Osteosynthesis of the humeral shaft fractures, with bridge plate

Abstracts

Os autores descrevem o método cirúrgico inédito para o tratamento das fraturas da diáfise do úmero, com placa colocada por técnica minimamente invasiva. Após estudos anatômicos, foram identificadas três acessos cirúrgicos pelos quais se pode introduzir uma placa na face anterior do úmero, sem risco de lesão vásculo nervosa. O acesso proximal se faz entre os múculos deltóide, lateralmente, e bíceps braquial, medialmente. Nas fraturas do terço médio o acesso distal é feito entre os músculos bíceps braquial e braquial com a placa introduzida de proximal para distal. Nas fraturas distais do úmero o acesso proximal é o mesmo, mas o acesso distal é o descrito por Kocher, com a placa introduzida de distal para proximal e fixada na face anterior da coluna lateral do úmero. O método aqui apresentado vem sendo utilizado desde junho de 2001, principalmente nos pacientes politraumatizados e polifraturados, por ser rápida, segura e por permitir que o paciente possa ser operado em decúbito dorsal horizontal. Além disso, não há necessidade de intensificador de imagem, ou mesmo aparelho de radiografia. Até o momento não foram observadas complicações vásculo nervosas nos 22 pacientes tratados.

Fraturas do úmero; Fixação interna de fraturas; Placas óssseas; Diáfises

ORIGINAL ARTICLE

Osteosynthesis of the humeral shaft fractures, with bridge plate

Bruno Livani^I; William Dias Belangero^II

^IMaster in Surgery FCM – UNICAMP

^IIPhD Professor of the Orthopedics and Traumatology Department of FCM – UNICAMP

^{Correspondence}

SUMMARY

The authors describe for the first time ever a minimally invasive plate osteosythesis for the treatment of the humeral shatf fractures. After anatomic human cadaver's studies, it was identified three surgical approaches for plate percutaneous insertion on the anterior surface of the humerus without vascular and nervous injury. The proximal approach is between the biceps and deltoid muscles. The distal approach for medial third fractures is between the biceps brachialis and brachialis muscles. The plate is inserted from the proximal to distal direction. For distal fractures, the proximal approach is the same described by Krocher, with the plate inserted from distal to proximal and fixed on the anterior surface of the lateral column of the humerus. This method has been used since June/2001 mainly for the treatment of multiple trauma patients, allowing other surgical procedures, and it has been showed very efficient. The patient is operated in DHD without image intensifier or x ray apparatus. Until the moment, 22 patients have been treated without vascular or nervous complications.

Key words: Humeral fractures; Fracture fixation, Internal; Bone plates; Diaphysis.

INTRODUCTION

The traditional treatment is still used to the humeral shaft isolated fractures⁽¹⁶⁾. However the surgical treatment is shown as the best choice ⁽¹⁵⁾ in obese people, patients with vascular or nervous injuries and mainly the ones with the multiple traumas, whose frequency has increased due to severe traumas⁽³⁾, result in complex fractures, mainly the upper limbs. Under the circumstances the patients have difficulty in assuming the orthostatic position and of using successfully the upper limbs fractured because of the injuries and also systemic healthy, not indicated the conventional treatment^(2,13). The surgical treatment, made with open reduction and tough internal fixation (plate and screws) or with the close focus with relative stability (blocked intramedular stalk), are the most used method^(7,14).

Procedures minimally invasive are suggested to the lower limbs treatment^(1,8,11,12) could be a very interesting choice fractures treatment, mainly in severe clinical patients. However, multicentered random studies that compare the performance of the blocked stalks to close focus with the plates to open focus, has shown some advantages towards the stalks, as its has been large number of cases with no retard of joining, pain dysfunction of the shoulder and re-operations in the patients treated with stalks. In addition, there was no important inter-operatory bleeding in in the surgery time procedure⁽⁵⁾.

Technically, against the stalks there is still the fact that these stalks need the intensifier image use and the position of the patient in lateral, ventral and semi-sitting, decubitus what can cause difficulty the others fractures treatment to be associated with multiple fractured and multiple traumatized patients⁽¹⁴⁾.

Taking these into considerations, the authors show the minimally invasive method for humeral shaft fractures surgical treatment.

MATERIALS AND METHODS

About the surgical technique

When a minimally invasive plate osteossynthesis is thought to be used in humeral shaft fractures, the first thing to avoid is the nervous radialis injury. Studying and seeing the human cadavers again, the approach for this procedure with no nervous radialis injury, or any other nervous vascular structures, defining the anatomical reduction of the bone fragments the anterior or posterior lateral surface described by Thompson in 1918 and Henry in 1966 ⁽⁴⁾, a free approach structure on the anterior surface of the humerus, which is full of nervous, on this surface is the brachialis muscle, which is innervated at the lateral surface by the radialis nervous and in the region of the medial by the cutaneous muscles. This anatomical detail allows the same to happen in the widespread longitudinal region, without harming its function. The only potentially risky structures of this study is the cutaneous lateral nervous of the forearm, sensitive branch of the cutaneous muscle located between the biceps brachialis muscles, brachialis and the radialis nervous between the brachialis muscles and the brachialisstyloradialis of the third distal of the arm^(6,10).

The operatory technique presentations

The procedures are done with the patient in horizontal dorsal decubitus on a conventional operatory table, with the elbows semi-flexed (Figure 1). Three approaches were defined, one proximal and two distal, depending on the fracture local, if medium or distal shaft.

The proximal approach is done between the biceps brachialis muscles, medially, and the deltoids muscle, laterally together with the cephalic vein, with 3,0 to 5,0 cm length. For the median third fractures, the distal approach with the same length is done between the biceps brachialis muscles and the brachialis, below of the focus. In this space the lateral cutaneous nervous of the forearm is easily seen, situated medially and superiorly to the brachialis muscle (Figure 2). The brachialis muscle is divided longitudinally to show the anterior surface of the humerus Figure 3. In the third distal fractures the approach used by Krocher ⁽⁴⁾ is to abort the lateral column of the humerus, with subperiosteos dissection of the crest of superepycondilus lateral humerus and distance of the set of muscles, the brachialis stylusradial and extensor radialis longus of the carpus and the radial nervous on the anterior surface (Figures 4a, 4b and 4c) The distance must be done with the use of a lever or separation apparatus of the Hohmann in order to avoid the radial nervous injury. For the third median fractures, straight plate DCP is used, normally with twelve punctures, of big fragments, which does not need mouldling, as the anterior surface of the humerus plane. The plate is inserted from distal to proximal, first the distal screw is the last to be fixed, let it slightly loosen to allow its adaptation to the bone. Next, abduct the arm around 60º to correct the deviation in varus and smooth traction spin the distal fragment, as long as the biochondilar axis stays in a orthogonal plane in relation of the biceps brachialis longus of the tendon, inserting, then the first proximal screw (Figure 5), Then the next screws, total of two (preferable with alternate punctures) or three in each fragment. For the distal fractures the same implant is used, which must be mouldled in its distal region to be fit in the lateral column of humerus, avoiding the blocking of the coronoid fossa or the olecranon (Figure 6). In this case the place is inserted from distal to proximal direction, to avoid wrong trajectory and the nervous radialis injury in the distal region, in this approach is located in the anterior surface to the plate (Figure 7).

The injury healing is used in a usual way and there is no need of the use of an aspirator drain, neither external immobilization. There is no need of the image intensifier or the radigraphs control during the surgical procedure. Sooner after the surgery, the patient if allowed to move freely the joints of the shoulder and elbow and use the operated limb for daily activities, such as, feeding and personal hygiene. The stitches of the suture are removed routinely between 10º and 15º days post operatory.

DISCUSSION

Despite the traditional method continue to be the chosen method for isolate fractures of the shafts of humerus⁽¹⁶⁾, in patients who need surgical treatment , the available methods are not free of risks and complication, and most of them occur because of this technique or the submission to the surgery⁽⁷⁾. From the 80 decade on, the procedure shortly invasive became common and the plate became outstanding in the treatment of the lower limbs fractures, but not for the shafts humerus fractures. The main purpose of this study is to show the possibility of treating shafts humerus fractures by minimally invasive technique, using two approaches to insert the plates, with no risk of iatrogenic injury of the radialis nervous, complication described in the treatment of these fractures by open approach. The use of the anterior surface approach, inserting the plate in the anterior surface of the humerus, is an excellent choice to avoid the radial nervous injury that rounded the medial, posterior and lateral region of the shafts of this bone. Coincidently, the humerus anterior surface, due to be plane, allows the plate slides easily on the surface and the focus of fracture, adapting perfectly to the topography of this bone (Figure 8)

About the technique performance, the patients not only took advantage of the previous and active immobilization of the limb, due to the slight severity of the surgery, but also with the obtained stability, that is enough to sustain the efforts of the daily activities, relieving the pain and fast recovery of the arch joint movement of the shoulder and elbow (Figures 9a, 9b, 9c)

This technique is a new perspective to the shafts humerus fractures treatment, especially in multiple traumatized and multiple fractured patients. However this technique is not suggested for patients with plexus brachialis injury, who were not able to do the active flexion extensive of the elbow. Theorically, fractures associated to radialis nervous injury, pathological fractures and exposed fractures of IIIB or IIIC degrees neither can be treated using this method. In radial nervous injury fractures and classical pattern described by Holstein and Lewis⁽⁹⁾, the nervous can be tied between the bones fragments, being necessary the direct approach of focus of the fracture. In the pathological fractures or with little bone storage (tumors, metabolic illness or osteoporoses) the quality of the bone can reject the fixation of the screws, and then, the end of the treatment. About the exposed fractures III-B and III-C, the external fixer is still the safer choice until the resolution of the injuries of the smooth regions; therefore prescribe the definite treatment as more appropriate.

CONCLUSION

The technique shown, besides being done with certain facility and security, has as main advantage of the possibility to be made in dorsal horizontal decubitus, with no need of sophisticated surgical instruments and neither they use of an intensifier image or radiographic apparatus. This technique is advised to multiple traumatized and multiple fractured patients, where there is need of the fixation of the concomitant fractures in other fragments and surgical procedures for other specialties.

REFERÊNCIAS BIBLIOGRÁFICAS

Work performed at Orthopedics and Traumatology Department of FCM –UNICAMP) - State University of Campinas

• 1. Belangero WD. Princípios Gerais de Osteossíntese e Fixação Biológica das Fraturas. In: Baldy FR. Fraturas Campinas, Autores Associados, 2000:23-28.
• 2. Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY (1985). The Results of plating humeral shaft fractures in patients with multiple injuries. The Sunnybrook experience. J Bone Joint Surg, 67-B:293-296.
• 3. Christensen S (1967). Humeral shaft fractures. Operative and Conservative Treatment. Acta Chir Scand, 133:455-460.
• 4. Crenshaw AH. Campbell's Operative Orthopaedics, 7th edn. The CV Mosby, St. Louis, 1987, Vol. 1:85-87.
• 5. Farragos AF, Schemitsch EH, McKee MD (1999) Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma, 13(4):258-267.
• 6. Gardner E, Gray DJ, O'Rahilly R. Anatomia: Estudo regional do corpo humano 4th edn. São Paulo, Guanabara Koogan, 1988:122-129.
• 7. Heim D, Herkert F, Hess P, Regazzoni P (1993). Surgical treatment of humeral shaft fractures. The Basel experience. J Trauma, 35(2):226-231.
• 8. Heitemeyer U, Kemper F, Hierholzer G (1987). Severely comminuted femoral shaft fractures: treatment by bridging-plate ostheosynthesis. Arch Orthop Surg, 106:327-330.
• 9. Holstein A, Lewis GB (1963). Fractures of the humerus with radial nerve paralysis, J Bone Joint Surg, 45-A (7): 1382-1388.
• 10. Hoppenfeld S, deBoer Piet. Vias de acesso cirúrgico em ortopedia Vias de acesso Anatômico, São Paulo, Manole, 1990:47-75.
• 11. Hungria Neto JS (1996). Fraturas diafisárias do fêmur. Ainda há indicação para uso de placas? Rev Bras Ortop, 31:444-448.
• 12. Krettek C, Schandelmaier P, Miclau T, Tscherne H (1997). Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury, 28(1):S20-S30.
• 13. Packer JW, Foster RR, Garcia A, Grantham AS (1972). The Humeral Fracture with Radial Nerve Palsy: Is Exploration Warranted? Clin Orthop Rel Res, 88:34-38.
• 14. Rommens PM, Blum J, Runkel M, Degreif J (1999). Interlocked nailing of humeral shaft fractures with the Unreamed Humeral Nail (UHN). Injury, 30:S-C64-S-C73.
• 15. Ruedi T, Moshfegh A, Pfeiffer KM, Allgower M (1974). Fresh fractures of the shaft of the humerus. Conservative or operative treatment? Reconstr Surg Traumat, 14:65-74.
• 16. Sarmiento A, Latta LL. Tratamento Funcional Incruento de las Fracturas. Buenos Aires, Panamericana, 1987:498-548.

Publication Dates

• Publication in this collection
  16 June 2004
• Date of issue
  June 2004

History

• Accepted
  09 Apr 2004
• Received
  17 Sept 2003