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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 4  |  Page : 212-217

Pediatric humeral fracture fixed by a single retrograde titanium elastic nail


Department of Orthopedics, Civil Service Hospital, Minbhawan, Kathmandu, Nepal

Date of Web Publication5-Feb-2018

Correspondence Address:
Kapil Mani K C
Civil Service Hospital, Minbhawan, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_17_17

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  Abstract 

Introduction: Almost all pediatric humerus fractures are well managed with conservative treatment with higher percentage of union rate. However there are certain conditions where surgical intervention will be inevitable like humerus fracture associated with polytrauma compound fractures, those with head and unacceptable alignment. It is not only the stable fixation but also the alignment which is important and can be maintained even by a single pre-bent elastic or flexible intramedullary nailing. Methods: This was a retrospective study of 28 pediatric humeral fractures fixed with a single retrograde titanium elastic nail from 2012 to 2016. Time to unite the fracture along with other complications was noted. The functional outcomes were assessed according to Broberg and Morrey for elbow function and Disabilities of the Arm, Shoulder and Hand (DASH) score for shoulder function. Results: Average age of patients was 8.85 1.84 (range 6 to 12 years). Time to unite the fracture was 8.28 2.43 weeks (range 6 to 12 weeks). There were 1 case of malunion around 10 degrees, 1 case of nail migration, one case of superficial infection at the site of nail entry, one case of transient radial nerve palsy and one case of nail protrusion in our study. There were 24 (85.71%) cases of excellent and 4 (14.29%) cases of good results according to Broberg and Morrey functional scores. Conclusion: Fixation of pediatric humerus fractures with a single flexible nail reduces operative time, radiation exposure, cost of treatment, chances of iatrogenic supracondylar fracture and ulnar nerve injury without compromising the final outcomes.

Keywords: Complications, functional outcomes, humerus fractures, pediatric, titanium elastic nail


How to cite this article:
Kapil ManiK, Acharya P, Pangeni BR, Marahatta SB. Pediatric humeral fracture fixed by a single retrograde titanium elastic nail. Apollo Med 2017;14:212-7

How to cite this URL:
Kapil ManiK, Acharya P, Pangeni BR, Marahatta SB. Pediatric humeral fracture fixed by a single retrograde titanium elastic nail. Apollo Med [serial online] 2017 [cited 2018 Nov 14];14:212-7. Available from: http://www.apollomedicine.org/text.asp?2017/14/4/212/224727


  Introduction Top


Almost all pediatric humerus fractures are well managed with conservative treatment even with a higher percentage of union rate.[1],[2] However, there are certain conditions where surgical intervention will be inevitable such as humerus fracture associated with polytrauma for early mobilization, compound fractures for wound care, those with head injury for nursing care, and in some cases with unacceptable angulation to maintain the alignment.[3]

Plate osteosynthesis is usually not recommended for humerus fracture in children. Due to violation of rotator cuff muscles and impingement on the shoulder, antegrade nailing is usually not preferred. While using the single nail instead of two nails, operative time is reduced, radiation exposure is decreased, chance of supracondylar fracture is low, cost is also reduced because of single use of nail, and final outcome is not compromised. The purpose of our study is to evaluate the final functional outcomes and radiological union of pediatric humeral fractures fixed by a single flexible intramedullary nailing in patients with surgical indications.


  Methods Top


This was a retrospective analytical study performed in Civil Service Hospital, Nepal, from September 2012 to August 2016. Ethical consent was obtained from the Institutional Review Board of our hospital. Altogether 28 patients with humerus fractures were enrolled in the study. Pediatric humeral fractures from 5 to 13 years along with the following criteria were included in the study: (1) noninfected Grade I and II compound fractures; (2) polytrauma patients with multiple fractures, head injury, and abdominal injury; (3) Diaphyseal humeral fractures with unacceptable alignment. Humerus fractures in patients of age <5 years and more than 13 years, Grade III compound fractures, fractures associated with infected wound, fractures associated with severe comminution, massive bone loss, severe osteopenia, and fractures within four centimeters of the shoulder and elbow joint were excluded from the study.

All of the surgeries were performed under general anesthesia. Preoperative antibiotic usually 500 mg of intravenous ceftriaxone was given ½ h before surgery. Appropriate size of the titanium nail was calculated by multiplying the narrowest diameter of medullary cavity of humerus by 0.4 in centimeter. The nail was precountered manually into C shape configuration for intramedullary three point fixation. The tip of nail was bent to 45° for easy passage through the fracture site. Around 5 mm to 1 cm of incision was given over lateral aspect of distal humerus just above the level of lateral epicondyle. An entry point was made 1.5–2 cm proximal to the physis with the help of owl or drill bit at least 0.5 mm greater than the planned titanium nail [Figure 1].
Figure 1: The entry portal on lateral aspect of distal arm above the elbow joint

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Now, the precountered nail tip was inserted into the medullary canal and advanced to the fractured site. Once the nail reached to the fracture site, close reduction was done under C-arm control and nail was advanced distally through the fracture site. Multiple and forceful reduction attempts were avoided to prevent iatrogenic fractures and nerve injury. Reduction and alignment of fracture were best maintained by rotating the nail in appropriate position. The nail was driven proximally within 1–2 cm of physis and distal end of nail was trimmed protruding 0.5 cm from the bone for easy removal of implant later on as shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. The wound was washed thoroughly with normal saline and closed with skin stapler. The titanium nail acts as an internal splint to maintain the alignment of fracture until it healed. After surgery, functional brace was applied over the arm as an additional external support for 3 weeks. During this period, patients were encouraged to do the pendulum exercises of arm. Four weeks after surgery, they were advised to do active as well as passive assisted exercises as tolerated. Radiographs were taken at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery to observe the fracture healing, the alignment of fracture, any infection, delayed union, nonunion, and limb length discrepancy. The functional outcomes were assessed at least 6 months after surgery according to Broberg and Morrey for evaluation of elbow function and DASH score for evaluation of shoulder function. Based on Broberg and Morrey system, categorical ratings were assigned according to the score achieved: A score of 95–100 points is rated excellent; 80–94 points as good; 60–79 points as fair; and <60 points as poor. Solid union was confirmed when at least three cortices showed periosteal new bone formation on standard plain anteroposterior and lateral views.
Figure 2: Anteroposterior and lateral views of arm showing displaced angulated fracture of proximal humerus

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Figure 3: Immediate postoperative X-ray of arm fixed with single retrograde titanium nail

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Figure 4: X-ray of same patient 1 month after surgery showing formation of callus around the fracture site

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Figure 5: United humerus fracture of same patient 3 months after surgery

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  Results Top


There were 16 (57.14%) of male and 12 (42.86%) of female in our study. Average age of patients was 8.85 ± 1.84 (range 6–12 years). There were six (21.42%) cases of compound fractures in our study. Mechanism of injury and associated injury along with humerus fractures were mentioned in [Table 1]. There were one case of malunion around 10°, one case of nail migration, one case of superficial infection at the site of nail entry, one case of transient radial nerve palsy, and one case of nail protrusion in our study. However, there were no cases of deep infection (osteomyelitis), growth disturbances, implant failure, supracondylar fractures, neurological injury, vascular injury, limb length discrepancy, nonunion, and delayed union. Superficial infection was healed by giving the intravenous antibiotic while transient radial nerve palsy was improved spontaneously 6 weeks after surgery. Time to unite the fracture was 8.28 ± 2.43 weeks (range 6–12 weeks) and average follow-up period was 24.71 ± 9.59 weeks (range 16–48 weeks). Final results were interpreted only after minimal follow-up of 6 months after surgery. Mean duration of trauma to surgery was 37 ± 21.76 h (range 12–86 h). Mean operative time was 28.21 ± 7.23 min (range 15–40 min) and mean duration of hospital stay was 10.42 ± 3.63 days (range 6–18 days). Implants were removed after mean time of 9.57 ± 1.45 months (range 5–9 months) after initial surgery. Functional outcomes were assessed based on the clinical and radiological features at the end of minimal follow-up period of 6 months. According to Broberg and Morrey system, there were 24 (85.71%) cases of excellent and 4 (14.29%) cases of good results; however, there were no cases of fair and poor results in our study. Based on the DASH scoring system, there was no difficulty or no residual symptoms related to the shoulder functions and all cases were rated as no disability level.
Table 1: The demographic profiles, mechanism of injury, associated injuries, complications, and time to unite the fractures

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  Discussion Top


Fracture shaft of humerus in children comprises 2%–5% of all pediatric fractures.[1],[2] Pediatric humeral fractures give excellent results with conservative treatments such as functional bracing, U slab, hanging cast, sling immobilization, or coaptation splints. Newborns and infants have significant potentials of remodeling and up to 70° of angulation can be corrected spontaneously with conservative treatment.[4] Beaty gives guidelines based on the patient's age: children under 5 years of age tolerate 70° angulation and total displacement, children 5–12 tolerate 40°–70° angulation, and children over 12 tolerate 40° and 50% apposition.[2] Pediatric humeral fractures require surgical intervention very infrequently. The impressive remodeling pathology of bone in children will compensate angular as well as rotatory deformity at least partially and greater mobility of shoulder joint will also have the added benefit for functional outcomes in fracture shaft of humerus.[5],[6] Operative treatment primarily requires in patients with compound fractures. Those associated with multiple long bones fractures, multisystem injuries, wound care in open injury, and nursing care in closed head injury and severely displaced fractures, in which appropriate alignment cannot be attained or maintained.[3],[7]

There is no consensus for an ideal operative treatment for pediatric humeral fractures when surgery is indicated.[8],[9] Open reduction with internal fixation with plates and screws carries ugly surgical scars, risk of infection, and neurological injury as well. Regarding the antegrade and retrograde insertion of nail, it is also the matter of debate in itself. Antegrade nail insertion may cause the problem of rotator cuff injury, proximal nail migration, shoulder impingement, and impairment of shoulder function.[10],[11] Retrograde entry portal through the olecranon fossa may cause the supracondylar fractures, triceps tendon irritation, heterotopic ossification of bone, and elbow pain as well.[12] Epicondylar entry point ensures no breach in the joint and no interference in joint motion. Retrograde titanium elastic nailing for pediatric humeral fractures is an ideal procedure as it causes minimal soft tissue stripping at fracture site, provides the alignment as well as stable fixation, and allows early mobilization of limb and children return back to school as early as possible.[1] Based on the very few published series and our experience, we can say that optimal functional results can be reproduced even after fixation with single retrograde flexible nail with added advantage of cost effective, less radiation exposure, decreased operative time, less chance of iatrogenic supracondylar fracture, and ulnar nerve injury.

In this study, one patient had a transient radial nerve palsy which was recovered spontaneously 6 weeks after surgery. Furlan et al. reported one patient with preoperative radial nerve palsy which resolved 12 weeks after injury.[5] Garg et al.[1] in 2009 found one patient with radial neuropraxia that recovered spontaneously within 4 months after injury and another patient with radial nerve palsy was treated with tendon transfer 1 year after injury.[1] Maruthi et al. in his study in 2013 reported a patient with radial nerve palsy that recovered spontaneously within 2 months after injury.[13] He mentioned that dual lateral point entry for retrograde nailing in pediatric humeral fractures is safe technique as compared to medial and lateral entry point technique. Garg et al.[1] treated 13 humeral fractures in children by antegrade or retrograde double titanium elastic nails.[1] Out of retrograde insertions, nine had medial and lateral entry portals and two had double lateral entry point techniques. Authors mentioned that rotator cuff should be incised along the line of fibers while doing through the antegrade technique. Similarly, cortex should be opened carefully to prevent supracondylar fracture, and epicondylar muscles should be separated carefully to avoid iatrogenic ulnar nerve injury while doing through the retrograde technique. Maruthi et al. fixed the fractures with two nails by retrograde dual lateral portals technique and reported that fracture is stable enough to lead fracture healing without angular and rotational deformity within 12 weeks.[13] In the current study, we used single retrograde prebent titanium nail that achieved the good alignment and reduction and acted as an internal splint till fracture healing occurred, thus reducing the cost and time of surgery with good to excellent results. The principle behind the single flexible nail is that it maintains the reduction, prevents the postoperative displacement, unacceptable malalignment, and rotatory displacement because it is prebent to “C-”shaped configuration before insertion with the apex of curve at fracture site to allow three-point fixation and stable reduction of fracture.[14]

In the current study, complete radiological union was achieved in all cases within a mean period of 8.28 ± 2.43 weeks (range 6–12 weeks). There was only one case of malunion around 10° which was functionally and esthetically acceptable. All the patients had full range of elbow and shoulder motion. The study of Furlan et al. showed that all the fractures united at a mean time of 7.2 weeks (range 5–11 weeks) after surgery.[5] Garg et al. mentioned that all the fractures in his study united unanimously without angular and rotational deformity of more than 10° within 12 weeks after surgical intervention.[1] Similarly, Maruthi et al. reported that all fractures united without an angular or a translational deformity of more than 10° within 12 weeks.[13] Similarly, Sheng reported that all fractures healed completely over a period of 3–6 months without shortening or rotational deformity.[15]

In this study, one patient had a superficial wound infection, one patient had proximal nail migration, another case had distal nail migration with skin impingement, and there were no cases of delayed union, nonunion, refracture, limb length discrepancy, osteomyelitis, or unacceptable malunion. Furlan et al. reported that, in their study, one case with a postoperative skin infection.[5] Maruthi et al. reported that there was clinical evidence of a superficial infection in one patient which was managed by regular dressing and antibiotics.[13] Mean duration of time from trauma to surgical intervention was 37 ± 21.76 h (range 12–86 h). This time interval between trauma and surgery was relatively early as compared to the other surgical procedures in our hospital because humerus fractures in our study were either compound or commonly associated with other fractures and we performed all the fractures in the same time at same setup. Mean operative time was 28.21 ± 7.23 min (range 15–40 min). This operative time was relatively quick as compared to other surgeries because we fixed the fracture with single elastic nail by giving small incision on lateral aspect of elbow. Mean duration of hospital stay was 10.42 ± 3.63 days (range 6–18 days). This time interval is relatively longer because all the patients with humerus fractures are polytraumatized and commonly associated with other injuries and fractures. Implants were removed after mean time of 9.57 ± 1.45 months (range 5–9 months) after initial surgery. Prolonged implantation of the nail was not recommended as it would be more difficult to remove. The problem was that as bone grew, the distal tip might become fully embedded in the epicondylar bone and may no longer be extracted.


  Conclusion Top


Titanium elastic nail fixation is an ideal procedure for treating pediatric humeral shaft fractures with Grade I or II compound injuries or associated with other long bone fractures, other systemic injuries in the body, and those with unacceptable alignment. Moreover, fixation with a single flexible nail reduces operative time, radiation exposure, cost of treatment, chances of iatrogenic supracondylar fracture, and ulnar nerve injury without compromising the final outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Garg S, Dobbs MB, Schoenecker PL, Luhmann SJ, Gordon JE. Surgical treatment of traumatic pediatric humeral diaphyseal fractures with titanium elastic nails. J Child Orthop 2009;3:121-7.  Back to cited text no. 1
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2.
Beaty JH. Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-72.  Back to cited text no. 2
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3.
Abosalism AA, Shams EI-Din AF, EL-Mowafy HM. Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children. Menoufia Med J 2015;28:125-32.  Back to cited text no. 3
    
4.
Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;(432):49-56.  Back to cited text no. 4
    
5.
Furlan D, Pogorelic Z, Biocic M, Juric I, Budimir D, Todoric J, et al. Elastic stable intramedullary nailing for pediatric long bone fractures: Experience with 175 fractures. Scand J Surg 2011;100:208-15.  Back to cited text no. 5
    
6.
Chee Y, Agorastides I, Garg N, Bass A, Bruce C. Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing. J Pediatr Orthop B 2006;15:45-50.  Back to cited text no. 6
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Gordon JE, Garg S. Pediatric humerus fractures: Indications and technique for flexible titanium intramedullary nailing. J Pediatr Orthop 2010;30:73-6.  Back to cited text no. 7
    
8.
Butin E, Herent S, Delehaye P. Treatment of humeral shaft fractures with the Marchetti nail: 50 cases. Rev Chir Orthop Reparatrice Appar Mot 2001;87:758-64.  Back to cited text no. 8
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Kesemenli CC, Subasi M, Arslan H, Necmioglu S, Kapukaya A. Comparison between the results of intramedullary nailing and compression plate fixation in the treatment of humerus fractures. Acta Orthop Traumatol Turc 2003;37:120-5.  Back to cited text no. 9
    
10.
Ajmal M, O'Sullivan M, McCabe J, Curtin W. Antegrade locked intramedullary nailing in humeral shaft fractures. Injury 2001;32:692-4.  Back to cited text no. 10
    
11.
Halder SC, Chapman JA, Choudhury G, Wallace WA. Retrograde fixation of fractures of the neck and shaft of the humerus with the 'Halder humeral nail'. Injury 2001;32:695-703.  Back to cited text no. 11
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12.
Stannard JP, Harris HW, McGwin G Jr., Volgas DA, Alonso JE. Intramedullary nailing of humeral shaft fractures with a locking flexible nail. J Bone Joint Surg Am 2003;85-A: 2103-10.  Back to cited text no. 12
    
13.
Maruthi CV, Shiva SU, Sujai S, Venugopal N, Vishal K, Nanjundappa HC, et al. Management of diaphyseal fractures of humerus in children using titanium elastic nailing system by lateral dual entry point approach: A prospective study. Sch J Appl Med Sci 2013;1:1060-3.  Back to cited text no. 13
    
14.
Thomsen NO, Dahlin LB. Injury to the radial nerve caused by fracture of the humeral shaft: Timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr Surg Hand Surg 2007;41:153-7.  Back to cited text no. 14
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Xie F, Wang S, Jiao Q, Shen Y, Ni XY, Ying H. Minimally invasive treatment for severely displaced proximal humeral fractures in children using titanium elastic nails. J Pediatr Orthop 2011;31:839-46.  Back to cited text no. 15
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