Date: Sun, 15 Jul 2001 18:37:50 +0600
Subject: Humerus fracture - neck and shaft
Hello all,
A male 44 years old admitted to us from another town with transverse fracture of the neck and spiral one of the shaft. No neurovascular injury. An injury was a couple of days before - fall from stair. I think about closed nailing here. What would be your plan for the case?
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THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Sun, 15 Jul 2001 10:36:51 -0700
From: Carlo Bellabarba
Looks from the one view like the proximal segment is minimally displaced. if that is really the case, and if this is an isolated injury, i would try closed treatment with a functional brace.
carlo bellabarba
seattle
Date: Sun, 15 Jul 2001 00:20:57 -0400
From: bruce meinhard
Sling for the proximal fracture 3 weeks, while at the same time, fracture brace for the shaft fracture provided crepitus at the fx site is present indicating no soft tissue interposition. Only if this were a polytrauma patient would I conside more aggressive operative management.
bpm
Date: Mon, 16 Jul 2001 01:16:23 +0600
From: Alexander Chelnokov
Hello Carlo,
CB> closed treatment with a functional brace.
We can't observe him for all needed period because the patient is from a small town far from here, and he was referenced to our institution because no ortho surgeon was available. Also he doesn't look compliant enough to leave him on his own with the sling/brace.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 16 Jul 2001 07:33:05 -0700
From: Chip Routt
Hello Alexander-
Please consider:
Patient remote address is not an indication for surgery.
Patient referral to a medical center is not an indication for surgery.
Anticipated or documented noncompliant patient behavior is not an indication for surgery. Imagine how he will care for your surgical implant, if he cannot even care for a sling and a brace.
Biplanar radiographs or CT scan of the proximal humerus would reveal fracture involvement there. This information would have impact on your treatment.
Good luck Alexander-
Chip Routt, M.D.
Date: Tue, 17 Jul 2001 00:51:57 +0600
From: Alexander Chelnokov
Hello Chip,
CR> Patient remote address is not an indication for surgery. Patient referral to a medical center is not an indication for surgery. Anticipated or documented noncompliant patient behavior is not an indication
All of mentioned of course can not be direct indications but the circumstances can strongly affect the choice.
CR> Biplanar radiographs or CT scan of the proximal humerus would reveal
Lateral view is attached.
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Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 16 Jul 2001 12:16:43 -0700
From: Chip Routt
Good luck Alexander-
Chip
Date: Mon, 16 Jul 2001 22:22:10 -0400
From: William Obremsky
I vote for closed treatment. It will heal whether he is compliant or not. f/u once a month is not too frequent and he would need even more frequent f/u if you operate on him.
Bill Obremskey
Date: Tue, 17 Jul 2001 00:11:30 EDT
From: Tom DeCoster
I've used a Polaris nail in a similar situation and it worked OK. I''m not sure if this case benefits from operative treatment or not, though.
TD
Date: Tue, 17 Jul 2001 18:19:06 +0600
From: Alexander Chelnokov
Hello All,
Closed antegrade nailing with a flat titanium nail was performed. Xrays of the result in attachment. Entry point is above the tubercle not to dis-impact the neck
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Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Wed, 18 Jul 2001 22:16:49 +0600
From: Alexander Chelnokov DTIG> Your post operative X-ray is quite impressive.I presume it was an unreamed
nail.
Yes. It is a flat titanium nail which is made from plates before the
surgery - some metalwork is needed. It is a weakness of the technology
- our institution has an appropriate workshop unit, which also makes
experimental or new equipment. But common city hospitals don't.
DTIG> How was the stability on the table after fixation?
The nail is elastic, not rigid, so stability is relative.
DTIG> Will you give any external support?
Sling only.
DTIG> Do you predetermine the nail length and select the nail
Yes. This type of nails is prepared before surgery using a
standartized lateral view of opposite humerus by cutting and bending
a triangle flat plate.
DTIG> or do you cut excess length on the table intraoperatively?
This also is an option. Sometimes if the nail still appears to be too
short or thin, an additional small plate can be used to narrow the
canal.
Best regards,
Alexander N. Chelnokov
Date: Thurs, 19 Jul 2001 10:10
From: Bill Burman
Alex
As noted by other list members, your case of a neck/shaft humeral fracture
does not appear to meet published indications for surgical stabilization. e.g. O'Brien, Guy and Blachut; Fractures - Master Techniques of Orthopaedic
Surgery; ed Don Wiss; LWW 2000 - see OTA
BFC Lecture Indications for humeral fixation Nonetheless this case is selected to showcase a new flexible im nailing
technique right through
the rotator cuff . IF any of the indications for surgery were in place, wouldn't an established
technique of less invasive, flexible im nailing such as: Hall RF Jr, Pankovich AM; Ender nailing of acute fractures of the humerus.
A study of closed fixation by intramedullary nails without reaming. J Bone
Joint Surg Am. 1987 Apr;69(4):558-67. Ogiwara N, Aoki M, Okamura K, Fukushima S., Ender nailing for unstable
surgical neck fractures of the humerus in elderly patients. Clin Orthop.
1996 Sep;(330):173-80. be more appropriate? Bill Date: Thu, 19 Jul 2001 23:22:06 +0600
From: Alexander Chelnokov Hello Bill,
BB> does not appear to meet published indications for surgical stabilization.
I would add "published in English". For instance in Kurgan any patient
with fracture of humerus of any type is immediately ex-fixed by a
small wire apparatus, and colleagues from there appear with similar
interest why some people use other ways of treatment. Genuine
functional braces are commonly unavailable here, it can be only
imitation using short plaster cast. Many hospitals use
thoraco-brachial casts. I know some hospitals where any humerus
fracture is plated. Complication rate of non-operative treatment
which can be seen here is not lower than after osteosynthesis.
BB> Indications for humeral fixation [...]
And fracture itself - at least to decrease disability time. In a
monograph of this techique originators (Klyuchevsky et al., 1993), for
humeral fractures it was 38 days which is obviously shorter than in
any non-operative approach.
BB> IF any of the indications for surgery were in place, wouldn't an
established technique of less invasive, flexible im nailing such as:
[...] be more appropriate?
I am aware of the technique and i would use it if something like the
mentioned were in stock in our OR.
Best regards,
Alexander N. Chelnokov
Date: Thurs, 19 Jul 2001 22:58
From: Bill Burman
AC> in Kurgan any patient with fracture of humerus of any type
is immediately ex-fixed Alex It is amazing to hear that under the dire medical economic circumstances
which are frequently described in your posts, the treatment of choice for
closed humerus fractures (without the indications published in the English
literature) is surgery. Your report of a higher complication rate with conservative care directly
contradicts a large experience by Sarmiento (OTA
BFC Lecture) and others notables (OTA
BFC Lecture) in this country. It is important to note that reports recommending conservative care of
most humerus fractures were written at a time when there was greater reimbursement
and therefore a greater incentive for surgical care. However it was also
a time of an ever increasing number of malpractice
lawyers. Have they managed to find their way over there yet? Your assertion that operative care by Klyuchevsky et al. (not listed
in PubMed),in 1993, reduced disability time for humeral fractures to 38
days (5.5 weeks) "which is obviously shorter than in any non-operative
approach" is debatable. For instance, Sarmiento JBJS 59A:597 1977 reports
"Within a few weeks nearly every patient could touch his face with
his hand and activities of daily living could be performed with minimum
difficulty." With your excellent English skills, it would be most helpful
if you could translate Klyuchevsky's report. I am sure there would be a number of
implant companies which would be happy to underwrite this work. AC> I am aware of the technique and i would use it if something
like the mentioned were in stock in our OR. I can't understand it. Why only a few days ago, against all odds, you
were just about to use flexible IM nails on a radius
malunion case. Perhaps somebody in the OR there has been reading these
posts and has hidden them. :-) Bill Date: Fri, 20 Jul 2001 16:11:07 +0600 From: Alexander Chelnokov BB> closed humerus fractures (without the indications published
in the English literature) is surgery. Suggestions that this is better than available non-operative options,
traditions, superstitions, wish to see aligned segment, etc. BB> Your report of a higher complication rate with conservative
care directly contradicts a large experience by Sarmiento
Does his experience include many conservatively treated patients from
xUSSR? I suppose he analyzed patients treated accordingly to his well-established
system of functional bracing, so the conclusion is relevant to the population
only. BB> It is important to note that reports recommending conservative
care of most humerus fractures were written at a time when there was greater I know about the approach, it works - but in conditions of availability
of functional braces, physicians familiar with the approach and so on. BB> Your assertion that operative care by Klyuchevsky et al. (not
listed in PubMed), I told about a monograph. I checked Medline - i did wrong transliteration
of russian names. Check for Kliuchevskii
VV, Zverev EV. BB> in 1993, reduced disability time for humeral fractures to 38
days (5.5 weeks) "which is obviously shorter than in any non-operative
approach" is debatable. For instance, Sarmiento JBJS 59A:597 1977 reports
"Within a few weeks nearly every patient could touch his face with
his hand "To touch his face" and return to physical work is not the
same. BB> activities of daily living could be performed with minimum
difficulty." The same is occured in some days, not weeks, with operative treatment
like nailing or ex-fix. BB> if you could translate Klyuchevsky's report. It is a ~300 pages book. BB> I am sure there would be a number of implant companies which
would be happy to underwrite this work. It is a rather popular technique in Russia. It was presented at many
meetings, accompanied by excibitions, so i suppose representatives of many
companies have seen the matter. As i told before, the method has an unpleasant
feature - a one must do some metalwork to make a nail suitable to medullary
cavity of a particular patient, so hardly ever the implants would be met
with enthusiasm by surgeons which have available any needed industrial implant.
BB> I can't understand it. Why only a few days ago, against all odds,
you were just about to use flexible IM nails on a radius
malunion case. The rod is specially designed for forearm bones, it is pentagonal with
transduction to rectangular, only few ones are left in our OR so i keep
them for forearms. I'll try to find other thin nails. Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia