Treatment of humeral shaft pseudarthrosis with a compression 3,5 mm AO plate plus thoracobrachial plaster cast

Abstracts

Foram avaliados 16 pacientes com pseudartrose diafisária de úmero submetidos ao tratamento cirúrgico, utilizando placa de compressão AO 3.5mm (DCP) e gesso toracobraquial. Com seguimento médio de 21 semanas obteve-se a consolidação óssea em 100% dos casos.

Pseudartrose do Úmero; Placa de Compressão AO 3,5mm; Aparelho Gessado Toracobraquial

ARTIGO ORIGINAL

Treatment of humeral shaft pseudarthrosis with a compression 3,5 mm AO plate plus thoracobrachial plaster cast

Ana Raquel Hayashi Tannura^I; Décio José Oliveira^II; José Wagner de Barros^III

^IFormer resident

^IIDoctor and Orthopaedic Surgeon in charge of Hand Surgery Sector

^IIIChairman

^{Correspondence}

SUMMARY

Sixteen patients with humeral shaft pseudarthrosis underwent surgical treatment, using AO 3.5mm compression plate (DCP) and thoracobrachial plaster cast, were evaluated. With a mean follow-up of 21-weeks, a bone healing was obtained in 100% of the cases.

Key words: Humeral pseudarthrosis, AO 3,5mm Compression plate, thoracobrachial plaster cast.

INTRODUCTION

Healing of a fracture takes place through bone regeneration, sometimes allowing reconstitution of the injured segment. The healed bone becomes able to endure mechanical stress to which is used to be submitted during motor function and weight bearing. However, there are factors that can the usual course of bone healing, delaying it or avoiding it to complete, thus producing respectively bone healing delay or pseudarthrosis⁽³⁾.

Several local factors may lead to abnormal healing, such as inadequate immobilization^(1,5,13,27), loss of bone substance⁽¹⁶⁾, bone infection⁽¹²⁾, deficient blood supply to fragments^(22,23,24) and a defective osteosynthesis⁽¹⁷⁾, besides of general factors such as age, kind of bone, fracture place in the bone and the patient constitution itself⁽²⁵⁾.

However, the most severe disturbance in fractures healing is pseudarthrosis, which is defined as the last anomalous stage of a not healing fracture. It is a well delimitated stage, and considered as being definitive from histopathological point of view, since spontaneous healing is practically considered to be impossible⁽⁴⁾.

Humeral shaft fractures are 1% of skeleton fractures, with a high rate of bone healing. However, some cases present unfavorable evolution⁽⁹⁾. Incidence of humeral pseudarthrosis⁽⁸⁾ ranges from 0% to 13% and, according to data⁽⁹⁾, this rate ranges from 5% to 15%.

There are several described operative methods in literature for treatment of humeral shaft pseudarthrosis^{(2, 7,11,18,19,20,21)}.

The objective of this paper was to evaluate the evolution of 16 patients with humeral pseudarthrosis who underwent surgical treatment with resection of fibro-cartilaginous tissue placed amongst the fragments, fixation with a compression 3.5mm AO plate, autologous bone grafting and external immobilization with a thoracobrachial plaster cast.

CASES AND METHODS

In the period among June 1992 and December 1999, 16 patients with humeral shaft pseudarthrosis underwent surgical treatment with a compression 3.5mm AO plate and a thoracobrachial plaster cast.

From the re-evaluated patients, 9 (56.3%) were male and 7 (43.7%) female. Age ranged from 18 to 67 years, averaging approximately 41 years. The right side was involved in 9 (56.3%) while the left side in 7 (43.7%).

Regarding localization, the proximal third of humeral shaft was involved in 3 (18.7%), mean third in 6 (37.5%) and the distal third in 7 (43.7%) of the patients.

Pseudarthrosis were atrophic in 15 (93.7%) of the cases and hypertrophic in 1 (6.3%), according to their classification⁽¹²⁾.

The patients were pre operatively evaluated clinically and radiologically (Figure 1 A-B). Fourteen (87.5%) cases of humeral pseudarthrosis came from closed humeral shaft fractures and two (12.5%) secondary to open fractures (grade II and grade IIIC of Gustillo classification), according to AO classification (Table 1).

From the 14 closed humeral fractures, 11 (78.6%) were treated with confectioner holder cast, 1 (7.1%) with a brace, 1 (7.1%) with a hanging plaster, and 1 (7.1%) by osteosynthesis. Open fractures were treated by conventional means and stabilized by external fixators.

Among all evaluated cases, there was nerve injury in 3 (18.7%), being 2 (12.5%) with radial nerve injury and 1 (6.3%) brachial plexus injury.

From the sample, 7 patients (43.8%) were obese.

General characteristics of these patients is presented in (Table 2).

SURGICAL PROCEDURE

Patients were submitted to general anesthesia, and positioned in horizontal dorsal decubitus. No tourniquet was applied. Surgical approach was antero-lateral⁽⁶⁾. Radial nerve was identified and isolated. Pseudarthrosis focus was identified and fibro-cartilaginous amongst fragments was removed. Bone fragments were stabilized by means of a 3.5mm AO dynamic compression plate, fixed to the lateral aspect of the humerus with at least 6 cortical in each fragment.

Autologous bone grafting from same side iliac bone was placed.

In cases of radial nerve injury, neurolysis was performed.

Prophylactic intravenous antibiotic was started before the surgery.

In immediate post surgery time, it was made a thoracobrachial plaster cast. This external immobilization was kept for 4 to 6 weeks. After this period, radiographs were taken and a confectioner holder cast or a brace were started and kept to the time of bone healing.

Motor assisted active physiotherapy for shoulder and elbow was used after the limb was released.

RESULTS

Healing was observed in all cases submitted to the proposed treatment.

Average time to clinical and radiological healing ranged from 12 to 40 weeks, with an average of 21 weeks (Figure 2 A-B).

Among the evaluated cases, in 3 (18.7%) loosing of screws happened after the thoracobrachial cast was removed.

No infection was observed, nor re-operation was needed.

In functional clinical evaluation before ambulatory discharge, 10 cases (62.5%) presented full range of upper limb movement, while 6 (37.5%) had partial recovery, without compromise of working activity.

DISCUSSION

Pseudarthrosis is the final stage of an bone healing abnormality⁽⁴⁾. There are biological and mechanical factors contributing to a fracture not to heal such as: kind and location of the fracture, distraction between bone fragments, infection, open reduction, unstable synthesis, insufficient blood supply of the fragments, inadequate immobilization, tissue interposition between fragments and patient profile.

In humeral fracture, several phenomena may be present during closed or open treatment, avoiding bone healing.

In our cases, the following were identified as related to non healing: focus instability, inadequate immobilization, and patient profile (obesity and treatment co-operation).

From the 16 humeral pseudarthrosis, 14 (87.5%) were related to closed treatment of the fracture, while the studied cases ^{(9, 26)}, secondary to open methods, presented an incidence of pseudarthrosis of 71% and 75% respectively.

From the 14 pseudarthrosis related to closed treatment of humeral fracture, 13 (92.8%) were treated with confectioner holder cast. This data shows that this kind of immobilization was probably insufficient to stabilize the humeral fracture, mainly in obese patients and with poor adherence to treatment.

Regarding location and kind of humeral shaft pseudarthrosis, there was a higher incidence of atrophic pseudarthrosis (93.7%) located in medium and distal thirds of humeral shaft (81.3%), similarly to other studies⁽¹⁵⁾. Theses findings may be explained by peculiarities of humeral blood supply⁽¹⁴⁾.

We decided to use DCP plates for 3.5mm screws aiming to minimize aggression to adjacent soft tissues, avoiding major damage to local blood supply. When using osteosynthesis with 3.5mm plates, we applied a thoracobrachial plaster cast to complement the treatment.

Our patients started motor physiotherapy after clinical and radiological clues of bone healing, however the literature ^{(9,11, 21,10)} suggests early mobilization. Functional impairment secondary to the prolonged time of immobilization was already present before the surgery, with no interference in daily life activities of these patients.

With this treatment method, bone healing was observed in 100% of the humeral shaft pseudarthrosis with one single surgical procedure. A similar result was described ⁽¹⁰⁾ using a 4.5mm DCP plate, without the thoracobrachial plaster cast.

The proposed treatment was shown to be adequate regarding the low incidence of complications and the high incidence of bone healing.

At the end of our evaluation, we found that surgical treatment with 3.5mm DCP plate, with a complementary thoracobrachial plaster cast was efficacious in treating humeral shaft pseudarthrosis.

REFERÊNCIAS BIBLIOGRÁFICAS

*Work performed in the Department of Orthopaedics and Traumatoloy of Hospital Escola da Faculdade de Medicina do Triângulo Mineiro - Uberaba - MG.

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Correspondence to

José Wagner de Barros

Disciplina de Ortopedia e Traumatologia

Departamento de Cirurgia do HE/FMTM

R. Getúlio Guaritá S/Nº - Bairro Abadia

CEP 38025-440 - Uberaba - MG

Publication Dates

• Publication in this collection
  21 Sept 2005
• Date of issue
  Mar 2002

History

• Received
  04 Jan 2001
• Accepted
  27 Nov 2001