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INTRODUCTION

Trauma is the leading cause of morbidity and mortality in the present age. The victim of bony injury may face prolonged immobilisation and loss of wages and it’s a tough time for the entire family. Besides, the patient often may have to live with the sequelae and functional disability.

Fractures of the shaft of humerus have been treated conservatively since ages, with good results. Sir John Charnley in his treatise “ The closed treatment of common fractures “ even states “ it is perhaps one of the easiest major long bone fractures to treat by conservative methods.” 1

However conservative treatment cannot be recommended in every case. Conservative treatment requires prolonged immobilisation of the fractured limb that leads to disuse of the involved limb, repeated hospital visits, disturbances in daily routine activities , troublesome in his or her professional duties and complications due to prolonged immobilisation such as stiffness of joint leading to prolonged recovery time.

Moreover if unstable fractures, comminuted fractures, fractures associated with nerve or vascular injuries are treated conservatively leads to complications like Non-union, Mal Union so these fractures need fixation.

Many options were available to treat fractures conservatively but taking into consideration pitfalls of it, an era of Fixation evolved. Aim of it was early restoration of joint motion and return to normal physiologic function and minimal morbidity.

Many modalities were also developed for fixations, intramedullary devices like Locking nail and plate osteosynthesis system. Fracture of humerus causes functional limitation of the arm.

Humeral shaft fractures account for 5% of all fractures. These fractures are mainly due to high energy trauma such as Road traffic accidents (RTA) and fall from height2. These fractures were treated by Functional bracing, Hanging cast, U splints which gave excellent results for healing of fractures with no or very less acceptable deformity as published by Sarmiento et all3 but required prolonged immobilisation leads to hampering of social and daily activities of person.

In the last two decades several operative procedures has been developed for treatment of humeral fractures such as intramedullary locking nail, plate fixation, intramdedullary rush wires, external fixation.

The present study attempts to highlight comparison in functional outcome and time of union in fracture shaft of humerus treated either by intramedullary nailing or by a plate osteosynthesis.

AIM AND OBJECTIVES

AIM –

To perform comparative study of use of Intrmedullary nail and Dynamic Compression Plate to treat Diphyseal fracture of Humerus at A.V.B.R.H

OBJECTIVES –

• To evaluate and compare the adaptability and acceptability.

• To evaluate and compare the functional outcome.

• To evaluate and compare pattern of callus formation and time of union.

• To evaluate and compare emerging complications

• To review the literature

REVIEW OF LITARATURE

Through all the changes in medical and surgical knowledge and in technique in the history of medicine, there are some subjects, such as fractures, in which, because of their nature, there has been very little change.

It is, therefore, easier to trace the history of fracture treatment back through many centuries than find what was known or done a hundred years ago about some of the "modern " diseases.

Because the mechanical factors in fractures were the same in the first century as they are in the twentieth century, the methods of treatment in ancient times are found to be similar, not only in principle but in practice, to those of our own day.4

In the earliest known surgical text, The Edwin Smith Papyrus, three cases of humeral fractures appear.5

The papyrus contains 48 cases of wounds and fractures topographically ordered from the skull to the chest and upper arm. The papyrus is incomplete and fractures of the humerus are the only limb fractures dealt with.

They have treated these fractures of humerus according to their way and with the substances they were having with them like follows –

‘‘A broken upper arm,’’ deals with the diagnosis, reduction, and bandaging of a fracture of the humerus. The prognosis of the injury is considered to be favourable. Reduction by traction is recommended: ‘‘Then you lay him out, with something folded between his shoulder blades. You have to pull his arms to lengthen his upper arms, until that break falls into its place’’.

A broken upper arm with a wound,’’ deals with a compound fracture of the humerus. Two kinds of injuries are distinguished according to the depth of the lesion. The examination of the injury is done with the fingers in the wound. The case introduces the technical term nekhebkheb referring to a movement of the fracture under the fingers of the physician, which has been translated to ‘‘wiggling’’ or ‘‘crepitating’’. If the wound is only superficial, two strips of cloth with alum, oil, and honey are applied. If bone penetrates the soft tissue and blood is issuing from the wound, the prognosis is considered hopeless and no treatment can be provided.

Then arrived era of The Hippocratic corpus( crica 440-340 BC).

The Hippocratic method of reduction of glenohumeral dislocations is known to most physicians. However, the Hippocratic approach to fractures of the humerus in De Fracturis (written circa 415 BC) has not been studied since the early nineteenth century. The author distinguishes prognostically between proximal and distal fractures of the humerus:

He developed his own method of reduction of humeral fractures –

The Hippocratic mode of reduction for fractures of the humerus (De Fracturis, VIII) has been interpreted and illustrated in later surgical texts Fig.: The patient is seated on a high stool with a hanging rod in the armpit so he can hardly sit. The patient’s elbow is flexed with a scarf with heavy weights under the forearm extending the upper arm. The physician then reduces the fracture manually. After reduction, bandages of linen are applied with the head of the bandages on the fracture. The bandages are soaked in cerate, an ointment of oil or fat mixed with wax or resin. The bandages should be changed every third day and replaced with increasing pressure. Stable fixation of the fracture may have been maintained by the bandages soaked in cerate. On the seventh or ninth day, the bandage is removed and the upper arm is washed in hot water. The bandage is reapplied and splints are added.

He said that humerus is naturally convex outwards, and is therefore apt to get distorted in this direction when improperly treated’’ because he was aware of the risk of varus displacement. In such cases he told that the humerus should be fixed with bands to the chest in valgus position after applying many-folded compresses under the elbow.

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Fig No - 1

Fig. Interpretations of the Hippocratic mode of reduction for fractures of the humerus (De Fracturis, VIII) [10] are shown. (Reprinted from (A) Primatice (1504–1570) [23], with permission from Bibliothe`que national de France, Paris, France), and (B) Joannis Scultetus (1595–1645)

Celsus distinguished between shaft fractures, proximal fractures, and distal fractures according to prognosis and treatment recommendations: ‘‘…there is least danger when the middle of the bone is fractured. The nearer the fracture is to either the upper or the lower end the worse it is; for they are at once more painful and more difficult to treat’’

Celsus described various fracture configurations, including transverse-, oblique-, and multifragmented fractures. He mentioned displacement of oblique fractures with abbreviation and described the sensation of crepitus: ‘‘If the fragments are in contact, they make a sound when moved and produce a stabbing sensation…’’5

According to Celsus, fractures of the humerus should be reduced immediately to prevent inflammation. The reduction is successful if the pain disappears and the arms become equal in length. The Hippocratic method of reduction is followed except for the use of bandage loops for extension (De Medicina, VIII, 10). As in Corpus Hippocraticum, Celsus prescribed successive application of bandages at the seventh or ninth day followed by splinting. When the proximal part of the humerus is broken, the bandages should be longer than if the shaft or distal part is broken. If the fracture is close to the shoulder, the skin should be fomented with hot water and wine and oil should be dropped on it. To prevent gangrene, Celsus recommended making the turns of the bandage numerous rather than tight. If the fracture is not in position, it could be reduced again on the seventh or ninth day. The splints should be tightened every third day and used for 2.3 of the time of healing (40 days in total). Celsus differed from Hippocrates in using six bandages instead of three; he applied larger pieces of linen and soaked it with wine and oil instead of cerate.

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Fig No - 2

An illustration of Oribasius’ mode of reduction for humeral fractures and glenohumeral dislocation using the Hippocratic bench, scamnum, is shown. (Reprinted from Vidius [29] and Brockbank W.

The man who was Vidius.

An accurate description of the humerus is found in Galen’s De ossibus ad tirones (circa AD 180):

‘‘The humerus, the largest bone except for the femur, articulates at both ends. At the shoulder end it has an epiphysis with a very large head on a small neck. A broad fossa in the front divides the entire head into two condyles… the humerus is bowed, yet not sharply and even not uniformly; because it is convex anteriorly and outwardly and concave in the reverse’’

Hippocrate gave directions to treat fracture humerus in 460-377 B.C like follows – having got a piece of wood a cubit or somewhat less in length, like the handles of spades, suspend it by means of a chain fastened to its extremities at, both ends; and having seated the man on some high object, the arm is to be brought over, so that the armpit may rest on the piece of wood, and the man can scarcely touch the seat, being almost suspended; then having brought another seat, and placed one or more leather pillows under the arm, so as to keep it a moderate height while it is bent at a right angle, the best plan is to put round the arm a broad and soft skin, or broad shawl, and to hang some great weight to it, so as to produce moderate extension.

"He used a fracture table called the Scamnum which he describes as follows: "But the best thing is, for any physician who practices in a large city, to have prepared a proper wooden machine, with all the mechanical powers . . . either for making extension, or acting as a lever."

GUY DE CHAULIAC (1300-1370) emphasized the use of ointments and salves in the treatment of fractures.4

For compound fractures he advised the extraction of "foreign substances such as arrows or pieces of bone", then "the separated parts of the bone should be brought together and the flesh wound deeply sutured and closed firmly ". The limb was then bandaged "in such a way that the wound can be attended to . . . without undoing all the bandages and supports".

In 1822 A.D. SIR ASTLEY COOPER published his textbook on fractures & dislocations.5

GIOVANNI DI VIGO ( 1460-1520) Placed Much stress on the healing of fractures by external application of various ointments and concoctions.4

In 1940, Caldwell proposed his technique of treating humeral shaft fractures relying on gravity to achieve proper position of the fracture.6

In this method, the arm is immobilised in a long arm plaster cast Known as Hanging Cast.

The cast is then suspended by a strap around the neck, which is connected to loops incorporated into the cast at the level of the forearm. Fracture alignment can be adjusted by adjusting the position at which the straps connect to the loops.

Sarmiento reported in 1977 about his results in humeral shaft fractures treated with an orthosis allowing for complete motion in shoulder and elbow joint.3,7

The basic design is a rigid light-weight plastic brace composed of an anterior and posterior shell joined by Velcro straps.

The hanging cast is applied as a circular plaster bandage which encases the upper extremity from its upper third to the wrist; it holds the elbow in 90 degree flexion, and is suspended from the neck by a sling. The plaster bandage is applied with the patient either sitting or recumbent as convenient or as condition of the patient permits, the elbow flexed to a right angle, with the forearm held in midpronation. An adequate length of stockinette is pulled over the arm, and a strip of saddlers' felt, one inch in width, is made to encircle the wrist just above the ulnar styloid. The plaster bandage is applied either with no other padding or with a few turns of flannel bandage. Fractures were treated by using functional braces also.

In 1855 A.D. the functional cast brace was introduced which was the fore runner in the treatment of Humeral shaft fractures.3,8-10

In 1852 A.D. ANTONNINE METHIJSEN devised the method of using bandage impregnated with plaster of Paris for reduction maintenance.11

In 1860 A.D. BUCK used skin traction to treat fractures.12

HUGH OWEN THOMAS (1831-1891) stressed the importance of uninterrupted & prolonged immobilization in fracture treatment.13

In 1880 the plaster of Paris came into common use for external immobilization.12

After invention of X-rays by ROENTGEN in 1895 science of bone including fracture treatment has advanced tremendously.14

The principles of gutter splint & plaster 'U' slabs were described by MC MURRY in 1939 & ROWLEY in 1942 respectively.15

Schittko stated in 2004 that nowadays operative treatment is the gold standard because of the development of new intramedullary and rotational stable implants.16

Open reduction & wire sutures fixation was attempted by ROGERS as early as 1827, this method did not receive wide acceptance in surgery due to sepsis.17

Curling was the first to report basic sequences of fracture healing in 1836 A.D.18

In 1894 Sir William Lane introduced the idea of metallic internal fixation in fracture treatment.16

The “beginnings” of intramedullary fixation go back into the 16th century. The conquistadors in America described how the Indians used wooden wedges to treat bone fractures.4

In 1897 Nicolaysen described the principles of medullary fixation for fractured bones, He & Delbet in 1906 published details of intramedullary fixation of bones.19

By the end of the 19th century, first experimental intramedullary fixations were performed in Europe. The pioneers were Bircher, König, von Langenbeck, Cheyne and Lane.4

Metallic pin traction was used by Codvilla & Steinman in 1907.12

In 1907 Lane introduced light plates.20

In 1907 Lambotte developed & promoted internal fixation methods.20

Alvin Lambotte of Belgium was the first surgeon to device an external fixation in 1907. Since then it has been improved by ROGER ANDERSON (1934), OTTO STADER (1937), HOFFMAN (1939) & ILLIZAROV (1950) in the following years. The external fixators are particularly helpful in open fractures of the Humerus.21

In 1912, Plate fixation for diaphyseal fracture was introduced by Beckmann.14

In 1912, Sherman introduced Vanadium steel bone plates & self tapping screws.20

Hey Grooves in 1914 was the first to declare that some fractures do require open reduction while there are many fractures which do well with skilful closed treatment & should not be operated upon.22

Robert Jones believed in early reduction of fresh fractures under anaesthesia in 1914.21

In 1914, Maclean introduced oval hole modified lane plate for compression after resorption at the fracture ends.20

In 1935, Pauwel's concept of tension band fixation applied to bone.20

In 1937 L.V.Rush & H.L.Rush reported use of steinmann pin in the medullary canal of Humerus & other long bones.23

In the beginning of the 20th century, Ernest Hey Groves (England) already used specially designed three- or four-edged intramedullary nails for the fixation of diaphyseal long bone fractures.22

In 1940 Kuntschner of Germany presented convincing evidence concerning the value of intramedullary fixation devices which simply fitted the entire length of the bone.24,25

In 1940, Lambrinudi suggested the placement of strong wires and thin metal sticks through the medullary canal.19

In 1943 Townsend & Gilfillan designed a plate with slots to allow the surgeon to coapt the fragments manually just before tightening the screws. It was thin & flexible, when greater strength was needed, two or more of these plates were stacked one on top of the other.21

None of the above authors made any reference to compression of bone. These plates were used to fix the fracture fragments, represented an extension of the old principle of splintage.

In 1948 Egger's & associates studied the effect of compression on healing of experimental fractures in animals & concluded that compression forces applied to healing bone fragments could influence the rate of healing. He designed the sliding compression caused necrosis & suggested muscle action provides the physiological amount of compression forces. But in the actual sense he just coapted the fragments & not compressed it.26

In 1949 Robert Danis (1880-1962) was the first surgeon to use a true compression plate in the treatment of acute diaphyseal fractures of long bones. He was a Belgium surgeon, graduated at Brussels. Initially he was interested in thoracic surgery, vascular surgery, anaesthesiology & on breast cancer & orthopaedics also. He was unhappy with the implants & instrumentation of fracture treatment & hence he devoted later part of his life on metallurgical properties of bone implants & its design & published the technique of osteosynthesis in 1932 & in 1949 " Theories & practice of Osteosynthesis".27

In 1950 Rush brothers treated fracture shaft of humerus with rush nailing with 100% good results.23

In 1950 Collison All the above mentioned plates, were compressed by a flat head screw. He modified his plate with a beveled slots, which were designed to accommodate chamfered screw head and compression.

In 1951 Venable, He modified Danis plate where the compression screw was oriented obliquely to make it more accessible, but this change made the junction between the compression screw and the threads of the anchoring screw insecure.

Stewart.M.J. & Hundley.J.H. in 1955 studied 223 humeral shaft fracture treated by conservative methods & formulated a grading for analyzing the final results.28

Dr. Whitson in 1954 demonstrated that, radial nerve does not pass in the spiral groove, instead it is separated by about 1-5 cm thick muscles, usually medial head of triceps & only near the inferior lip of the groove it is in direct contact with the humerus where it pierces lateral intramuscular septum.29

P.G.Laing in 1956 studied the blood supply of adult humerus by injecting a radio opaque dye into the brachial artery of cadavers & according to his study the main nutrient artery arises in 2/3rd of cases from the brachial artery & in the remaining from the profunda brachii artery.30

In 1958 M.E.Muller assembled a group oh friends, general & orthopaedic surgeons to discuss the poor results obtained with both non-operative methods of fracture treatment in the country. This nucleus in the same year developed into the group called A.S.I.F.( Association for the Study of Internal Fixation) or A.O. ( Arbeints gemein schaft fur osteosynthese fragen).26

Four principles were accepted during the meeting:-

1) Anatomical reduction.

2) Rigid Internal fixation.

3) Atraumatic technique on soft tissue as well as bone to preserve blood supply.

4) Early pain free active mobilization of muscles & joints adjacent to the fracture.

To prove or disprove these principles they started working in 3 different directions:-

1) Animal experimentation on the pathophysiology of bone repair under various biomechanical conditions with or without internal fixation.

2) Creation of compression armamentarium taking advantage of modern technology.

3) Careful clinical follow up in patients treated for fresh fractures, non-union & malignant conditions.

They took the help of Robert Mathys, a manufacturer, FRITX STRAUMMAN a metallurgist & developed over 1400 items for use in the surgery of fractures.

Dr. Arthur Holstein & Gwilyn Lewis of California in 1963 described "Humeral fracture syndrome" in which they said, in case of fractures of distal third humerus, which are usually spiral, the distal bone fragment had always displaced proximally with its proximal end deviated radialwards, the radial nerve was caught in the fracture site & if there was a comminuted fragment, that damages the nerve. If there was no displacement, the radial nerve was spared.31

Johansson studied complications associated with antegrade & retrograde K- nailing for fractures of the humerus. L.KLENERMAN of Middlesex in 1966, described a series of 98 patients with humeral shaft fracture treated with conservative methods with good results. S.E.CARROL, University of Ontario, Canada, studied the blood supply of humerus & according to his study, 2/3rd of humerus has single nutrient artery.11,32

In 1982 Perren.s.m. & Klauge devised a BIOLOGICAL (FIXATION) PLATE. The screw slots are inclined even on the undersurface of the slots & hence the high degree of inclination of screws, upto 40 degrees. It is made up of Titanium which is more flexible & hence less stress protection. Lag screws applied through the plate is twice as effective as that of conventional lag screws. The slots are symmetrical & there is no gap in the mid section of the plate which makes it more versatile for the use in any type of fractures.33

In 1989 Seidal developed locking nail for the humerus. Closed nail techniques have reduced blood loss, infection rates & length of stay in the hospitals, With locking nails, the fixation is rigid, no rotational instability & external splintage is not required.34

In 1989 LIMITED CONTACT DYNAMIC COMPRESSION PLATE was devised by PERREN.S.M. It stands for a new concept of biological plating HUBER, KEESELER.H.W. & REHM.K.E. in 1996 recommended the use of flexible intramedullary nails in fractures of long bones in children. They concluded that to correct angulation & to avoid plaster immobilization in diaphyseal fractures in childhood closed nailing with flexible intramedullary nails is an easy & safe method.33

R.G.Mccormack, D.Brien et. al. in 2000 compared the fixation of fractures of shaft of Humerus by Dynamic Compression Plate or Intramedullary nail & suggested that open reduction & internal fixation with DCP remains the best treatment for unstable fractures of the shaft of the humerus.35

....And the options goes on increasing for fixation of humeral shaft fractures from simple pinning , intramedullary nailing to locking intramedullary nailing.

Fixation of fractures with plate also evolved from simple light plate and from compression plate to modern locking plate.

ANATOMY 36

Arm comprises important role in the upper extremity. It is the major weight bearing portion of upper extremity. The arm (Brachium) Extends From the shoulder to the Elbow(Cubitus).The bone of the upper arm is Humerus , its upper end meets with the scapula and forms shoulder joint , its lower end articulate with radius and ulna to form elbow joint.

SURFACE LANDMARKS OF THE ARM –

1. Greater tubercle of the humerus is the most lateral bony point in the shoulder region. It can be felt just below the acromian, deep to deltoid when the arm is by the side of trunk.

2. The shaft of the Humerus is felt only indistinctly because it is surrounded by muscles in its upper half , the humerus is covered anteriorly by the biceps and brachialis and posteriorly by triceps.

3. The medial epicondyle of the humerus is a prominent bony projection on the medial side of elbow.

4. The lateral epicondyle of humerus is less prominant bony projection than medial. It can be felt in the upper part of depression on the posterolateral aspect of the elbow in the extended position of the forearm.

OSTEOLOGY OF ARM –

HUMERUS

It is the longest bone of the upper limb.

It has an upper end , a shaft and a lower end....

UPPER END –

1. Head is directed medially , superiorly and posteriorly. It articulates with glenoid cavity of the scapula to form a shoulder joint. The head forms about one third of sphere and is much larger than the glenoid cavity.

2. The line separating head from rest of the upper end is called Anatomical neck.

3. The lesser tubercle is an elevation of anterior aspect of upper end.

4. The greater tubercle is an elevation that forms the lateral part of an upper end. Its posterior aspect is formed by three impressions upper, middle and lower for insertions of muscles of Rotator cuff.

5. The intertubercular sulcus or bacipital groove separates the lesser tubercle from greater tubercle. The sulcus has medial and lateral lips that represents downward prolongations of the lesser and greater tubercles.

THE SHAFT –

The shaft is rounded in its upper half and triangular in the lower half. It has three borders and three surfaces.

BORDERS –

1. The upper one third of anterior border forms the lateral lip of the intertubercular sulcus. In its middle part , it forms an anterior margin of the deltoid tuberosity. The lower half of an anterior border is smooth and rounded.

2. The lateral border is prominent only at the lower end where it forms the lateral supracondylar ridge. In the upper part, it is barely traceable upto the posterior border of greater tubercle. In the middle part, it is interrupted by the radial or spiral groove.

3. The upper part of medial border forms the medial lip of the intertubercular sulcus. About the middle it presents a rough strip. It is continuous below with the medial supracondylar ridge.

SURFACES –

1. The anterolateral surface lies between the anterior and lateral borders. The upper half of this surface is covered by the deltoid. A little above the middle it is marked by a V shaped deltoid tuberosity. Behind the deltoid tuberosity the radial groove runs downwards and forwards across the surface.

2. The anteromedial surface lies between the anterior and medial borders. Its upper one third is narrow and forms the floor of the intertubercular sulcus. A nutrient foramen is seen on this surface near its middle, near the medial border.

3. The posterior surface lies between the medial and lateral borders, its upper part is marked by an oblique ridge. The middle one third is crossed by the radial groove.

LOWER END –

The lower end of humerus forms the condyle which is expanded from side to side, and has articular and non-articular parts. The articular part includes the following.

1. The capitulum is a rounded projection which articulates with the head of radius.

2. The trochlea is a pully shaped surface. It articulates with the trochlear notch of the ulna. The medial edge of the trochlea projects downwards down 6mm more than the lateral edge, his results in the formation of carrying angle.

The non-articular part includes the following –

1. The medial epicondyle is a prominent bony projection on the medial side of the lower end. It is subcutaneous and is easily felt on the medial side of elbow.

2. The lateral epicondyle is smaller than the medial epicondyle. Its anterolateral part has a muscular impression.

3. The sharp lateral margin just above the lower end is called as lateral supracondylar ridge.

4. The medial supracondylar ridge is a similar ridge on medial side.

5. The coronoid fossa is a depression just above the anterior aspect of the capitulum. It accommodates the head of radius when the elbow is flexed.

6. The olecrenon fossa lies just above the posterior aspect of the trochlea. It accommodates the olecrenon process of the ulna when elbow is extended.

OSSIFICATION –

The humerus ossifies from one primary centre and 7 secondary centres. The primary centre appears in the middle of the diaphysis during the 8th week of development.

The upper end ossifies from 3 secondary centres –

- One for the head in the first year

- One for greater tubercle in the second year

- One for lesser tubercle in the fifth year

The three centres fuses during 6th year to form one epiphysis which fuses with the shaft during 20th year. The epiphyseal line encircles the bone at the level of the lowest margin of the head. This is the growing end of the bone.

The lower end ossifies from 4 centres which form 2 epiphyses. The centre include - --

- One for capitulum and lateral flange of trochlea in the first year,

- One for medial flange of trochlea in the 9th year,

- One for the lateral epicondyle in the 12th year

All the three fuses during 14th year to form one epiphysis which fuses which the shaft at about 16th years.

The centre for medial epicondyle appears during 4-6 years , forms a separate epiphysis, and fuses with the shaft during the 20th years.

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Fig.No.3

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Fig.No.4

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Fig.No.5

Arterial supply of the Adult Humerus:- 26 , 30

Healing of the fracture like any other wound, depends upon blood supply (Johnson-1927). P.G.Laing(3) from the surgical & pathological services, department of veterans service hospital, Lancaster, studied the blood supply of adult humerus by injecting radio opaque contrast medium into the brachial artery of cadavers & taking radiographs. The largest artery supplying the humerus is termed as the main nutrient artery.

According to his study, the main nutrient artery arises in 2/3 cases from the brachial artery & in the remaining cases from the profunda brachii artery. The point of entry of the main nutrient artery to the humerus is a restricted area, beginning on the medial side of the distal third & spiraling upwards & medially to the dorsal surface of the middle third of the shaft. This was proved by dissection in cadavers undertaken by S.E.Carroll in the university of Ontario, Canada. CARROL’s study also revealed that 2/3 of the humerus had single nutrient foramen & the mean position is distal to the midpoint of the humerus & distal to the insertion of the deltoid. ¾ of the foramen are found in the medial border or the anteromedial border or the anteromedial surface.

The main nutrient artery on or before entering the bone divides into ascending & descending branches. The ascending branch travels up the medullary canal & anastamoses with accessory nutrient arteries & with periosteal vessels through transcortical vessels. In most cases, a peculiar coiled arrangement of the beginning of the ascending branch was noted in the study of P.G.Laing. Descending branches are usually smaller, divides immediately into branches to reach supracondylar region. Accessory nutrient arteries vary from 1-4 in number & may arise from anterior circumflex humeral artery or profunda brachii artery. These arteries enter the bone either in the spiral groove or in the anterolateral surface, mostly in the upper third of the shaft. No accessory nutrient artery was found between the site of the main nutrient artery & the epicondylar region.

Practical importance of blood supply:- 26,30

Healing of fracture depends upon the blood supply (Johnson 1927). Injury to nutrient artery at the time of trauma or during manipulation or during surgery, may be a significant predisposing factor for non-union (Steward 1955, Watson Jones 1955, Kennedy 1957,Mercer 1959,Turek1959). If surgeons could avoid the area of cortex of the humerus containing the nutrient artery foramen during open reduction an improvement in the result might be expected (S.E.Carroll).The danger of damaging the blood supply during operation is maximum in open reduction of fractures at the junction of middle & lower third. In such cases upper end of lower fragment will depend on epicondylar vessels & periosteal stripping of the lower fragment should be avoided. Because of the intremedullary course of the nutrient artery, it may get damaged during intramedullary nailing & at the same time periosteum is stripped extensively, blood supply will be jeopardized unduly.

MUSCULAR ANATOMY OF THE ARM – 36

Arm is composed of two compartments Anterior and Posterior. The anterior compartment of the arm contains three muscles-the coracobrachialis, brachialis, and biceps brachii muscles-which are innervated predominantly by the musculocutaneous nerve.

The posterior compartment contains one muscle-the triceps brachii muscle-which is innervated by the radial nerve.

ANTERIOR COMPARTMENT –

Corachobrachialis –

The coracobrachialis extends from the tip of coracoids process of the scapula to the medial side of the midshaft of the humerus.

It passes through the Axilla and is penetrated and innervated by the musculocutaneous nerve.

The coracobrachialis flexes the arm at the glenohumeral joint.

Biceps brachii –

The biceps brachii muscles has got two heads –

• The short head of it originates from coracoids process in conjunction with coracobrachialis.

• The long head originates from supraglenoid tubercle of scapula.

The tendon of long head of biceps passes through the glenohumeral joint superior to the head of humerus , then passes through the intertubercular sulcus and enters the arm. In the arm the tendon joins with its muscle belly and together with the muscle belly of the short head , overlies the brachialis muscle.

The long head and short head converges to form a tendon which inserts on a radial tuberosity.

As the tendon enters the forearm , a flat sheet of connective tissue (bacipital apponeurosis) fans out from the medial side of the tendon to blend with the deep fascia covering the anterior compartment of the forearm.

The biceps brachii muscle is a powerful flexor of the forearm at the elbow , it is also the most powerful supinator of the forearm when elbow is flexed. Because the two heads crosses the glenohumeral joint , the muscle also flexes the arm.

The biceps brachii muscle is innervated by the musculocutaneous nerve.

A tap on the tendon of biceps brachii at the elbow tests predominantly spinal cord segment C6.

Brachialis –

The brachialis muscle originates from the distal half of the anterior aspect of the humerus and from adjacent parts of the intermuscular septa, particularly on the medial side. It lies beneath the biceps brachii muscle, is flattened dorsoventrally, and converges to form a tendon , which attaches to the tuberosity of ulna.

The brachialis muscle flexes the forearm at the elbow joint.

Innervations of brachialis muscle is predominantly by the musculocutaneous nerve. A small component of the lateral part is innervated by the radial nerve.

POSTERIOR COMPARTMENT –

Triceps brachii –

It is the only muscle of the posterior compartment of the arm. It has got three heads –

• The long head originates from the infraglenoid tubercle of the scapula.

• The medial head originates from the extensive area on the shaft of the humerus inferior to the radial groove.

• The lateral head originates from a linear roughening superior to the radial groove of the humerus.

The three head converge to form a large tendon , which inserts on the superior surface of the olecrenon of the ulna.

The triceps brachii muscle extends the forearm at the elbow joint.

Innervations of triceps brachii is by branches of the radial nerve.

A tap on the tendon of triceps tests predominantly spinal cord segment of C7.

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Fig.No.6

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Fig.No.7

Arteries of the Arm:- 36

Brachial artery:-

It is the continuation of axillary artery. It extends from the lower border of teres major muscle to the neck of the radius where it divides into ulnar & radial arteries. It is superficial throughout its course, anteriorly, it is related to medial cutaneous nerve of the arm & the median nerve in the upper & lower halves respectively. Medially, it is related to ulnar & median nerve in the upper & lower parts respectively. Laterally, it is related to biceps, coracobrachialis & median nerve.

Branches:-

1) Profunda brachii artery leaves through the lower triangular space, runs in the spiral groove with the radial nerve. Apart from the muscular branches it supplies the following arteries, nutrient artery, deltoid branch, middle collateral & radial collateral vessels. The deltoid branch ascends between the lateral & long head of triceps & anastamoses with the descending branch of posterior circumflex humeral artery. The middle collateral branch ascends in the substance of the medial head of triceps to the elbow where it anastamoses with the interosseous recurrent artery behind the lateral epicondyle. The radial collateral artery accompanies the radial nerve through the lateral intermuscular septum & then descends between the brachialis & the brachioradialis to the front of the lateral epicondyle where it anastamoses with the radial recurrent artery.

2) Superior ulnar collateral artery arises little below the middle of the arm & accompanies the ulnar nerve & ends deep to flexor carpi ulnaris by anastamoizing with posterior ulnar recurrent artery.

3) Inferior ulnar collateral arteries ( supra trochlear) starts about 5 cms above the elbow & ends by anastamoizing with anterior ulnar recurrent artery.

4) Nutrient artery to humerus sometimes arises from the profunda brachii artery in the radial sulcus.

Veins of the Arm –

Paired brachial veins pass along the medial and lateral sides of the brachial artery, receiving tributaries that accompany branches of the artery.

In addition to these deep veins, two large subcutaneous veins, the basilica vein and the cephalic vein are located in the arm.

The basilic vein passes vertically in the distal half of the arm , penetrates the deep fascia to assume a position medial to the brachial artery , and then becomes the axillary vein at the lower border of the teres major muscle.

The brachial vein join the basilic or axillay vein.

The cephalic vein passes superiorly on the anterolateral aspect of the arm and through the anterior wall of axilla to reach the axillary vein.

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Fig.No.8

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Fig.No.9

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Fig.No.10

NERVES - 36

Musculocutaneous nerve

The musculocutaneous nerve leaves the axilla and enters the arm by passing through the coracobrachialis muscle. It passes diagonally down the arm in the plane between the biceps brachii and brachialis muscles. After giving rise to motor branches in the arm, it emerges laterally to the tendon of the biceps brachii muscle at the elbow, penetrates deep fascia, and continues as the lateral cutaneous nerve of forearm.

The musculocutaneous nerve provides:

• motor innervation to all muscles in the anterior compartment of the arm; and

• sensory innervation to skin on the lateral surface of the forearm.

Median nerve

The median nerve enters the arm from the axilla at the inferior margin of the teres major muscle. It passes vertically down the medial side of the arm in the anterior compartment and is related to the brachial artery throughout its course:

• in proximal regions, the median nerve is immediately lateral to the brachial artery; in more distal regions, the median nerve crosses to the medial side of the brachial artery and lies anterior to the elbow joint.

The median nerve has no major branches in the arm, but a branch to one of the muscles of the forearm, the pronator teres muscle, may originate from the nerve immediately proximal to the elbow joint.

Ulnar nerve

The ulnar nerve enters the arm with the median nerve and axillary artery .It passes through proximal regions medial to the axillary artery. In the middle of the arm, the ulnar nerve penetrates the medial intermuscular septum and enters the posterior compartment where it lies anterior to the medial head of the triceps brachii muscle. It passes posterior to the medial epicondyle of the humerus and then into the anterior compartment of the forearm.

The ulnar nerve has no major branches in the arm.

Radial nerve

The radial nerve originates from the posterior cord of the brachial plexus and enters the arm by crossing the inferior margin of the teres major muscle. As it enters the arm, it lies posterior to the brachial artery. Accompanied by the profunda brachii artery, the radial nerve enters the posterior compartment of the arm by passing through the triangular interval.

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As the radial nerve passes diagonally, from medial to lateral, through the posterior compartment, it lies in the radial groove directly on bone. On the lateral side of the arm, it passes anteriorly through the lateral intermuscular septum and enters the anterior compartment where it lies between the brachialis muscle and a muscle of the posterior compartment of the forearm-the brachioradialis muscle, which attaches to the lateral supraepicondylar ridge of the humerus. The radial nerve enters the forearm anterior to the lateral epicondyle of the humerus, just deep to the brachioradialis muscle.

In the arm, the radial nerve has muscular and cutaneous branches

• Muscular branches include those to the triceps brachii, brachioradialis, and extensor carpi radialis longus muscles. In addition, the radial nerve contributes to the innervation of the lateral part of the brachialis muscle. One of the branches to the medial head of the triceps brachii muscle arises before the radial nerve's entrance into the posterior compartment and passes vertically down the arm in association with the ulnar nerve.

Surgical Anatomy of Humerus:-26

Humerus is not a weight bearing bone & therefore compression forces are not a factor & shortening does not significantly worsen the end results. The freely movable scapulohumeral articulation minimizes tortional stresses.

Humerus is the most easily reducible of all the long bones which can easily be accomplished under sedation. Malunion up to 20 degrees of anterior angulation & 30 degrees of varus is tolerated without compromising function of appearance.13Transverse fractures of the middle third of humerus heals slowly because of small fracture surface area. Distraction & angulations may occur due to long lever arm which is difficult to immobilize. Proper rotation is also a problem during healing as the forearm is usually is brought in front of the chest causing the distal fragment to rotate internally while the proximal fragment is in neutral rotation.

The critical zone is at the junction of the middle third & lower third of the shaft. Here lies the radial nerve and it is close to the bone as it penetrates the lateral intermuscular septum. Here too main nutrient artery enters the shaft medially near the insertion of the coracobrachialis tendon. The blood supply to the shaft is limited compared to metaphysis. Middle third shaft fracture may damage the nutrient artery, thus contributing to delayed & non-unions.

MECHANISM OF INJURY 11,13

Humeral shaft fractures result from direct & indirect trauma. In majority of cases, they are the result of direct injury such as in road traffic accident(RTA) and fall from height. It may also result from indirect trauma such as fracture due to extreme muscle contractions in cases of seizure disorder.

Compressive forces result in fracture in proximal or distal end of humerus. Bending forces, however, typically result in transverse fractures of the humerus shaft.

Torsional forces result in spiral fracture patterns. The combination of bending & torsion usually results in an oblique fractures, often with an associated butterfly fragment. Greater amounts of comminution & soft tissue injury results from high energy injuries.

The muscle forces that act on the humeral shaft produce characteristic deformities. A fracture proximal to the pectoralis major insertion results in abduction & internal rotation of the proximal fragments secondary to the pull of rotator cuff, while the distal fragment is displaced medially by pectoralis major. If the fracture is distal to the pectoralis major insertion & proximal to the deltoid insertion, the distal fragment is laterally displaced by the deltoid, while the pectoralis major, latissimus dorsi & teres major displace the proximal fracture medially. When the fracture is distal to deltoid insertion, the proximal fragment is abducted & flexed while the distal fragment is proximally displaced.

Patient with humeral shaft fracture presents with history of trauma, arm pain, swelling & deformity. The arm is shortened with local tenderness & crepitus on gentle manipulation. Neurovascular status of the extremity must be assessed. Associated injuries should be examined and life threatening injuries must be managed first.

The standard X-ray views include anteroposterior & lateral views. The shoulder & elbow joint should be included in each view.

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Fig No - 11

Biomechanics of Fracture

CLASSIFICATION

According to Rockwood & Green26, fractures of the humeral shaft may be conveniently classified on the basis of various factors. Several categories are used for full descriptive classification of individual fractures.

1) Communication with external environment.

a) Open.

b) Closed.

2) Location of fracture.

a) Above the pectoralis major insertion.

b) Below the pectoralis major insertion but above the deltoid insertion.

c) Below the deltoid insertion.

3) Degree of fracture.

a) Incomplete.

b) Complete.

4) Direction & character of fracture line.

a) Longitudinal.

b) Transverse.

c) Oblique.

d) Spiral.

e) Segmental.

f) Comminuted.

5) Associated injury.

a) Nerve

i. Radial.

ii. Median.

iii. Ulnar.

b) Blood vessels.

i) Brachial artery.

ii) Veins.

6) Intrinsic condition of bone.

a) Normal.

b) Pathological.

i) Due to local pathology.

ii) Bone atrophy.

iii) Inflammatory process.

iv) Neoplasia.

7) Disorders affecting entire skeleton.

i) Congenital abnormalities.

ii) Metabolic bone disease.

iii) Disseminated bone disorders of unknown etiology.

II. According to L. Klenerman(1966) of London, fractures of the shaft of humerus were classified depending on the level of fracture.

1) Fractures of upper third.

2) Fractures at the junction of upper & middle third.

3) Fractures of middle third.

4) Fractures at the junction of middle & distal third.

5) Fractures of the lower third.

III. According to A.O.Classification26,

Muller, M.E. Allgower, Willenegger, classified fractures of the humeral shaft based on the morphologic characteristics & the location of the fracture. Depending on the fracture it is classified into simple- A, Wedge- B & Complex-C. Further Spiral fractures of the Humerus are given the number 1, Oblique fractures of the Humerus are given the number 2 and Transverse fractures of the Humerus are given the number 3.. Each subgroup is divided into A1, A2, A3, B1,B2,B3 and C1,C2,C3. & each group is further subdivided into 3 subgroups denoted by a number .1, .2, .3 & finally there are 27 subgroups. A1 indicates the simplest fracture with best prognosis & C3 the most difficult fracture with worst prognosis.

A- Simple fracture.

A1 Simple fracture, Spiral.

A1.1 Proximal zone.

A1.2 Middle zone.

A1.3 Distal Zone.

A2 Simple fracture, oblique.(greater than or equal to 30 degrees)

A2.1 Proximal zone.

A2.2 Middle zone.

A2.3 Distal zone.

A3 Simple fracture, transverse.(less than 30 degrees)

A3.1 Proximal zone.

A3.2 Middle zone.

A3.3 Distal zone.

B- Wedge fracture.

B1 Wedge fracture, spiral wedge.

B1.1 Proximal zone.

B1.2 Middle zone.

B1.3 Distal zone.

B2 Wedge fracture, bending wedge.

B2.1 Proximal zone.

B2.2 Middle zone.

B2.3 Distal zone.

B3 Wedge fracture, fragmented wedge.

B3.1 Proximal zone.

B3.2 Middle zone.

B3.3 Distal zone.

C- Complex fracture.

C1 Complex fracture, spiral.

C1.1 with two intermediate fragments.

C1.2 with three intermediate fragments.

C1.3 with more than three intermediate fragments.

C2 Complex fracture, segmental.

C2.1 with one intermediate segmental fragment.

C2.2 with one intermediate segmental &additional wedge fragment(s).

C2.3 with two intermediate segmental fragments.

C3 Complex fracture, irregular.

C3.1 with two or three intermediate fragments.

C3.2 with limited shattering (4cms).

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Fig No – 12: Classification Of Fracture

MANAGEMENT

Many methods have been described for the treatment of humeral shaft fractures. Good to excellent results have been reported in most series of humeral shaft fractures treated by non-operative or by open reduction & internal fixation. But non-operative methods are associated with a significant risk of non-union, malunion, fracture disease. Open reduction & internal fixation is required in unstable fracture, comminuted fracture even though it is associated with relatively high incidence of delayed union, non-union, risk of infection and the risk of radial nerve injury.

The numerous methods available today allow considerable individuality in the selection of the technique. The type & level of fracture, the patient’s age & co-operation of the patient, the degree of fracture displacement & presence of associated injuries are factors that influence the choice of treatment.

NON-OPERATIVE TREATMENT:-

HANGING ARM CAST:37,38

It is a traction method introduced by Caldwell in 1933, which uses dependency traction provided by the weight of the cast to effect fracture reduction. This dependency traction may cause fracture distraction resulting in delayed union or nonunion.

The indications include displaced midshaft fractures with shortening, particularly those fractures with an oblique or spiral pattern. It is useful when certain principles are followed.

i) The arm must always be in dependent position and it is considered to cause fracture distraction.

ii) It should be of light weight and extend from at least 2 cms proximal to the fracture site to the wrist joint distally, with the elbow in 90 degree flexion and forearm in neutral rotation.

iii) The sling must be securely fixed at the wrist by a loop of POP, to correct lateral angulation place the loop on the dorsum of the wrist and to correct the medial angulation placed on the volar side. Lengthening the sling corrects posterior angulation while shortening corrects anterior angulation.

iv) Check X-ray has to be done weekly.

v) Shoulder and hand range of motion exercises are instituted as pain subsides.

COAPTATION SPLINT:39

A molded plaster slab (U shaped brachial splint) is placed around the medial and lateral aspects of the arm, extending around the elbow and over the deltoid and acromion with a cuff and collar introduced by Rowly in 1942. It does not cause hanging effect at the fracture site as in the hanging cast. It has distinct advantage of allowing exercises of elbow, wrist, hand & to some extent the shoulder during the entire period of immobilization.

ABDUCTION HUMERAL SPLINT:28

Stewart has advocated the use of humeral abductional splint in humeral shaft fractures. Closed and continued observation is required. It increases level of comfort as well as it eliminates effect of gravity.

SHOULDER SPICA CAST ( THORACO HUMERAL SPICA CAST):26

It is recommended in the early healing stage of the unstable fractures where delayed or non-union appears imminent. It usually replaced by a simpler form of treatment following reduction for maintenance. Patient non compliance is the main disadvantage, more so in hot and humid climates, old, obese patients and in patients with significant pulmonary problems.

OPEN VELPEAU METHOD:40

Gilchrist has described the open velpeau type cast for undisplaced or minimally displaced fractures in active and unmanageable children or for some elderly patients unable to tolerate hanging cast. The desired degree of abduction and forward flexion at shoulder is maintained by axillary & forearm pads. In these cases patient comfort, not fracture reduction is the critical consideration. Early humeral fracture brace application is considered as well.

FUNCTIONAL BRACING:15,41,42,43

The humeral functional brace was first described by Sarmiento in 1977. A functional brace is an orthosis that effects fracture reduction through soft tissue compression. Use of this device maximizes shoulder and elbow motion. This brace initially was custom-made and designed as a wrap around sleeve. Now a days these braces comes prefabricated. It consists of an anterior shell (contoured for the biceps tendon distally) and a posterior shell. These shells are circularized with velcro straps, which can be tightened as swelling decreases. The proximal aspect of the brace approaches the acromion laterally and encircles the arm underneath the axilla medially. Distally, the sleeve fashioned to avoid the medial and lateral epicondyles permitting free elbow motion.

Contra indications include :-

i) Massive soft tissue injury or bone loss

ii) Unreliable or uncooperative patient

iii) Inability to obtain or maintain acceptable fracture alignment.

The fracture brace can be applied acutely or 1-2 weeks after application of a hanging arm cast or coaptation splint. If the brace is applied acutely, the patient should be re-evaluated to assess the extremity`s neurovascular status and amount of arm or forearm oedema. The patient instructed to keep the arm hanging free of the body, use of a sling may result in varus angulation. The patient is followed at weekly intervals for the first 3-4 weeks to assess fracture alignment & is instructed to do pendulum exercises and range of motion of the shoulder, elbow, wrist and hand. The patient is encouraged to remain upright to allow gravity assisting fracture reduction. When patient comfort permits, the brace removed for hygiene. The brace is worn for a minimum of 8 weeks post reduction.

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Fig No - 13

OPERATIVE TREATMENT:

INTRAMEDULLARY NAILS:

There are two types

1. Flexible intramedullary nails-23

Include Ender nails, Hackenthal nails and Rush nails. They can be used retrograde from the distal humerus or antegrade near the rotator cuff. These nails do not provide rigid fixation or prevent shortening or rotational control. Use of a functional brace should be considered for additional stability.

2. Interlocking nails like Seidal nails, Russel Taylor nails.44,45

These nails usually rely on proximal screw or distal screw or pin fixation to provide stability. They maintain alignment of unstable fracture preventing fracture shortening and rotation. They can be used to stabilize fractures from 2 cms distal to the surgical neck to 3 cms proximal to the olecranon fossa. These nails can be inserted antegrade through the rotator cuff/ greater tuberosity or retrograde proximal to the olecranon fossa with or without prior reaming.

PLATES & SCREWS:35,46

Plates and screws are devices which are fastened to bone for the purpose of fixation.

They are principally differentiated by their function as-

i. Neutralization plate

ii. Buttress plate

iii. Compression plate

iv. Tension band plate

Plates and screws fixation undergone continual design modification and improvements. Some of them are

a. Regular ASIF with ordinary round holes

b. Semi-tubular plate

c. Round holes with key holes at the end of the plate for facilitating the Muller`s compression device.

d. Dynamic compression plate (DCP)

e. Limited contact-DCP (LC-DCP)

Plates offer the benefits of anatomical reduction, stable fixation without violation of the rotator cuff and early function of the muscle-tendon units and joints.

Disadvantages of plate fixation include opening up of the fracture site causing soft tissue trauma, evacuation of the fracture haematoma, risk of bone refracture after plate removal, plate irritation and rarely an immunologic reaction.

Basic designs of plating are:

a. Careful handling of implant

b. Correct plate contouring before application

c. Drill diameter slightly smaller than screw diameter

d. Measurement of screw holes with depth gauge

e. Proper orientation of screw heads in the plate

f. Final tightening of all screws and assessing the fracture stability before closure.

Plates used are must be of appropriate length and screw fixation should be adequate.

Over torquing of the screws should be avoided during insertion. Minimal soft tissue stripping must be performed; butterfly fragments must not be devitalized. Severe comminuted fragments require cancellous bone grafts.

A 4.5 mm broad DCP is usually used for shaft fractures in average to large sized patients. In smaller patients, a 4.5 mm narrow DCP may be used. If the fracture permits, the plate should be applied in compression with lag screw insertion whenever possible. These plates are fixed to bone with the help of 4.5mm cortical screws.

COMPLICATIONS AND ITS MANAGEMENT

The complications of fractures of the humeral shaft are:

1. Nerve injury

a. Radial nerve

b. Ulnar nerve

c. Median nerve

2. Vascular injury

3. Non-union

4. Mal union

Radial nerve injury:47,48,49

This is the most common complication. It could occur at the time of injury or following manipulative reduction or operative treatment or rarely due to callus. Up to 18% of humeral shaft fractures have an associated radial nerve injury. Although the Holstein-Lewis fracture (oblique, distal third) is the best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle third fractures. Most nerve injuries represent a neurapraxia or axonotmesis; 90% will resolve in 3-4 months. Electromyography and nerve conduction studies can aid in determining the degree of nerve injury and monitor the rate of nerve degeneration.

Early exploration is indicated for radial nerve palsy associated with open fractures. Penetrating injuries develop after fracture manipulation are due to trapping of nerve ends between fractured fragments. Radial nerve palsies that occur at the time of closed humeral fracture should be observed and radial nerve exploration is preferred at 6 to 12 months after injury if there is lack of neurologic improvement.

Other Nerves:

Ulnar nerve 50 |2(18.18%) |1(9.09%) | |

|Total |11(100.00%) |11(100.00%) | |

|Mean Age |39.00 |32.18 | |

|SD |13.42 |14.89 | |

Graph 1: Age wise distribution of patients in both the groups

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The age varies from 20-60 yrs in both groups. The mean age in group I is 39 yrs and in group II is 33 yrs. Maximum patients were from age 20-40 yrs in group I (36%) and from 20-30 yrs in group II.(54%).

There was no statistical difference in age amongst two groups.

Table 2: Gender wise distribution of patients in both the groups

|Gender |Nail Group |Plate Group |ﭏ2-value |

|Male |10(90.91%) |10(90.91%) |0.00 |

| | | |p-value=1.00 |

| | | |NS,p>0.05 |

|Female |1(9.09%) |1(9.09%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 2: Gender wise distribution of patients in both the groups

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There was higher incidence for male patients in both groups. (90%)

Table 3: Distribution of patients according to classification of fracture in both the groups

|Classification of fracture |Nail Group |Plate Group |ﭏ2-value |

|A |5(45.45%) |2(18.18%) |2.06 |

| | | |p-value=0.35 |

| | | |NS,p>0.05 |

|B |4(36.36%) |5(45.45%) | |

|C |2(18.18%) |4(36.36%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 3: Distribution of patients according to classification

of fracture in both the groups

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In group I type A fracture were commonest (45%) in group II type B fracture were commonest (36%)

Table 4: Distribution of patients according to mode of Injury in both the groups

|Mode of injury |Nail Group |Plate Group |ﭏ2-value |

|RTA |5(45.45%) |7(63.64%) |0.80 |

| | | |p-value=0.66 |

| | | |NS,p>0.05 |

|Fall from height |4(36.36%) |3(27.27%) | |

|Trivial Trauma |2(18.18%) |1(9.09%) | |

|Assault |0(0.00%) |0(0.00%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 4: Distribution of patients according to mode of Injury in both the groups

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RTA was the most common mode of injury in both groups of patients as in group I 5 patients (45%) were injured due to this and 7 patients in Group II (64%) were injured due to this. History of fall was the second commonest mode.

Table 5: Distribution of patients according to anatomical level in the humerus in both the groups

|Anatomical Level |Nail Group |Plate Group |ﭏ2-value |

|Lower 1/3rd |1(9.09%) |2(18.18%) |5.81 |

| | | |p-value=0.21 |

| | | |NS,p>0.05 |

|Middle-lower 1/3rd |1(9.09%) |5(45.45%) | |

|Middle 1/3rd |7(63.64%) |4(36.36%) | |

|Middle-upper 1/3rd |1(9.09%) |0(0.00%) | |

|Upper 1/3rd | 1(9.09%) | 0(0.00%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 5: Distribution of patients according to anatomical level in the humerus in both the groups

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The most common site in arm was affected was middle 1/3rd in group I (63%) and middle-lower 1/3rd in second group (45%).

The difference between two was not statistically significant.

Table 6: Distribution of patients according to associated Injuries in both the groups

|Associated conditions |Nail Group |Plate Group |ﭏ2-value |

|# B.B Forearm |1(9.09%) |0(0.00%) |8.81 |

| | | |p-value=0.18 |

| | | |NS,p>0.05 |

|# Olecrenone |1(9.09%) |0(0.00%) | |

|# D/E Radius with # Ulna |0(0.00%) |1(9.09%) | |

|Gross Oedema |0(0.00%) |1(9.09%) | |

|Wrist drop |0(0.00%) |2(18.18%) | |

|Ipsilateral # Ulna |0(0.00%) |1(9.09%) | |

|None |9(81.82%) |4(36.36%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 6: Distribution of patients according to associated Injuries in both the groups

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9 patients (82%) from group I and 6 patients from group II (54%) got isolated fracture shaft humerus.

Table 7: Distribution of patients according to ASA grading in both the groups

|ASA Grading |Nail Group |Plate Group |ﭏ2-value |

|I |9(81.82%) |10(90.91%) |0.38 |

| | | |p-value=0.53 |

| | | |NS,p>0.05 |

|II |2(18.18%) |1(9.09%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 7: Distribution of patients according to ASA grading in both the groups

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Maximum patients in both groups were not having any major systemic illness as 9 patients (82%) from group I and 10 patients (91%) from group II was under ASA Grade I. remaining patients were under grade II. No patients were under grade III , IV and V.

Table 8: Distribution of patients according to time of

Union in both the groups

|Time of union(wks) |Nail Group |Plate Group |t-value |

|Mean |18.72 |13.27 |5.30 |

| | | |p-value=0.000 |

| | | |S,p0.05 |

|Superficial Infection |0(0.00%) |1(9.09%) | |

|Impingement syndrome |1(9.09%) |0(0.00%) | |

|Iatrogenic Radial Nerve Palsy |0(0.00%) |0(0.00%) | |

|None |8(72.73%) |10(90.91%) | |

|Total |11(100.00%) |11(100.00%) | |

Graph 10: Distribution of patients according to complications

in both the groups

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Complication rate of 27% found in group I as 3 patients out of 11 had complications. In second group this rate was pretty good of 9% as only one patient had complication.

There was no statistical difference between two groups.

Table 11: Distribution of patients according to radial nerve injury

|Radial nerve injury |On admission |After fixation |Total |

|No. of patients |2 |0 |2 |

|Percentage(%) |18.18% |0.00% |18.18% |

Graph 11: Distribution of patients according to radial nerve injury

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Two patients had associated radial nerve injury along with humeral shaft fracture. (18.18%). No iatrogenic radial nerve palsy was found.

DISCUSSION

The arm serves an important role in upper extremity. It articulates or perhaps participates to form two major joints of upper limb shoulder and elbow which required vitally in life to perform major activities of life.

To achieve satisfactory functional results diphyseal fractures of humerus needs near anatomical reduction.

Majority of patients of our institute are from rural areas so affordability is a major factor. Patient wants a low cost fixation to his fracture. In such a senario plate fixation can be preferred over locked nailing as the cost of nailing is higher than that of plating. The need for low cost biological fixation method lead us to do this comparative study.

The variables of this study were compared in two groups and with some other related studies.

1. Age –

In a comparative study done by T.MULIER and D.SELINGSON on 55 patients they found age of patients ranges between 30-40yrs. R.G Mccormak et all in his prospective study of 44 patients found that such fractures were common in age group of 35-45 yrs. F.S.L Meekars et all noted mean age for fracture shaft of humerus is 38 yrs. M.Changulani and U.K. Jain reported commonest age range of 30-50 yrs for fracture shaft of humerus. Mohit Bhandari and Michael D. Mckee in his meta-analysis of 215 patients found commonest age range of 25-50 yrs and mean age was 35yrs. Another study of 401 fractures done by R.Ekholm , J.Adami and they have noted mean age of 40 yrs. Kiran Singisetti et all reported mean age of 45 yrs. Amit B Putti , Rajendra Uppin recorded mean age of 32 yrs in their comparative study. In recent comparative studies done are recorded mean age of 39 yrs ranges from 20-60yrs. A comparative study done by S.Raghvendra and Haresh Bhalodiya , they found mean age of 40 yrs. In our study mean age is of 36 yrs ranges from 20-60 yrs which co-relates with other studies.

2. Gender distribution-

Mohit Bhandari and Michael D. Mckee found in his meta-analysis of 215 patients that the fracture was male predominated. R.Ekholm and J.Adami found in his study of 401 fractures that male was on high predominance than female. S. Raghavendra and Haresh Bhalodiya found that male was predominated. Other all studies highlight male predominance for this fractures. Male predominance than female for this fracture due to high exposure of males to high energy trauma than females.

3. Classification of fractures –

Rockwood classified fractures simply into three types – A , B , C

A – Simple Fracture

B – Wedge fracture

C – Complex fracture

Each fractures has its subclasses. Many studies done on treatment of humeral shaft fractures includes their inclusive fractures classified according to this gross classification. It will be also easy to plan a management according to it.

In an study of 401 patients done by R.Ekholam et all (2006) he found that simple fractures were by far the most common and all were treated by nailing.

In many mentioned studies simple fractures were treated by nailing and some of wedge fractures too. Many of wedge fractures were treated by plate fixation. Complex fractures were exclusively treated by plate fixation as some of them required bone grafting.

In our study simple fractures and some of wedge fractures were treated by an intramedullary nail fixation and all other wedge fractures and complex fractures were fixed with plate.

4. Mode Of Injury -

T. Mulier et all recorded the commonest cause to cause this type of fracture is high energy trauma such as due to road traffic accident and secondly due to fall from height .R.G Mccormack reported road traffic accident is the commonest cause for such type of injury.

Mohit Bhandari and Michael D. Mckee in his meta analysis of 215 patients reported that R.T.A being the commonest cause for such type of injury.

All other articles are in favour that such type of injuries are commonly occur due to R.T.A. this is because this fracture is common in young age group which exposes to road traffic accidents very oftenly.

In our study the commonest mode of injury is R.T.A and 2nd is the fall from height which is in conjunction with other studies.

5. Fracture Anatomy -

F.S.L Meekers et all in his study noted that majority of fractures were treated was at middle 1/3rd of shaft. Fractures associated in 5 cm of surgical neck and in 5cm of olecrenon fossa were excluded.

R.Ekholam et all (2006) in his meta-analysis of 401 patients found that fracture of shaft of humerus were commonest in middle 1/3rd and of spiral type.

M.Changulani and U.K jain found that majority of fractures were located in the middle 1/3rd of shaft.

Amit B Putti and Rajendra Uppin reported maximum fractures at middle 1/3rd level and some fractures at lower 1/3rd level.

S.Raghvendra et all in his studies noted that fracture is common at middle 1/3rd of shaft. He recorded 20 cases out of 36 cases fractured at mid shaft of humerus.

In our study majority of fractures were in middle 1/3rd of shaft which is in support with others.

6. Associted Injury –

T Mulier et all reported 15% of associated injuries along with fracture shaft of humerus which was operated on the same day of shaft of humerus. Mohit bhandari and Micheal D Mckee found 40% associated injuries. Amit B Putti and Babu B Putti recorded 50% of associated injuries.

In our study we came across associated injuries like compartment syndrome , fracture of both bones of forearm , fracture of ulna and olecrenon , fracture of D/E radius. These fractures were managed according to their need of emergency.

7. Follow-up -

In a study done by R.G Maccormak et all (1999) the mean follow-up was of 12 months (6-33 months). In a prospective comparative study done by Kiran Singisetti et all (2009) he followed up the patient for 12 months (range 10-24 months). In a study done by M.Changulani et all (2006) follow-up time was of 14 months.

In our study the follow up time was of 12 months.

8. Time of union –

T. MULIER et all (1997) found mean time of union of 16 weeks and range from 8weeks to 65 weeks. He found that union time was less in case of plate fixation than nail fixation. R.G Mccormak et all (1999) found less time of union in patients treated with plate osteosynthesis. Some of their patients treated with nailing went into non-union and was underwent second surgery. A study done by F.S.L Meeker’s et all (2002) they found that time of union in patients treated with nailing was significantly longer than in patients treated with plating. M.Changulani et all (2006) reported in their study that time of union was similar in both groups. In a meta-analysis done by Mohit Bhandari et all (2006) they found less time required for union in plating group than nailing group and delayed union and non union was higher in nailing group. In a study done by Amit Putti et all (1999) he reported mean time of healing of 18 weeks in patients treated with nailing group and of 16 weeks in patients with plating. A comparative study done by S.Raghvendra et all (2010) he reported mean time of healing was 25.9 weeks in patients treated with plating and 34.6 weeks in patients treated with nailing group.

In our study we found that mean time of union in patients treated with nailing was 18.72 weeks and for the patients treated with plate osteosynthesis was 13.72 weeks which is lower than nailing which co-relates with other mentioned studies.

9. ASES Score –

To asses patients functionally American shoulder and Elbow surgeons developed a score. This score based on the performance of the patient while doing 13 included daily routine activities. These were arranged as normal, with mild compromise, difficult and great difficult. Grades were given according to score as poor, good and excellent and total score was of 52 points.

R.G Maccormak et all (1999) reported mean ASIS score in a patients treated with nailing was 46 and in patients treated with plate fixation was of 49 . In a study done by M.Changulani et all (2006) he used ASES score to asses the patient post-operatively for functional outcome and he found that mean ASES score in patients treated with nailing was 44 and that of patients treated with plate fixation was 45 yrs. A study done by Kiarn Singisetti et all (2009) he reported the mean ASES score was of 46 in patients treated with nail fixation and 49 in patients treated with plate fixation.

10. Complications –

T. Mulier et all (1997) found non-union rate of 30% in patients treated with nailing and 20% in patients treated with plating. They have also found functional restrictions after nailing. F.S.L Meeker et all (2002) in his comparative study in 232 patients found that non-union rate was significantly high in patients treated with nailing as 14.8% for which they were reoperated. In a meta-analysis done by Mohit

Bhandari et all (2006) they reported high rate of shoulder impingement in patients treated with nailing. A study done by R.Ekholm in 401 patients of fracture shaft of hunerus (2006) they reported functional restrictions in patients treated with nailing rather than plating and high rate of non-union in patients treated by nailing. Amit Putti et all(2009) reported complication rate of 50% in patients treated with nailing and of 17% in patients treated with plating. S.Raghwendra et all (2010) in his study found that significant restrictions of movements were present in patients treated with nailing group.

In our study we have not found any non-union or delayed union. No one patient from our study group required re-operation but we have complication rate of 29% in patients treated with nailing rather than of 9% rate in patients treated with plating. Complications were in the form of restriction of movements , shoulder stiffness and impingement syndrome.

11. Results –

All the above mentioned studies were reported highest rate of union, less time required for union , excellent functional outcome and less complications. So all the above mentioned studies done by T.Mulier et all (1997), F.S.L Meeker (2002), Mohit Bhandari et all (2002) , R.Ekholam et all (2006), Amit Putti et all (2009) and S.Raghvendra et all (2010) found less complications and excellent outcome in patients treated with plate fixation rather than nailing.

In out study we found 100% union in patients treated either nailing or plating with excellent functional amount in patient treated with plating (ASES Score 49) than nailing (ASES Score 45) with very less rate of complications (9%) than of nailing (30%) with faster healing of fracture (Mean Time of union 14 weeks) than in patients treated with nailing (Mean time of union 19 weeks).

SUMMARY

The study is a prospective randomized comparative study of 22 patients of fracture shaft of humerus in adults treated by compression plating and closed nailing. The subjects were divided into 2 groups, Group I patients (n=11) were treated by open reduction and dynamic compression plating and Group II patients (n=11) were treated by closed reduction and intramedullary nailing. The patients were followed up for assessment of radiological and functional results.

In brief -

1) All patients coming to A.V.B.R.H satisfying the inclusion criterion were included in the study.

2) The age group of the patients varied from the 20 to 60 yrs the average being 35 yrs. the maximum no of patients being in the 28 – 38 age group.

3) The series revealed a male preponderance with a Male:Female ratio of 4:1.

4) Both limbs were equally affected.

5) RTA was the most common mechanism of injury.

6) The patients mostly (60%) belonged to occupations requiring heavy labour.

7) Most common level of bones affected was middle third. Fractures of the upper third were uncommon.

8) Open fractures(27%) were uncommon and were treated immediately with definitive management.

9) Acute injuries presenting within 2 weeks were included and the average injury to surgery interval was 5 days.

10) In group I, patients with comminuted fracture , with doubtful fixation were given postoperative immobilization in the form of U slab for 3 weeks and then he was mobilised. Rest patients from group I were mobilised from day 3. Patients from group II were mobilised from day 2.

11) The union time was, 13.27 wks in group I and 18.72 wks in group II.

12) There were few complication and superficial infection in group I, shoulder stiffness, functional restrictions, impingement syndrome were found in group II.

13) Functional results were assessed by ASES Score. The score was 45 in group II and 49 in group I.

CONCLUSION

• Plating required extensive soft tissue exposure, more duration of surgery and blood loss , more chances of injury to radial nerve. It also gives comparatively bigger post-operative scar and delayed mobilisation.

• Interlock Nailing needs proper technique , minimal invasive exposure , small incisions , minimal blood loss , less soft tissue exposure, less surgical time and early mobilisation.

• But functional restrictions are higher in nailing , non union , delayed union are also higher in nailing ,also one cant asses radial nerve intraoperatively, time required to heal the fracture is longer render ultimately prolonged functional recovery.

• Plating was cost-effective than nailing.

• Taking into consideration all the above mentioned points; Plating is the treatment of choice to treat diphyseal fractures of humerus.

BIBLIOGRAPHY

1) Charnaley J - The closed treatment of the common fractures - 3rd ed:1961, Pg 99.

2) L. Klenerman, london, England - fractures of the shaft of the humerus

3) A.Sarmiento, J.B.Zagorski, G.A. Zych, L.L.Latta & C.A. Capps- Functional Bracing for the Treatment of fractures of the Humeral Diaphysis. J.B.J.S.vol-82A April 2000, No.4, 478-486.

4) William Arthur Clark - History of fracture treatment up to the sixteenth century, J Bone Joint Surg Am. 1937;19:47-63.

5) Stig Brorson MD, PhD , Management of Fractures of the Humerus in Ancient Egypt, Greece, and Rome An Historical Review

6) Caldwell J - Treatment of fracture shaft humerus by hanging cast, surh,Gynaec and Obst. 70:421 - 423 , 1940.

7) Augusto Sarmiento, Alan Horowitch, Albert Aboulafia, C. Thoma Vangsness. Jr. functional bracing for Comminuted Extra-Articular fractures of distal Third of the Humerus. J.B.J.S vol-72B No.-2, March 1990, 283-287.

8) Sarmieto A et al - Functional bracing of fracture of the shaft of humerus. JBJS 1977 ; 59A : 596-601.

9) Sarmiento A, Latta LL - Functional fracture bracing J. AAOS 1999 Jan ; 7(1) : 66-75.

10) Sarmiento A, Jagorski JB, Zych GA - Functional bracing for the treat ment of the fractures of humeral diaphysis. JBJS Am. 2000; 82 : 478-486.

11) Klenerman. L. – Fractures of shaft of the Humerus. J.B.J.S. vol-48B, 1966, 105-111.

12) Stewart - Traction and its Appliances.

13) Mast. J. W., Spiegel. P. G., Harvey. J. P., Harrison. C. – Fractures of the Humeral shaft. Clin. Orthop, vol-12, 1975, 960-970.

14) P. V. A. Mohandas, S. Ravindran, Management of fresh fractures of the shaft of the humerus by Internal Fixation. Indian Journal of Orthopaedics, vol-16, 1982, 44-51.

15) Rowly - A simple method of reducing fracture shaft humerus. Br Med. Journal 1934;2

16) T. De Baere Cliniques Universitaires St-Luc, Brussel - conservative treatment of humeral shaft fractures : literature review.

17) Hey- Groves EW - Methods and results of transplantation of bone in the repair of defects caused by injury or disease. Br. J Surg. 1918; 5 : 185-242.

18) Instructional Course Lectures.

19) Jochen Blum1, René Engelmann2, Raphael Küchle2, Matthias Hansen1, Pol M. Rommens2 - Intramedullary Nailing of Humeral Head and Humeral Shaft Fractures.

20) A.J Thakur – Textbook of Elements Of Fixation.

21) Watson Jones- Fracture & Joint Injuries.

22) Hey- Groves EW - Methods and results of transplantation of bone in the repair of defects caused by injury or disease. Br. J Surg. 1918; 5 : 185-242.

23) Rush LV - Atlas of Rush pin techniques. Meridian Beribon Co. 1976, pg 243.

24) Kuntscher G - The Kuntscher method of intramedullary fixation. JBJS 1958 ; 40A : 17-26.

25) Kuntscher G - Intramedullary surgical technique and its place in ortho paedic surgery - My present concept. JBJS 1965 ; 47A : 809 – 818.

26) Rockwood And Green – Textbook Of Fractures of Adult

27) Dijkstra S, Staper J, Boxma H, Wiggers T - Treatment of pathological fractures of the humeral shaft due to bone matastases - a comparision of intramedullary locking nail and palte osteosynthesis with adjunctive bone cement - J Surg. Oncology 1996, Dec ; 22(6) : 621-6.

28) Stewart MJ, Hundley JM - Fracture of the humerus - a comparative study In methods of treatment. JBJS 1955; 37A : 681-92.

29) Whitson. R. O.- Relation of radial nerve to the shaft of the Humerus. J.B.J.S. vol- 36A, 1954, 85-91.

30) Laing. P. G. – The Arterial supply of the adult Humerus. J.B.J.S. VOL-38A, 1956, 1105-1116.

31) Arthur Holstein & G. B. Lewis – Fractures of the Humerus with Radial nerve paralysis. J.B.J.S. vol-45A, 1963, 1382-1388.

32) Carrol. S. E.- A study of the nutrient foramina of the humeral Diaphysis, J.B.J.S. vol-45B, 1963, 176-181.

33) S. M. Perren – Physical & Biological Aspects of Fracture Healing with Special reference to Internal Fixation. C.O.R.R. No.138, Jan 1979, 175-196.

34) Wu.C.C., & shih.C.H. - Treatment for Nonunion of the shaft of the humerus: Comparison of plates & Seidel interlocking nails. Can.j.surg., vol-35, 1992, 661-665.

35) R.G. Mc Cormack, D.Brien, R.E.Buckley, M.D. McKee, J. Powell, E.H. Schemitsch - Fixation of fractures of the shaft of the Humerus by Dynamic compression plate or Intramedullary nail J.B.J.S. vol-82B, 2000, 336-339.

36) Gray’s Anatomy – 31st Edition

37) Caldwell J - Treatment of fracture shaft humerus by hanging cast, surh, Gynaec and Obst. 70:421 - 423 , 1940.

38) A. D. Laferte1, m.d., and p. David nutter, m.d. detroit, mich. - the treatment of fractures of the humerus by means of a hanging plaster case "hanging cast".

39) Shantaram SS - Modified coaptation splint for humeral shaft fractures Orthopaedic review. J CORR Nov. 1991; 20(11) : 1033-39.

40) Gilchrist DK - A stockinette- velpeau for immobilisation of the shoulder gridle. JBJS 1967; 49A : 750-51.

41) Rockwood CA, Green DP, Bucholz RW - Fractures in adults, 4th ed, 1994, pg 1028-1029.

42) Rommens PM, Verbruggen J, Broos P - Retrograde interlock nailing of fracture of the humeral shaft - a clinical study. Unfallchirurg 1995 Mar ; 98(3) :133-8.

43) R. Bhalla, T.S.Narang & L.H.Lobo- Functional Brace Treatment of the fracture of the Shaft of the Humerus. Indian Journal of Orthopaedics vol-16, No.1, 1982, 9-3.

44) Tom EJ, Carsi D, Garcia C, Marco F - Treatment of pathologic frac tures of the humerus with Seidel nailing. Clin. Orthop. 1998 May 350:51-5.

45) Russel TA, Taylor JC - Surgical technique manual - Russel Taylor humeral interlocking naik system, Smith and nephew Richards.

46) Naiman.P. T., Schein.A.J., & Siffert.R.S.- Use of ASIF compression plates in selected shaft fractures of upper extremity: A preliminary report. Clinical orthop vol-71, 1970, 208-211.

47) JayendraKumar. J. Shah & Nazir Ahmad Bhatti- Radial Nerve Paralysis Associated with Fractures of the Humerus. C.O.R.R.1983, 172-176.

48) Dabezies. E. J., Banta. C.J. Murphy. C. P. D’Ambrosia. R. D. – Plate fixation of the Humeral shaft for acute fractures with & without Radial nerve injuries. J Orthop Trauma vol-6, 1992, 10-13.

49) Calos. M. Olarte, Michael Darowish, Bruce. H. Ziran - Radial nerve Transposition with humeral fracture fixation: preliminary results. C.O.R.R. vol-413, 2003; 170-174.

50) Jesse. B. J. – Complex Non-union of the Humeral Diaphysis. J.B.J.S. vol-72A, 1990, 701-703.

51) Robert. J. Foster, George. L. Dixon Jr, Allan. W. Bach, Ross. W. Appleyard, Thomas. M. Green – Internal Fixation of Fractures & Non-Union of the Humeral Shaft. J.B.J.S. vol-67A, No.6, July 1985, 857-864.

52) Ivan. F. Rubel, Peter Kloen, Deirdre Campbell, Meng, Mark Schwartz, Alan Liew, Elizabeth Myers & David L. Helfet – Open Reduction & Internal Fixation of Humeral Nonunions. J.B.J.S. vol-84A, No.8, Aug 2002, 1315- 1322.

53) John. L. Esterhai, Jr, Carl. T. Brighton, R. Bruce Heppenstall, & Albert Thrower – Nonunion of the Humerus. C.O.R.R. No. 211, Oct 1986, 228-234.

54) D. Ring, J.B. Jupiter, J. Quintero, R.A.Sanders, R.K. Marti- Atrophic Ununited Diaphyseal fractures of the Humerus with a bony defect. J.B.J.S. vol-82B, No.6, Aug 2000, 867-871.

55) Tzu-Liang Hsu, Fang-Yao Chiu, Chuan-Mu Chen, Tain- Hsiung Chen – Treatment of Nonunion of Humeral Shaft Fracture with Dynamic Compression Plate & Cancellous Bone Graft J Chin Med Assoc, Vol-68, Feb 2005, No.-2, 73-76.

56) William. H., George. M. W. – Non-union of the Humeral shaft. C.O.R.R. vol-219, 1987, 206-212.

57) Stanley Hoppenfeld & Peit deBoer. M. A.- Surgical exposures in Orthopaedics. Third edition, 2003, 79-84.

58) Ruf W, Pauly E - Interlocking nailing of the humerus. Unfallchirurg Jun e 1993 ; 96(6) : 323-8.

59) Jensen C. H., Hansen D. & Jorgensen U.- Humeral shaft fractures treated by interlocking nail, A preliminary report on 16 patients. Injury 23(4) – 1992: 234-236.

60) Heim. D., Herkert. F., Hess. P., Regazzoni. P. – Surgical treatment of Humeral shaft fractures: the Basel experience. J Trauma, , vol-35, 1993, 226-232.

61) James P. Stannard, Howard W. Harris, Gerald McGwin, Jr., David A. Volgas and Jorge E. Alonso - Intramedullary Nailing of Humeral Shaft Fractures with a Locking Flexible Nail , J Bone Joint Surg Am. 2003;85:2103-2110.

62) T. Mulier , D.Selgison , W.Sioen , J. Van Den Berg – Operative treatment of humeral shaft fractures.

63) R. G. McCormack, D. Brien, R. E. Buckley, M. D. McKee, J. Powell, E. H. Schemitsch - Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail.

64) F. S. L. Meekers, p. L. O. Broos - operative treatment of humeral shaft fractures the leuven experience.

65) M. Changulani & U. K. Jain & Tulsi Keswani - Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study.

66) Mohit Bhandari, Michael Mckee – Compression Plating Versus Intramedullary Nailing of humeral shaft fractures – a meta analysis.

67) R Ekholm, J Adami, J Tidermark , K. Hansson – An epidemiological study of fracture of shaft of the humerus.

68) Kiran Singsetti , M.Ambedkar – Nailing versus plating in humerus shaft fractures,a prospective comparative study.

69) Amit Putti , Rajendra Uppin – Locked Intramedullary nailing versus dynamic compression plating for humeral shaft fractures.

70) Lori A. Michener, PhD, PT, ATC,a Philip W. McClure, PhD, PT,b and Brian J. Sennett, MD,c Richmond, Va, andGlenside and Philadelphia, Pa - American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: Reliability, validity, and responsiveness.

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