A Thesis Presented to the Graduate School Faculty of Medicine, University of Alexandria In partial fulfilment of the requirements of the Master Degree in Orthopaedic Surgery & Traumatology. By Amr Mansour Mohammed Hassan

ANALYSIS OF THE COMPLICATIONS FOLLOWING OPEN REDUCTION AND INTERNAL FIXATION OF DIAPHYSEAL FRACTURES OF THE HUMERUS

Introduction

Introduction Fractures of the humeral shaft are relatively common injuries. They represent about 3 % of all fractures. Mechanism of Injury  Direct trauma is the most common especially RTA.  Indirect trauma such as fall on an outstretched hand.  Pathological fractures. Introduction

Classification AO classification A = Simple fracture B = Wedge fracture C = Complex fracture Introduction

Classification According to the line of fracture Introduction Segmental WedgeSpiral Transverse Oblique

Treatment Treatment Non operative treatment: Has a long and well-established history of success with union rate up to 95% Includes: 1. hanging cast: 2. coaptation splint: U shaped slab Introduction

Treatment: Non operative treatment: 3. Functional bracing 4. Body Bandage Introduction

Treatment Non operative treatment: 5. Abduction humeral splint 6. Skeletal traction Introduction

Treatment 1. Fractures with unacceptable alignment 2. Open fractures 3. Segmental fracture 4. Floating elbow 5. Associated vascular injury 6. Pathological fracture 7. Humeral fractures in polytraumatized patients Indications for operative management B. Operative treatment: Introduction

Treatment Methods of surgical fixation: 1. Compression plate fixation Advantages: anatomical reduction rigid fixation high union rate avoid shoulder complications Disadvantages: extensive soft tissue exposure radial nerve injury long operative time infection 2. External fixator: B. Operative treatment : Introduction

Treatment  3. Intramedullary fixation  Flexible intramedullary nailing  Rigid intramedullary rod fixation B. Operative treatment: Introduction

Complications of humeral shaft fracture 1. Neural complications: Radial nerve injury : 8- 11% Introduction

Complications of humeral shaft fracture 2. Malunion: >20° of anterior angualtion >30° of varus angulation >3 cm shortening 3. Nonunion: > 6 months 4. Joint stiffness. Introduction

AIM OF THE WORK

AIM OF THE WORK The aim of the work is to analyse the complications through 1 year following open reduction and internal fixation of diaphyseal fractures of the humerus.

PATIENTS

Patients The study included 70 patients presented to El-Hadara University Hospital Age: age 21 – >5016 Ranged from 20 to 78 years old with a mean age of 40 years.

Gender: There were 43 males and 27 females Patients The right side was affected in 34 patients and the left side was affected in 36 patients Side affected:

 Mechanism of trauma  Type of fracture  Associated preoperative radial nerve injury Patients Mode of fractureNumberPercent Fall from height RTA Pathological22.9 Assault45.7 Total70100 TypeNumberPercent simple comminuted811.4 wedge Total Radial nerve affectionNo.% Absent Present22.86

Methods Methods

A full workup including history taking, clinical examination and radiological evaluation as well as laboratory investigations were done Methods

Surgical technique:  Anesthesia: Methods The operation was performed under general anaesthesia. All of our patients received intravenous antibiotics prior to the skin incision.

Surgical technique: 35 patients were operated through anterolateral approach in supine position with arm on arm board Methods

Surgical techniques: 35 patients were operated through posterior approach in lateral position Methods

Methods of assessment : No pain Full range of motion of shoulder and elbow Good radiological alignment Excellent Activity pain Loss of between 20ºand 40º of shoulder range of motion in a single direction and elbow range of flexion and extension Malunion with an angle more than 10º Fair  Results were assessed according to Stewart and Hundley’s scoring system Methods Constant pain more than 40º Loss of shoulder range of motion in a single direction and elbow range of flexion and extension Non-union or iatrogenic radial nerve palsy Poor Occasional pain Less than 20º loss of shoulder range of motion in a single direction and elbow range of flexion and extension Malunion with an angle less than 10º Good

RESULTSRESULTS

Distribution of the studied cases according to the results RESULTS

Union time: RESULTS Union time (weeks)NumberPercent 0 – – – Non union > Range Mean S.D

Pain RESULTS

Elbow ROM

Factors that may affect the final score 1. Age 1. Age : Relationship between result and age RESULTS Age Net result Total (n=70) Unsatisfactory (n=7) satisfactory (n=63) No.% % % 20 – – – > χ2χ MC p0.285

Factors that may affect the final score 2- Gender Relation between net results and patients gender RESULTS Gender results Total (n=70) Unsatisfactory (n=7) satisfactory (n=63) No.% % % Male Female χ2χ FE p0.236

Factors that may affect the final score 3- Level of fracture Relationship between results and level of fracture RESULTS Level of fracture Results Total (n=70) Unsatisfactory (n=7) satisfactory (n=63) No.% % % Lower 1/ Middle 1/ Upper 1/ χ2χ MC p0.189

RESULTS Complications

Thirty two years old male patient, RTA RESULTS Preopretive Non union after 6 months Complications Immediate after fixation

RESULTS Complications

RESULTS Complications

Cases

Cases presentation

Conclusion

1.The use of dynamic compression plate in treatment of midshaft fracture humerus gives excellent results with a low rate of complications. 2.The use of anterolateral approach as surgical approach in (ORIF) of midshaft fracture humerus gives excellent functional outcome and doesn't affect extensor mechanism of elbow. Conclusion

3.The anterolateral approach is a safe surgical exposure with low rate of iatrogenic radial nerve injury. In fractures with proximal extension the approach can be extended upward. 4.The use of posterior approach as surgical approach in ORIF of midshaft fracture humerus is indicated in lower third or midshaft fractures of the humerus with distal extensions. But it affects extensor mechanism of the elbow giving some extension deficits. Conclusion