|Year : 2020 | Volume
| Issue : 2 | Page : 54-58
Humeral interlocking intramedullary nailing without image intensifier in a developing country
Olalekan Akeem Anipole1, Stephen Adesope Adesina2, Samuel Uwale Eyesan1, Innocent Chiedu Ikem3, Akinsola Idowu Akinwumi4, Philip Oluyemi Bamigboye5, Oluwafemi Oyewole Oyewusi6
1 Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, Nigeria
2 Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State and Bowen University, Iwo, Osun Sate, Nigeria
3 Department of Orthopaedic Surgery and Traumatology, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
4 Department of Family Medicine, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
5 Department of Family Medicine, Brighthope Specialist Hospitals Limited, Lagos State, Nigeria
6 Department of Family Medicine, Bowen University Teaching Hospital, Ogbomoso, Oyo State, Nigeria
|Date of Submission||29-May-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||15-Dec-2020|
Dr. Olalekan Akeem Anipole
Department of Surgery, Bowen University, Iwo, Osun State
Source of Support: None, Conflict of Interest: None
Background: Interlocking intramedullary nailing under image intensifier has been a standard approach to surgical treatment of humeral fractures. Aim: We present the outcome of humeral interlocking nailing without image intensifier in a developing country. Materials and Methods: This is a prospective study of consecutive patients with humeral shaft fractures who were treated with Surgical Implant Generation Network interlocking nailing for humeral shaft fractures using an external jig system. They were followed up for at least 6 months if there was no evidence of fracture healing and restoration of functional activities. Data collected were processed with the Statistical Package for the Social Sciences and summarised in percentages and means. Results: Forty-five patients with 46 humeral shaft fractures were studied, with a mean age and standard deviation of 46 ± 14.6 years and male-female ratio of 1.8:1. At 3 months, 44 (95.7%) of the patients have had radiographic evidence of fracture healing. Over the same period, 35 (76.1%) of them had achieved shoulder abduction >90°, 37 (80.5%) had achieved painless shoulder flexion-abduction-external rotation movement and 42 (91.3%) had achieved full activities of daily living. Conclusion: In a resource-constrained population where image intensifier is difficult to come by, humeral interlocking intramedullary nailing could still be performed using external jig system with a satisfactory outcome.
Keywords: Developing country, external jig, humeral fracture, interlocking intramedullary nailing
|How to cite this article:|
Anipole OA, Adesina SA, Eyesan SU, Ikem IC, Akinwumi AI, Bamigboye PO, Oyewusi OO. Humeral interlocking intramedullary nailing without image intensifier in a developing country. Niger J Orthop Trauma 2020;19:54-8
|How to cite this URL:|
Anipole OA, Adesina SA, Eyesan SU, Ikem IC, Akinwumi AI, Bamigboye PO, Oyewusi OO. Humeral interlocking intramedullary nailing without image intensifier in a developing country. Niger J Orthop Trauma [serial online] 2020 [cited 2022 Dec 4];19:54-8. Available from: https://www.njotonline.org/text.asp?2020/19/2/54/303431
| Introduction|| |
Humeral shaft fractures constitute about 3% of all fractures in adults. The fractures can be treated non-operatively, with good results in most cases, but nowadays, an all-encompassing approach to the care of patient is emphasised. Hence, the approach to the management of fracture of humeral shaft has changed from manual manipulation, splintage and prolonged immobilisation to internal fixation, which permits early joint mobilisation and return to normal activities of daily living (ADL) as early as possible.
Treating humeral fractures by dynamic compression plate fixation or intramedullary nailing allows earlier mobilisation and rapid return to work., Plate fixation provides satisfactory results, and it is a common operative modality for treating humeral shaft fractures in the developing world but has the disadvantage of long incision, excessive periosteal stripping, less stable fixation in an osteoporotic bone, increased risk of infection and iatrogenic radial nerve palsy.,,,
Interlocking intramedullary nailing has a number of relative biological and biomechanical advantages over plating, some of which include less invasive surgery, hence less blood loss, undisturbed fracture hematoma (for close nailing), it uses a load-sharing implant, it has less fatigue failure and less infection rate.
For efficient and effective performance of locked intramedullary fixation of long bone fractures, intra-operative image intensifier is usually required. However, in resource-poor environments like ours, an external jig system for nailing with or without an image intensifier is an option. Surgical Implant Generation Network (SIGN) nails were used in this study and were provided with the external jig.
We hereby evaluate the treatment of humeral shaft fractures using interlocking intramedullary nails with external jigs without intra-operative image guidance.
| Materials and Methods|| |
This is a prospective study of consecutive patients with humeral shaft fractures who were treated with intramedullary interlocking nailing over a period of 5½ years between July 2014 and December 2019 in a Nigerian Missionary Teaching Hospital. The humeral shaft was defined as the part of the humerus, that is, 2 cm below the surgical neck and 3 cm above the olecranon fossa. Inclusion criteria were fractures within the above-stated boundaries. All open fractures were included irrespective of the Gustilo–Anderson Classification. Fractures outside the boundaries were excluded from the study. Informed consent was obtained from the patients and ethical clearance obtained from the ethical committee of the hospital.
Patients with fresh fractures had either closed reduction or reduction through about 3 cm incision for finger-assisted reduction, while those with non-union had a completely open reduction. In finger-assisted reduction, after making above-mentioned incision at the fracture site, it was deepened through the subcutaneous tissue and fascia, then with one finger, the muscles were split to access the fracture site. With traction and manual manipulation, the introduced finger was used to achieve fracture reduction, after which reaming was done to a step higher than the nail to be inserted. Internal fixation with SIGN® standard interlocking nails and SIGN® intramedullary fin nails using an external jig system [Figure 1]a and [Figure 1]b without an image intensifier was performed for all of them [Figure 2]a and [Figure 2]b. Both antegrade and retrograde approaches were utilised. Compression at the fracture site was achieved manually and bone grafting performed where necessary. All the surgeries were performed by two surgeons.
|Figure 1: (a) Pre-operative radiographs showing AO 12-A2 fracture. (b) Immediate post-operative radiograph showing standard Surgical Implant Generation Network interlocking nail. (c) Three-month post-operative radiographs showing fracture union. (d) Shoulder flexion-abduction-external rotation exercise at 3-month post-operative period|
Click here to view
|Figure 2: (a) Pre-operative radiographs showing AO 12-A3 fracture. (b) Immediate post-operative radiograph showing Surgical Implant Generation Network fin nail. (c) Three-month post-operative radiographs showing fracture union. (d) Shoulder flexion-abduction-external rotation exercise at 3-month post-operative period|
Click here to view
Antibiotics were administered for 5 days or longer in case of open fractures or other injuries. The patients were followed up clinically and radiographically according to SIGN follow-up protocol for at least 6 months if there was no evidence of fracture healing and restoration of functional activities.
Data collected were processed with the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows version 16, Armonk, NY, USA: IBM Corp.) and summarised in percentages and means. P = 0.05 was considered statistically significant.
| Results|| |
Forty-five patients with 46 humeral shaft fractures were included in this study. The age range of the patients was from 20 to 75 years, with a mean age and standard deviation of 46 ± 14.6 years. Twenty-nine of them were male, whereas 16 were female, giving a male-female ratio of 1.8:1. The major cause of the humeral fractures was road traffic crash (36 [80%]). Others (9 [20%]) included fall and assault. Twenty-five (54.3%) of the fractures involved the right humerus, whereas 21 (45.7%) involved the left. Forty-four (95.7%) of the fractures were closed, whereas two (4.3%) were open fractures. The open fractures were Gustilo–Anderson IIIA. Thirty-two (71.1%) patients presented with isolated humeral shaft fractures, six (13.3%) had associated head injury, three (6.7%) had associated soft-tissue injury and four (8%) presented with multiple fractures. Twenty-six (57.8%) patients had no previous treatment for the fracture, 11 (24.4%) had previous traditional bone setters' (TBS) treatments, four (8.9%) had cast application and two (4.4%) had open reduction and internal fixation (ORIF) with plate and screws and rush nails, respectively. The AO classification of the fractures, parameters of the fracture fixation, evaluation of the fracture healing and functional outcome are presented in [Table 1], [Table 2] and [Table 3].
|Table 1: Fracture distribution according to AO classification. AO 12-A3 constitutes the greatest percentage of the fractures|
Click here to view
|Table 3: Evaluation of fracture healing and post-operative functional outcome|
Click here to view
All the standard SIGN nails were locked with four screws except the first patient whose fracture was locked with three screws and the most proximal screw removed due to its penetration into the shoulder joint, leaving the nail with two screws. All the fin nails were proximally fixed with two screws. The mean post-operative days before discharge home and standard deviation were 5.7 ± 1.4. Only one of the patients was lost to follow-up. Two of the patients presented with joint stiffness before the surgery, which limited their post-up functional outcome. The results of the evaluation of fracture healing and functional outcome were expressed in [Table 3]. The data of the patient who was lost to follow-up were not utilised in the analysis of fracture healing and functional outcome and those who presented with joint stiffness were also not utilised in the analysis of functional outcome.
Post-operative complications included two (4.3%) cases of deep infections (one was infected non-union), two (4.3%) cases of the prominence of the nails above the greater tuberosity, one (2.2%) case of screw penetration into the shoulder joint and three (6.5%) cases of radial nerve injury (neuropraxia). There was no mortality.
| Discussion|| |
Many studies have reported encouraging success in the treatment of humeral shaft fractures with interlocking intramedullary nailing.,,, The humeral fractures presented in various patterns with AO 12-A3 being the most common presentation. In a study done by Raja Gopal et al., AO 12-A3 also constitutes the majority (55%) of the fractures they studied. This explains that the most common pathomechanism associated with humeral fracture is that of direct impact generating a tensional stress, which eventually results in a transverse fracture. Close reduction was used for all the fresh fractures without an image intensifier. The only patient who had retrograde nailing initially had ORIF with plate and screw in another centre but presented to our centre with implant failure and humeral non-union. He had removal of broken plate, fibrolysis and fixation with a fin nail through a retrograde approach, and by 3 months, the fracture had united.
Size 8 mm nail constituted the greatest percentage (71.7%) of the nail used in this study followed by size 9 mm. Raja Gopal et al. who also performed reaming before nail insertion used nails of 7–8 mm in their own study which was carried out in India. The difference in the nail sizes may have reflected racial variations.
Fracture union in this study was based on the combination of radiographic, clinical and mechanical evidences of fracture healing. Fracture union in this study was not absolutely based on the appearance of three cortices bridging callus. Studies have shown that disagreement and variability exist amongst clinicians and researchers with regard to clinical and radiographic definitions of fracture healing., Certain studies on the reliability of plain radiography in assessing fracture healing concluded that radiographs do not define union with enough accuracy and are generally inconclusive in determining the stage of union.,, In a systematic review done in 2008, out of 59 studies that used clinical criteria in defining union, absence of pain or tenderness at the fracture site on weight bearing, absence of pain on palpation at the site of fracture and the ability to weight bear were the most commonly used criteria to define fracture healing. Patient-centred approaches which assess the quality of life and function are therefore gaining popularity in the evaluation of fracture union., These are the points on which SIGN protocol on the assessment of fracture healing is now based.
By 3 months, 44 (95.7%) patients have had radiographic evidence of healing [Figure 1]c and [Figure 2]c. The rate of fracture healing in this study is strongly comparable with similar reported studies, in which intra-operative image intensifier was utilised. With the use of intra-operative image intensifier, the fracture union rate achieved in the study by Raja Gopal et al. at corresponding 3 months was 80%. Previous studies have shown that healing at 6 months ranged between 90% and 95.8%.
The functional outcome of the studied patients is as follows: 35 (76.1%) and 42 (91.3%) of the patients could perform shoulder abduction at 3 and 6 months, respectively. Thirty-seven (80.5%) and 42 (91.4%) of them could perform painless shoulder flexion-abduction-external rotation movements at 3 and 6 months, respectively [Figure 1]d and [Figure 2]d. Patient-satisfactory ADL was achieved amongst 42 (91.3%) as early as 3 months, and by 6 months, all the patients have had restoration of their ADL.
The two cases of post-operative deep infections presented pre-operatively with infected broken plate and gunshot injury, respectively, but both of them eventually had fracture healing. Robinson et al. also reported two (6.7%) cases of deep infection, which were controlled with the nail in situ. In the two (4.3%) cases of nail prominence above the greater tuberosity, there was the unavailability of shorter nails, hence the constraint to use the relatively longer nail. The fractures united at 3 months, after which the nails were removed. Nail prominence and impingement have been reported,, as causes of shoulder pain and limitation of shoulder movement. In this study, one of the patients had shoulder pain and limitation of shoulder movement beyond 6 months, which resolved thereafter.
Two of the three cases of radial nerve injury recovered by 3 months, while the remaining one recovery at 6 months with physiotherapy. Chandan et al. and Kivi et al. reported 5% and 1.3% of cases of radial nerve injury, respectively.,
| Conclusion|| |
In a resource-constrained population where image intensifier is difficult to come by, humeral interlocking intramedullary nailing could still be performed using an external jig system with satisfactory outcome. However, adequate pre-operative planning, adequate reduction and static locking are all essential to ensure an excellent result.
The authors greatly appreciate SIGN Fracture Care International, its founder and president, Dr. L. G. Zirkle, for the free donation of SIGN implants and instruments.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflict of interests
Surgical implant generation Network (SIGN) at 451 Hills Street, Suite B, Richland, WA 99354 USA provided the instrumentations and implants free of charge for all the patients. The provision was not specifically for this study, but it is in line with their efforts to generally help patients in the developing countries have their fractures treated by internal fixation if indicated without paying for the implants.
| References|| |
Gupta S, Kumar M, Reddy KR, Prasad SG, Gopichand K. Comparative study of management of humeral diaphyseal fractures by DCP plate and IMIL nail. J Evol Med Dent Sci 2014;17:1782-8.
Sarmiento A, Waddell JP, Latta LL. Diaphyseal humeral fractures: Treatment options. Instr Course Lect 2002;51:257-69.
Chandan RK, Sinha V, Bhushan D. Comparison of results between dynamic compression plate and interlocking nail for the management of fracture shaft of humerus. Int J Orthop 2020;6:249-52.
Crates J. and A.P. Whittle, Antegrade interlocking nailing of acute humeral shaft fractures. Clinical orthopaedics and related research, 1998:40-50.
Ayotunde OA, Sunday OK, Oluwatoyin A, Dare OJ. Results of surgical treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone grafting. Acta Ortop Bras 2012;20:223-5.
Chao TC, Chou WY, Chung JC, Hsu CJ. Humeral shaft fractures treated by dynamic compression plates, ender nails and interlocking nails. Int Orthop 2005;29:88-91.
Cole PA, Wijdicks CA. The operative treatment of diaphyseal humeral shaft fractures. Hand Clin 2007;23:437-48.
Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: A review. J Shoulder Elbow Surg 2011;20:833-44.
Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate fixation for humeral shaft fractures: A systematic review of overlapping meta-analyses. Medicine (Baltimore) 2015;94:e599.
Changulani M. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus: Reply to Subasi and Cebesoy. Int Orthop 2008;32:141.
SIGN Fracture Care International. Technique manual of SIGN IM Nail & Interlocking Screw System Insertion & Extraction Guide; 2016. Available from: https://www.signfracturecare.org
. [Last accessed on 2020 Mar 14].
Bhat S, Rao SK, Ortho D. The functional outcome of antegrade unreamed humeral interlocking nailing in adults. J. Orthopaedics 2005;2e2.
Raja Gopal H, Madan Mohan M, Pilar A, Tamboowalla K. Functional outcome of ante grade interlocking intramedullary nailing for humeral shaft fractures. Int J Res Orthop 2017;3:1127.
Ikem IC, Ogunlusi JD, Ine HR. Achieving interlocking nails without using an image intensifier. Int Orthop 2007;31:487-90.
Ikem I, Esan O, Orimolade E, Adetiloye A, Toluse A. External jig in the placement of distal interlocking screws. Niger J Orthop Trauma 2011;10:28-31.
Solomon L, Warwick D, Nayagam S. Apley's System of Orthopaedics and Fractures. 9th
ed. London: Taylor and Francis; 2010.
Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P3rd
, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma 2002;16:562-6.
Morshed S, Corrales L, Genant H, Miclau T 3rd
. Outcome assessment in clinical trials of fracture-healing. J Bone Joint Surg Am 2008;90 Suppl 1:62-7.
Hammer RR, Hammerby S, Lindholm B. Accuracy of radiologic assessment of tibial shaft fracture union in humans. Clin Orthop Relat Res 1985;199:233-8.
Blokhuis TJ, de Bruine JH, Bramer JA, den Boer FC, Bakker FC, Patka P, et al
. The reliability of plain radiography in experimental fracture healing. Skeletal Radiol 2001;30:151-6.
Davis BJ, Roberts PJ, Moorcroft CI, Brown MF, Thomas PB, Wade RH. Reliability of radiographs in defining union of internally fixed fractures. Injury 2004;35:557-61.
Morshed S. Current options for determining fracture union. Adv Med 2014;2014:708574.
Robinson CM, Bell KM, Court-Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br 1992;74:558-62.
Sherif F. The outcome of interlocking nailing of humeral shaft fractures, a one year hospital based study. Int J Orthop 2018;4:95-9.
Baltov A, Mihail R, Dian E. Complications after interlocking intramedullary nailing of humeral shaft fractures. Injury 2014;45 Suppl 1:S9-15.
Kivi MM, Soleymanha M, Haghparast-Ghadim-Limudahi Z. Treatment outcome of intramedullary fixation with a locked rigid nail in humeral shaft fractures. Arch Bone Jt Surg 2016;4:47-51.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]