Fracture humerus is commonly presents in polytrauma cases especially in road traffic accidents and accounts for approximately 3% of all orthopaedicinjury(1,2,3).Biological fixation and relative stability has advantage over absolute anatomical reduction with compromising soft tissue and vascularity(4).Precise reduction and absolute stable fixation has its biological price(5).Evidence shows that a biological fixation is far superior over a stable mechanical fixation (6). From conservative cast and braces to internal fixation with nailing, plating and screw, treatment of humeral fracture has evolved a lot with their complications[7-12]

Minimally invasive technique for humerus shaft fracture has shown promising results recently [13-16].

AIM To evaluate the results of fixation of  diaphysealhumerus fractures by anterior bridge plating

OBJCTIVES

1. To evaluate the post operative condition
2. To observe the time period for union
3. To compare the post operative range of motion with the normal range of motion
4. To assess radiological and functional outcome

MATERIALS AND METHODS

The study will be carried out at a 1000 bedded tertiary care hospital. It is a prospective, non competitive, observational result oriented study.

The study would be carried out after approval from ethics committee.

The study would be carried out on 20 patients

4.5 mm LCDCP will be used

The study would be carried for a duration of 1 year from September 2024 to May 2025

The functional outcome would be evaluated using UCLA shoulder score and MEPS score

Follow up at 0 6 and 12 months

Inclusion criteria

Adult patients above 18 years

No head injury

No neurovascular injury

Grade 1 open fractures

Exclusion criteria

Age less than 18 years

Grade 2 and 3 open fractures

Head injury

Neurovascular injury

Intra articular fractures

Patients unfit for surgery

SURGICAL TECHNIQUE

The patient positioned supine, brachial plexus block given

2-3 cm incision between medial border of deltoid and proximal biceps, 5 cm caudal to acromion process was made.

Retraction of biceps to expose musculocutaneous nerve overlying brachialis muscle, brachialis split

Sub-brachialis, extra-periosteal tunnel was created and a 4.5 mm DCP was passed through the incision. Angulation, length and rotation are restored using traction.

Confirmation of reduction done. Each side of plate is fixed by two screws in anterior to posterior direction.Tunnel is created in such a way to avoid any iatrogenic nerve injury.

MEPS SCORE

UCLA score

FOLLOW UP

35 year old male patient suffering from closed displaced diaphysealhumerus fracture without distal neurovascular deficit. Follow up was taken at 3months post operatively and 12 months post operatively

Pre operativexray

Immediate post operativexray

3 months follow up

12 month follow up

CLINICAL IMAGES

RESULTS

Arm was immobilized in a neck wrist sling or broad arm pouch for pain control in the first 5 days if necessary, mainly at night while sleeping. Stitches were removed on 12th post-operative day. The patients were advised to perform passive gentle limb range of motion exercises as their pain control permits. Immobilizer was removed after stitch removal. However they were informed to take out the limb and perform informed exercise for 8 to 10 times a day.

After radiological signs of healing, a rehabilitation program was started. The aim was to gain full mobility, muscular strengthening and proprioception as soon as possible. The total rehabilitation period depends on the individual patient’s progression. The final goal is to restore ache free functional to full range of motion and strength. The union time and complications were noted. The follow up was taken at 6, 12 and 18 months.

The patients shoulder and elbow function were analyzed using the UCLA shoulder score18 and the Mayo elbow performance score (MEPS)19 The UCLA shoulder score was graded into excellent to good (>27 points), fair to poor (<27 points). Elbow function was graded on the MEPS basis into excellent (≥90 points), good (75–89 points), fair (60–74 points), or poor (<60 points). Based on the anteroposterior and lateral radiographic view Union was accepted as the presence of bridging callus in three of the four cortices and absence of pain. Also any loss of fracture reduction was analyzed in similar radiographs.

DISCUSSION AND CONCLUSION

Despite the requirement of high surgical expertise and time taken for adaptation of the procedure, the MIPO technique seems to be reproducible and applicable in almost all types of shaft humeral fractures. Lower rates of iatrogenic nerve injury with minimal bone vascularity disruption, and soft tissue dissection are all the advantages over conventional plate technique. Though indirect reduction and plate placement is technically difficult and requires experience, Plates can be safely used anteriorly or anteromedially over the humeral shaft. Bridging the fracture fragment, with fixation only at either ends of the plate and bone.

Excellent to good results have been achieved with sub brachialis plating with no major soft tissue problems and with functional results as per other methods. Open technique of plating interferes with the local vascularity, leading to osteonecrosis underneath the plate, which may cause delayed healing to non healing

REFERENCES

1. Epps CH Jr, Grant RE. Fractures of the shaft of the humerus. In: Rockwood CA Jr, Green DP, Bucholz RW, editors. Rockwood and Green’s fractures in adults. 3rd ed. Philadelphia: Lippincott Williams & Williams, 1991.
2. Tsai CH, et al. The epidemiology of traumatic humeral shaft fractures in Taiwan. IntOrthop. 2009; 33:463-7. Doi:10.1007/s00264-008-0537-8
3. Frigg R, Wagner M. AO Manual of fracture management.Chapters1.2: Concepts of fracture fixation. 2006.
4. Baumgaertel F, Buhl M. Fracture healing in biological plate osteosynthesis. Injury. 1998; 29(Suppl 3):C3-6.
5. Frigg R, Wagner M. AO Manual of fracture management. Chapters 1.2: Concepts of fracture fixation, 2006.
6. Baumgaertel F, Buhl M, et al. Fracture healing in biological plate osteosynthesis. Injury 1998; 29 (Suppl 3): C3‑
7. Camden P. Fracture bracing of the humerus. Injury 1992; 23: 245‑
8. Hunter SG. The closed treatment of fractures of the humeral shaft. ClinOrthopRelat Res 1982;164:192‑
9. Chao TC, et al. Humeral shaft fractures treated by DCP, Ender and interlocking nails. IntOrthop 2005;29:88‑
10. Ajmal M, et al. Antegrade locked intra medullary nailing in humeral shaft fractures. Injury 2001;32:692‑
11. Petsatodes G, et al. Antegrade interlocking nailing of humeral shaft fractures. J OrthopSci 2004;9:247‑
12. Santori FS, Santori N. The Exp Nail for the treatment of diaphyseal humeral fractures. JBJS Br 2002;84 (Supp 3):280.
13. Apivatthakakul T, et al. MIPO of the humeral shaft fracture: Is it possible? A cadaveric study and preliminary report. Injury 2005;36:530‑
14. Zhiquan A, et al. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007;21:628‑
15. Ziran BH, et al. Percutaneous plating of the humerus with locked plating: Technique and case report. J Trauma In j Infect Crit Care 2007;63:205‑
16. Livani B, et al. Is MIPO in humeral shaft fractures really safe? Postoperative ultra sonographic evaluation. IntOrthop 2009;33:1719‑