DOUBLE PLATING FOR POST OPERATIVE NON-UNION IN FRACTURE SHAFT HUMERUS - Case report

Dr Gaurav Guptal , Dr G G Kar, Dr S R Bala3, Dr G N Roy4, Dr S BhattacharyyaS

Introductio'n : N on-Union of fracture of lower shaft Humerus presents

an intriguing problem. This becomes a nightmare if the case had been operated before - leading to loss of endosteal blood supply in nailing and soft tissue stripping in plating.

Current treatment options include Exchange nailing, compression plating, ilizarov ring fixator for fixation . Various types of bone grafts have been proposed. These include cancellous bone graft, free fibula, Vascularised fibula and cortical only graft. All these methods have their pitfalls.

In the present report, we describe an alternative management option for a non union of shaft humerus 10Y2 month following interlocking nailing. For this case, we did 90-90 double plating on anterior and lateral aspect with cancellous bone grafting. The fracture has united with excellent functional results.

Case Report:

A 48 year old male had a road traffic accident and sustained a closed fracture of shaft of humerus without any neurovascular compromise. A closed interlocked nailing was done elsewhere within 4 days of the trauma. The patient had a normal wound healing with an uneventful post-op recovery. On serial radiographs at regular intervals, the fracture failed to show signs of union . The patient was getting calcium supplements, calcitonin, ultrasound stimulation, physiotherapy.

He presented to us IOY2 months after the interlocked nailing . Clinically the movements were full at shoulder and elbow, and there was no neurovascular deficit. There was no associated medical illness . A fresh radiograph showed non union with a gap, very scanty callus and a large

Fig. 1 : Pre-op radiograph

butterfly fragment. We decided to take him for surgery. Under general anaesthesia we removed the

interlocked nail and exposed the fracture site through Henry 's anterolateral approach. Freshening of the fracture ends was done. After reduction, we fixed it with an Egger's plate placed on anterior and a semitubular plate on the lateral aspect. Cancellous bone graft harvested from the ipsilateral iliac crest was impacted at the fracture site. A posterior slab was given after closure.

• •

Fig.2: Implants Fig. 3 :Immediate postoperative x-ray

Postoperatively, the slab was removed on 5th day and the patient was discharged subsequently. An arm guard was kept for 6 weeks . The wounds healed well under antibiotic cover and all stitches were removed on II th day. Active shoulder and elbow mobilisation was given on the 11 th day itself.

There was some restriction of shoulder and elbow movement initially, which improved with exercises. We allowed him normal activity after 3 months. At 5 Y2 months follow up the fracture had united satisfactory with only a terminal flexion lag of 20 0 at the·elbow.

1. PGT, 2-4: Consultant Orthopaedic surgeon, 5. Director BORRC, Kolkata

Vol. 20, No.1, September 2005

17

18 Dr Gaurav Gupta et al : Double plating for non-union Humerus

Fig .7 Fig. 8

DiscUfsion :

Non-union in Humeral fracture is not an uncommon situation. ~n the lower part of shaft, the joint is too close to the fracture site and the mechanical stress at the site during elbow movement is too much. Moreover, the contour of ti'e Humerus in this region makes it very difficult for any si~gle plate to hold the fracture effectively. But to achieve good healing and allow early mobilisation with preservation of the function of elbow and shoulder, a stable and strong fixation is mandatory.

The double plate construct becomes much stronger when 2 plates are applied at right angles to each other. Mear et al 2 showed that this construct is 235 times stronger than a single plate on compression side and 35 times stronger than a single plate on tension side. Rubel et al 3

did a comparative study of37 cases with mid shaft fracture of the Humerus in whom 19 were treated by single ~CP and 18 by double plate construct. All the non-unions were Supplemented by bone grafts. In biomechanica' part of the study they found that a 2 plate construct was stiffer afl d stronger than the single pbte construct in all the test models.

fig. 'J

Fig. 6

Fig. 5-9 : Showing function of the limb

Although a large area of the bone is stripped of soft tissue attachments during double plating, the AO/ ASIF 4 has repeatedly emphasised the provision of maximum mechanical stability for good healing and described the stripping of periosteum over large area of bone together with rigid, anatomical fixation of all fracture fragments.

Mast J et al 5 and Perren SM et a]l4 have pointed that limited separatipn of muscle and preservation of the periosteum are important for fracture healing. Their experience shows that the biological determinants 0 .

fracture healing are at least as important as the mechanical. In our opinion, respect to fracture biology is

undoubtedly important. But the cOI.1plex anatomy of the lower part of shaft of Humerus coupled with its proximity to the joint frequently rerders a single plate construct unable to provide stable fixation and thus effectively courol movements, specially rotation. In this scenario, double plating can be th-:: ;:mswer to difficul~ non-unions . This provides strongest fixation, reha~ilitation is quick, procedure is simple and functional results are excellent.

Journal of West Eengal Orthopaedic Association

Dr Gaurav Gupta et al : Double plating for non-union Humerus

References:

1. Rosen H. The treatment of Non Unions and pseudoarthrosis of humeral shaft. OCNA Oct 1990. 725-742

2. Mear D C. Material and orthopaedic surgery. Baltimore; William and Wilkins. 1979

3. Rubel et al. Open reduction and internal fixation of humeral non-union, a biomechanical study. JBJS (Am) 2002; 84: 1315-1322

4. Muller et al. Manual of Internal fixation . 3,d ed. 1991

5. Mast J et al. Planning and reduction technique in fracture surgery. Heidelberg: Springer - Verlag, 1979.

6. Stewart MJ et at. Fracture of the Humerus. JBJS (Am) 1995.77: 681 -92

7. Rockwood and Green's Fractures in adults. 5th ed - 2001

8. Bohler L. The treatment of fractures . Supplementary volume of the fifth Eng edition. New York; Grune and Stratton. 1996

9. Trotter DH et al: Nonunion of the Humerus: Rigid

Vol. 20, No.1, September 2005

19

fixation, bone grafting, and adjunctive bone cement. Clin Orthop 204: 162, 1986

10. Muller ME. Treatment of the Non-Union by compression. Clin orthop. 1965; 43: 83-92

11. Rosen H: Treatment of Non-unions: General principles. In Chapman MW (ed) : Operative orthopaedics. Philadelphia, 1. B. Lippincott, 1988, 489-508

12. Healy WL et al : Non-union of the humeral shaft. Clin Orthop 219 : 206, 1987

13. BarquetA et al : A combined therapeutic protocol for aseptic non-union of the humeral shaft: A report of 25 cases. J Trauma 29 (l) : 95, 1989

14. Perren SM. The concept of biological plating using Limited Contact Dynamic Compresion Plate ( LC-DCP): scientific background, design and application. Injury. 1991; 22 (suppll); 1-41

15. Bell MJ et al. The results of plating in humeral shaft injuries. The Sunnybrook experience. JBJS (Br), 1985; 67: 293-296