture site
  • Transverse or short oblique fracture pattern
  • Intraarticular extension of fracture line
  • Fracture characteristics not in acceptable criteria

Radial nerve palsy alone is not an absolute indication for operative intervention

Absolute indications for fracture fixation

• Open fracture (Compound fractures) 
• Vascular injury requiring surgical intervention
• Brachial plexus injury    
• Floating elbow   
• Compartment syndrome
• Periprosthetic humeral shaft fractures
• Failed Conservative treatment

Approach for fixation

• Anterolateral Approach-
  • Open with wide dissection
  • MIPPO technique
  • Proximal third to middle third shaft fractures

• Posterior Approach-
  • Distal to middle third shaft fractures
  • Cases requiring visualization of radial nerve

Distal Tibia Fracture- What is the ideal treatment plan?

Should I choose Nailing or Plating technique?

A 52 YO male, visited ER with swelling & pain on the right leg. He had RTA on the same day.

What is the ideal treatment plan?

PRE-OP X-RAY

• Ideal line of management of distal tibial spiral fractures includes Computed Tomograph of the ankle joint to look for intraarticular extension of the fracture and/ or fracture of the posterior malleolus.
• Studies have demonstrated the importance of CT scan in detecting previously unreported injuries as seen on plain radiographs.

• However, in this scenario no CT scan were done, lateral view on plain radiograph demonstrated fracture line extending to intraarticular region (marked by yellow arrow)

Should I choose nailing or plating?

• In this case, Plating by MIPPO technique was used
• We have included two notable findings, which need to be addressed regarding surgical decision about the mode of fixation and their outcomes as noted in the recent studies.

• Procedure done by MIPPO technique using GPC fixLOCK Anteromedial distal tibial plate (without tab).
• Lag screw placement to achieve fracture reduction and fixation.
• Lag screw placed directly perpendicular to fracture site apart from plate construct.
• Second lag screw placed through the combi hole of the locking plate.
• We recommend treatment as per AO principles of fracture fixation with anatomical reduction of the intraarticular fracture, soft tissue handling (fracture environment), preserving blood supply, and early restoration of function.

Inter-Trochanteric Fractures Series – PART 1

From today, we’re starting the series of InterTrochanteric Fractures.
Today we’re talking about Significance of maintaining Medial Calcar in IT Fracture Management.

CASE 1

PRE OP X-RAY

Clinical Presentation:
– 80 years male.
– Slip and fall at home.
– Severe pain in left hip with inability to stand

Radiological investigation:
– X-Ray pelvis with both hips – Anteroposterior view

Diagnosis:
– Unstable intertrochanteric fractutre.

CASE 2

PRE OP X-RAY

Clinical Presentation:
– 84 years female.
– Fall in bathroom.
– Severe pain in right hip with inability to stand

Radiological investigation:
– X-Ray pelvis with both hips – Anteroposterior view

Diagnosis:
– Unstable intertrochanteric fractutre.

Surgical Principles and lacunae in Management

• Standard of management for unstable intertrochanteric fracture is proximal femoral nailing because of its superior biomechanical properties.
• Lacunae
  • Inability to obtain reduction with non maintenance of medial calcal is unacceptable.
  • It can be obtained by proper patient positioning and closed manipulation (increasing limb adduction in Case 1).
  • Carry out open reduction if result is unsatisfactory
  • Appropriate maintenance of medial calcar with centre-centre placement of spiral blade leads to proper directional controlled collapse on weight bearing and hence fracture union.
  • While poor reduction inturn leading to non centre-centre placement of spiral blade increases chances of fracture non union and blade cut-out rates.

Tibia Intramedullary Nailing – Case Discussion – PART 2

Tibia Nailing Pearls and Pitfalls

Case Discussion

Part 2

• Malalignment after intramedullary nailing of tibial shaft fractures is fairly common with prevalence as high as 36%.
• Malalignment depends highly upon variable factors such as-
  • Location of the fracture- More in metaphyseal fractures than in diaphyseal fractures
  • Fracture configuration
  • Nail entry point
  • Location of nail in proximal and distal fragment

• We have already discussed in our last segment, about the location of proper entry point and its importance.
• It is also important to achieve proper position in distal segment.
• Fractures near the middle of the shaft (isthmus) are less likely to fix in a malaligned position as the nail fits snugly whereas at the proximal and distal end of the bones the medullary canal is wider.
• Medial entry point and laterally directed nail insertion can lead to valgus malalignment.
• Slightly distal entry point in proximal fragment with the herzog bent in the nail can cause anterior angulation malalignment.

Technical tips for proper reduction of fracture using Poller screws

• The concept of Poller screw was first popularized by Krettek et al in 1999. They called the screws “poller screws” because the screws guided the nail like the “poller” (retractable bollard) traffic control devices guide traffic in Europe.
• One rule of thumb is to apply the screws on the concave side of a deformity.
• The blocking screw around the nail relieves axial strain in the fixation construct, while the interlocking screws through the nail control length and rotation

Step by step guide

• Draw a line down the long axis of the displaced, flared segment of bone.
• Draw a second line along the plane of the fracture, ensuring to bisect the first line.
• Identify your acute angles
• Place your screw in the acute angle of the metaphyseal or flared segment.
• Insert your guide wire under fluoroscopy guidance, ensuring the tip passes the correct side to ensure reduction.
• Insert your nail, which should be deflected on engaging the screw providing reduction and compression at the fracture site.
• If reduction could be improved further by the addition of a further screw, this should be placed in the acute angle nearer to the isthmus.

Take home message

• Poller (blocking) screws are an important adjunct for intramedullary nailing; aiding fracture reduction at the metaphyseal– diaphyseal junction, and offsetting deforming forces which can lead to malalignment.
• Fracture should always be held in reduced position before inserting the guide-wire and reaming. This is important because the nail will always follow the reamed tract.

Comminuted Proximal Humeral Head Reconstruction

One of our surgeons have shared a very interesting case with us. A 58 year old male presented to the ER after RTA, with pain & swelling over the left shoulder.

CASE DISCUSSION

• 58 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over left shoulder
• Co-morbities – Diabetes, Hypertension

Importance of medial calcar support and long axis alignment of the fracture

• Various studies have postulated and shown importance of medial calcar support and prevention of varus malalignment in significantly reducing the risk of fixation failure in proximal humeral fracture fixed with locking plates.
• Inadequate fracture reduction with lack of medial bony continuity in addition to lack of medial calcar screws makes the construct as unstable with high possibility of failure leading to Nonunion, fracture redisplacement, malunion, and or implant failure & breakage.

• With medial calcar continuity and importance of calcar screws highlighted. We would also highlight importance of primary cortical strut grafting (Allograft/autograft) during fracture fixation to give structural strength to the construct and prevent fracture redisplacement.
• Before commencing on bone grafting, surgeon needs to reduce the comminuted facture with help of non absorbable sutures.
• We are highlighting certain pearls from the discussion of this technique published by Panayiotis Dimakopoulos et al.

• With this technique author has avoided implants for fracture fixation.
• Concept of suture fixation can also be applied along with other methods discussed here in teaching Tuesday session.
• This article reading is must to understand various fracture geometry and understanding restoration of fracture fragments.
• The principles of suture fixation can be reapplied when using other fixation methods.
• Invariably, the humeral head is facing superiorly with the tuberosities displaced to either side of it.
• Two heavy nonabsorbable sutures are passed through the bone of the head fragment, 1 cm proximal to the fracture line at both the medial and the lateral border of the articular surface.
• Additional sutures are then passed through each tuberosity fragment (or near the site of tendon insertion into the fragment in osteoporotic bone or when intensive comminution is present), and the rotator cuff tendons are mobilized.
• Finally, two additional pairs of sutures are inserted laterally and medially through 2.7-mm drill holes in the diaphysis.
• These sutures are then passed through the opposite tuberosity, near the musculotendinous junction, and on to the neighboring area of the articular segment (i.e., from the medial diaphysis toward the greater tuberosity and from the lateral diaphysis toward the lesser tuberosity as well as to the adjacent articular fragment).

Key points for management of comminuted fractures

• Place sutures into the rotator cuff for control and fixation of the tuberosities.
• K-wires were used by several authors to joystick the fragments and achieve graft position.
• Matassi et al describes the placement of a single screw through the locking plate to push the fibula medially until it apposes the medial cortex of the humerus (to indirectly reduce the medial column) before subsequently placing several shaft screws through it.

Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43:1939–1942.

Take home message

• Appropriate fracture reduction with continued medial bony support.
• Two calcar screws placed to support bony fragment.
• Use sutures in bony fragments/or rotator cuff to help in reduction of fracture.
• Use bone graft to provide structural support to the medial calcar.
• Respect soft tissue attachment to the fragments to prevent osteonecrosis of the humeral head.