|Year : 2017 | Volume
| Issue : 2 | Page : 114-117
Lower radial nerve palsy in mid shaft humerus fracture using medial plating
Ajaydeep Sud1, Munish Sood2, Amresh Ghai2, JP Khatri1
1 Department of Orthopaedics, CH (WC) Chandimandir, Haryana, India
2 Department of Orthopaedics, Base Hospital Delhi Cantt, New Delhi, India
|Date of Web Publication||13-Feb-2018|
Dr. Munish Sood
CH (WC), Chandimandir - 134 107, Haryana
Source of Support: None, Conflict of Interest: None
Background: The fixation of the fracture is considered to be the best treatment option for early mobilization in midshaft humerus fracture. The aim of the present study is to compare the functional outcome after fixation of midshaft humerus fracture using medial and anterolateral plating techniques. Materials and Methods: Sixty-one patients with midshaft humerus fracture were operated using medial and anterolateral plating technique. In Group A (n = 30), the patients were operated using medial plating for fixation while in Group B (n = 31), the patients were operated using anterolateral plating. The patients were assessed clinically, radiologically and using Mayo elbow score and the University of California-Los Angeles (UCLA) shoulder rating scale. Results: Both the groups were matched in terms of age, gender, mode of injury, side involved, and duration of injury to surgery. Postoperative radial nerve palsy was observed in four patients in Group B which was found to be statistically significant (P = 0.04). The mean UCLA shoulder score improved significantly, 28.53 in Group A and 29.16 in Group B at the final follow-up (P < 0.001). The mean Mayo's elbow score also improved significantly, 85.33 in Group A and 87.41 in Group B at the final follow-up (P < 0.001). There was no significant difference in terms of functional outcome at the final follow-up while comparing both the groups. Conclusion: The medial and anterolateral plating techniques for midshaft humerus have the similar functional outcome. The medial plating technique is associated with lower radial nerve injuries.
Keywords: Humerus fracture, medial plating, radial nerve palsy
|How to cite this article:|
Sud A, Sood M, Ghai A, Khatri J P. Lower radial nerve palsy in mid shaft humerus fracture using medial plating. J Mar Med Soc 2017;19:114-7
| Introduction|| |
Fractures of the midshaft humerus are the commonly seen injuries in the orthopedics emergency and account for 1%–2% of all the fractures. The mode of injury in these fractures varies from high-velocity road traffic accident and fall from height in the younger population to trivial injuries in the elderly population. Treatment options in these fractures vary from conservative to operative intervention.,, However, the ideal treatment of these fractures is still debatable.
Various studies have reported satisfactory results with the conservative treatment., However, conservative treatment is associated with prolonged immobilization, nonunion, and pseudarthrosis. Surgical intervention in the form of intramedullary nailing and plating has the advantages of early mobilization and return of functions. However, intramedullary nailing has been documented to have disadvantages such as rotator cuff tear, tendinopathies, and delayed union., Plating has been associated with disadvantages such as the higher incidence of radial nerve palsy and more extensive surgery.,
Anterolateral plating has been commonly used as a fixation method for midshaft humerus fracture. In our search of data on the PubMed, there are very few studies about the functional outcome after medial plating of the humerus fracture.,, In the present study, we have compared the functional outcome using anterolateral and medial plating using anterolateral technique in midshaft humerus fracture.
| Materials and Methods|| |
This was a comparative observational study of 61 patients with midshaft humerus fracture who were operated using plating technique and evaluated by the surgeons. A preoperative radiograph of the arm including shoulder and elbow joint was obtained in all the patients with suspected humerus fracture. Informed written consent was taken from all the patient regarding open reduction and internal fixation procedure and willingness to participate in the study.
Consecutive patients were included in the study, and the group was assigned alternatively. In Group A, all the patients operated using medial plating were included, while in Group B, all the patients operated using anterolateral plating were included. The inclusion criteria were age >18 years, unilateral fracture, and a minimum follow-up of 1 year. The exclusion criteria were fracture with neurovascular injury, pathological fracture, compound Grade 3 fracture, fractures older than 4 weeks.
All the patients were operated in the supine position under general anesthesia with 90° abduction at the shoulder joint using the standard anterolateral approach for fracture fixation. A prophylactic dose of injection cefotaxime 1 g was given 30 min before the start of the operative procedure and continued 12 hourly for 3 days postoperatively. An anterolateral incision was given over the arm as per standard technique. The biceps was retracted medially, and the brachialis was longitudinally split to expose the fracture. In Group A, the plate was placed on the anteromedial aspect of the humerus after reducing the fracture [Figure 1]a,[Figure 1]b,[Figure 1]c while in Group B, plating was done on the lateral surface. In anterolateral plating, additional procedures such as contouring of the plate and erasing of deltoid insertion were also performed wherever desired.
|Figure 1: (a) showing anterolateral exposure, (b) minimal retraction on lateral side, and (c) plating on the medial surface|
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The patients were advised active shoulder and elbow exercises postoperatively. Sutures were removed on 10th–14th postoperative day. Plain radiographs of the patients were obtained postoperatively and during each follow-up. The patients were assessed clinically, radiologically and using Mayo elbow score and the University of California-Los Angeles (UCLA) shoulder rating scale at 6 weeks, 3 months, 6 months, and the final follow-up.,
Mayo elbow score is used to assess the level of restriction in the elbow during activity of daily living (ADL) caused by the pathology. It involves 4 subscales: pain, the range of movements of the elbow joint, stability, and disorders in ADL, and the clinical information is evaluated based on a 100 points scale.
The UCLA shoulder has 5 subscales: active forward elevation and strength (surgeon reported) and pain, function, and satisfaction (patient reported). A maximum score of 35 is possible with higher scores indicating better outcomes.
Both the groups were compared demographically (gender, age, side involved) using Chi-square test while other factors such as time of surgery, operative time, complications, and functional outcome were compared using unpaired t-test in terms of P value, degree of freedom (Df), and 95% confidence interval (CI) of this difference. P< 0.05 was considered as statistically significant.
| Results|| |
Sixty-one patients with midshaft humerus fracture were evaluated in the study. There were 30 patients in Group A and 31 patients in Group B. The mean age of study group was 33.71 years (range 19–70 years). There were 17 female and 44 male patients in the present study.
The mean age of the patients in Group A and B was 34.66 years (range 21–65 years) and 32.80 years (range 19–70 years), respectively (P = 0.52, CI − 3.92–7.64, Df 58). There were 21 male and 9 female in Group A and 23 male and 8 female in Group B (P = 0.72, CI − 0.28–0.19, Df 59). The mode of injury and type of fracture based on AO classification in both the groups are as shown in [Table 1]. In Group A, 18 patients sustained injury to the right arm and 12 sustained injury to the left arm while in Group B, 21 patients sustained the injury to the right arm and 10 sustained injury to the left arm (P = 0.53, CI − 0.33–0.17, Df 59).
All the patients in Group A were operated by anteromedial plate while all the patients in Group B were operated by the anterolateral plate. The patients in Group A and B were operated at a mean of 5.53 days (range 1–15 days) and 5.03 days (range 1–18 days), respectively (P = 0.61, CI −1.44–2.44, Df 59). The operative time in Group A and B was 71.16 min (range 45–100 min) and 67.25 min (range 45–100 min), respectively (P = 0.26, CI −3.03–10.85, Df 59). Four patients had radial nerve palsy postoperatively in Group B (P = 0.04, CI 0.01–0.26, Df 59) which improved with conservative treatment. The mean hospital stay in Group A and B was 5.33 days (range 4–15 days) and 4.64 days (range 4–8 days), respectively (P = 0.69, CI −0.10–1.14 Df 59). The radiological union [Figure 2]a,[Figure 2]b,[Figure 2]c was seen in Group A and B at 5.1 months (range 3–12 months) and 4.8 months (range 3–12 months), respectively (P = 0.62 CI −0.96–1.49, Df 59). Nonunion was seen in two patients (one in each group) which required an additional procedure in the form of bone grafting. One patient had a superficial infection in Group A which improved with oral antibiotics and daily dressings [Table 2]. The mean UCLA shoulder score improved significantly from 24 at 6 weeks to 28.53 at the final follow-up in Group A (P < 0.001) and from 23.70 at 6 weeks to 29.16 at the final follow-up in Group B (P < 0.001). The mean Mayo's elbow score improved from 59.5 at 6 weeks to 85.33 at the final follow-up in Group A (P < 0.001) and from 56.29 at 6 weeks to 87.41 at the final follow-up in Group B (P < 0.001) [Table 3].
|Figure 2: (a) fracture shaft humerus, (b) postoperative X-ray using medial plating, and (c) uniting fracture at 3-month follow-up|
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|Table 3: Functional Mayo elbow and University of California-Los Angeles shoulder score|
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| Discussion|| |
The operative intervention in the form of plating and nailing has become the standard treatment of choice in patients with midshaft humerus fracture for early mobilization.,, Anterolateral plating has been commonly used as a treatment option in the treatment of the humerus fracture. The medial plating option in the treatment of midshaft humerus has not been commonly reported.,, The present study was a comparative midterm study of 61 patients with midshaft humerus fracture who were managed with either anteromedial plating (Group A) or anterolateral plating (Group B) using anterolateral approach.
Both the groups were matched in terms of age, gender, mode of injury, and side involved. Further, both the groups were matched in terms of duration of injury to surgery [Table 1].
The operative time and length of hospital stay in both the groups were comparable. The contouring of plate was required in a significantly higher number of patients in Group B as compared to Group A. This fact can be attributed to the relatively flat nature of the medial humeral surface as compared to the lateral surface where contouring and elevation of the deltoid insertion are required. However, the lateral and posterior surfaces of the humerus are the tensile surface where plate should ideally be placed. The stresses on humerus are more of rotational stresses as humerus is a non-weight bearing bone. Thus plating may also be done on the medial surface of the humerus. Postoperative radial nerve palsy was observed in four patients in Group B which was found to be statistically significant (P = 0.04). All the radial nerve palsies were neurapraxia injuries and these injuries recovered spontaneously. We believe that lateral plating leads to more traction on the radial nerve during manipulation of fracture and placement of plate which is not the case with medial plating technique. Several other authors have also reported lesser radial nerve palsy using medial plating.,,
The radiological union was seen relatively earlier in Group B as compared to Group A, but it was not statistically significant. Nonunion was observed in two patients (one in each group). One patient required exchange plating and bone grafting because of implant failure while another patient was managed with autogenous bone grafting. Various other studies have also shown similar union rate using medial or lateral plating technique.,, Functional outcome for shoulder using UCLA shoulder score  and elbow using Mayo's elbow score  improved significantly in both the groups. However, on comparing both the groups at the final follow-up, there was no significant difference in terms of functional outcome. One of the main limitations of our study is that we have not calculated the minimum sample size before the start of the study.
| Conclusion|| |
Based on this study, the medial plating technique for midshaft humerus provides functional outcome and union rate similar to anterolateral plating technique. However, medial plating technique is associated with lower radial nerve traction injuries as compared to anterolateral plating.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]