|Year : 2018 | Volume
| Issue : 2 | Page : 112-115
Study of locking compression plate in the fixation of comminuted diaphyseal humerus fracture
Ravi Kumar1, Virender Kumar Sahni2, Manoj Garg2, Neeraj Kumar2
1 Department of Orthopaedics, AIIMS, Patna, Bihar, India
2 Department of Orthopaedics, Maharaja Agrasen Hospital, New Delhi, India
|Date of Web Publication||22-Nov-2018|
Dr. Ravi Kumar
Department of Orthopaedics, AIIMS, Phulwari Sharif, Patna - 801 507, Bihar
Source of Support: None, Conflict of Interest: None
Background: Humerus shaft fracture accounts for 20% of all humeral fractures. Comminuted fracture of humerus requires great surgical skill to obtain stable fixation. The aim was to study the effect of locking compression plate (LCP) in the fixation of comminuted diaphyseal humerus fracture. Materials and Methods: This is a prospective study done over 12 months in which 30 consecutive skeletally mature, closed diaphyseal comminuted humerus fractures underwent fixation with LCP and outcome evaluated in terms of radiological evidence of healing, functional outcome, and complications if any. Results: Union of all thirty fractures was achieved primarily. There was no implant-related complication. The mean Mayo Elbow Performance Score at 6-month follow-up was 90.5, while the mean University of California and Los Angeles score (UCLA) at 6-month follow-up was 29.66 with minimum 24 to maximum of 34. Conclusions: Internal fixation of comminuted diaphyseal humeral fractures with locking plates described in this study allows an intensive program of rehabilitation immediately after surgery and is associated with a high union rate.
Keywords: Comminuted, fracture fixation, humerus fracture, locking plate
|How to cite this article:|
Kumar R, Sahni VK, Garg M, Kumar N. Study of locking compression plate in the fixation of comminuted diaphyseal humerus fracture. J Orthop Traumatol Rehabil 2018;10:112-5
|How to cite this URL:|
Kumar R, Sahni VK, Garg M, Kumar N. Study of locking compression plate in the fixation of comminuted diaphyseal humerus fracture. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2019 Mar 22];10:112-5. Available from: http://www.jotr.in/text.asp?2018/10/2/112/245999
| Introduction|| |
Fractures of the humeral shaft (diaphysis) account for approximately 3% of all fractures and represent 20% of all humeral fractures., They have bimodal distribution. One group consists of mostly young males of 21–30-year age group and the other of older females of 60–80 years. Various literature is available showing the advantages of the conservative method of treatment., Fracture with intra-articular extension, neurovascular injury, and pathological fracture almost always require operative treatment. Comminuted fracture of the shaft and distal one-third can be a surgical challenge requiring great surgical skills and optimal implant design to obtain stable fixation to attain early mobilization.
Precise reduction and absolute stable fixation have its biological price. There has been evidence to show the superiority of biological fixation over a stable mechanical fixation. This led to the development and improvement in the techniques of biological fixation for fractures and also the development of stabilization systems that help in achieving a biological fixation.,
Many authors have proved the superiority of locking plates over dynamic compression plates in various cadaveric long-bone models.,, Some biomechanical studies have suggested that locking-plate constructs are stiff and suppress interfragmentary motion to a level that may be insufficient to reliably promote secondary fracture healing.,,
In our knowledge, the literature has very limited reports related with the effect of locking compression plate (LCP) in the fixation of comminuted diaphysis humerus fracture and henceforth our study was with the aim to study the effect of LCP in the fixation of a comminuted diaphyseal humerus fracture.
| Materials and Methods|| |
This prospective study was hospital based and conducted from January 2016 to December 2016. Patients were selected from those who had attended the emergency or outpatient department with closed comminuted humerus fracture not more than a month old in skeletally mature individual. A clearance from Ethical Committee of institute was obtained. Written informed consent was obtained from all the patients or their family for participation in the study. On admission, demographic data were recorded, and thorough clinic-radiological evaluation was performed. Preoperatively, the exact modality of surgery and fixation was decided. Postoperatively, patients underwent thorough clinical evaluation including assessment of functional status using UCLA shoulder score and Mayo Elbow Performance Score (MEPS) along with radiological evaluation. We used AO synthes locking plates in all of our thirty participants (4.5 mm Narrow LCP/metaphyseal locking plate/Posterolateral locking plate). A posterior approach was the one used in all patients.
In the immediate postoperative period, care was given to the general condition and fluid balance. Adequate antibiotics were given as per the hospital protocol for orthopedic surgeries. The patient was discharged according to the overall well-being of the patient, preferably on 3rd or 4th day, with medications convenient to be taken at home. Postoperatively, range of motion (ROM) of the shoulder and elbow was begun within the 1st week.
Patients were evaluated both clinically and radiologically. Our scheduled follow-ups were at 2 weeks, 1 month, 2 months, 3 months, and 6 months.
During the follow-up:
- The course of fracture healing was documented radiologically
- Evaluation of any possible loss of reduction that might have occurred, compared to immediate postoperative radiographs
- Assessment of functional status using UCLA shoulder rating scale and MEPS done at 6 months of follow-up
- Assessment and analysis of any complications observed.
Follow-up of our patients ranged up to 25 weeks. No patient was lost to follow-up.
| Results|| |
The age group of the patients in our study ranged from 21 to 65 years. Most of the patients (33.33%) belong to middle aged between 51 and 60 years indicating the need for use of LCP in adult. Most of our patients were male (73.34%). It reflected the general population which visits our both outpatient as well as the emergency trauma section. In our study, the most common mode of injury (n = 22, 73.33%) was a road traffic accident, of which 17 were males and 5 were females. Fall from stairs or slip on the floor was responsible for injury in eight (26.67%) patients, of which three were females and five males. In our study, all the participants had closed fractures.
Out of thirty participants, fractures in 16 patients were of AO/OTA Type B1, thus making it the most common type in our study. The fracture in seven patients was AO/OTA-B2; in two participants, it was AO/OTA–B3; and 5 participants had AO/OTA Type C1 pattern.
Union of all thirty fractures was achieved primarily. Seventy percent of the patients had a union by 16 weeks, while remaining 23.33% had union by 20 weeks and remaining 6.67% had union by 24 weeks. Mean time duration is 15.66 weeks.
We had no case of any pure implant-related complications such as loosening, screw breakage, or implant failure.
- ROM at 4 weeks: The mean arc of motion at 4 weeks was 77.66°. The ROM was from a mean minimum of 21°–97.83°
- ROM at 2 months: The mean arc of motion at 2 months was 89.66°. The ROM was from a mean minimum of 15°–105°
- ROM at 3 months: The mean arc of motion at 3 months was 100°. Mean range was 12° (minimum) to 115.53° (maximum)
- ROM at 6 months: The mean flexion-extension arc of the elbow after 6 months was 112°. Mean range was from a minimum of 6° to a maximum of 121.5°.
The mean MEPS at 6-month follow-up was 90.5 which is excellent.
The mean UCLA at 6-month follow-up was 29.66 which is good.
| Discussion|| |
The overall incidence of humeral diaphysis fractures is increasing worldwide in both developed and developing countries. Our experience with the locking plate has given favorable results.
Early mobilization and rehabilitation played a significant role in achieving optimal functional outcome, especially when dominant upper limb was involved.
As per a study done by Tytherleigh-Strong et al. among the wedge and complex fracture pattern, the most common type is B1 which is what even our study reflects. In another study done by Shetty et al. which was basically a study for locking plate in diaphyseal fracture, the maximum number of cases was of AO/OTA type C2. Similarly, demographic profile of the group which underwent locking plate fixation among wedge and complex fracture patterns in the study done by Singh et al. shows AO/OTA type B1 along with B3 as having highest incidence.
All the fractures in our study had healed both clinically and radiologically by 24 weeks. Seventy percent of the patients had union by 16 weeks, while remaining 23.33% had union by 20 weeks and remaining 6.67% had union by 24 weeks. Mean time duration is 15.66 weeks.
Study done by Ghosh et al. found that maximum number of fractures (73.3%) in plating group united clinically in the interval of 11–13 weeks and maximum of Fractures (73.3 %) had radiological union in the period of 12–16 weeks in plating group.
A study done by Shetty et al. showed that union was observed at a mean period of 12.9 weeks (range: 10–20 weeks).
In a study conducted by Singisetti and Ambedkar, a higher rate of excellent and good results and a tendency for the earlier union were seen with the plating group.
The mean flexion-extension arc of the elbow after 6 months was 112°. The mean range was from a minimum of 6° to maximum of 121.5°. Arc of motion of more than >100° was present in 21 (70%) patients and <100° of arc of motion in 9 (30%) patients. Ten patients in our study group had extensor lag ranging of 10° or more. To prevent this, drain must be put so that the hematoma and fibrous tissue do not get accumulated. Second, patients must be advised to avoid pushing and lifting any heavy object during the first 6 months. However, active and passive flexion and passive extension can be started from 3rd postoperative day onward.
The mean ROM in the study conducted by Singh et al. among the group who were managed with LCP after a 12-month follow-up was 130° (range 120°–140°) which is comparable to our study.
The MEPS was used because it emphasizes the most important patient outcome factors, i.e., pain and ROM. We obtained 21 (70%) excellent, 8 (26.66%) good, and 1 fair results in our study and all of them were able to return to their preinjury occupation and lifestyle. The mean MEPS at 6-month follow-up was 90.5, and all patients were satisfied with their results.
UCLA shoulder rating scale was used to assess shoulder function. The mean UCLA at 6-month follow-up was 29.66, with minimum 24 to a maximum of 34. As per literature, the study done by Singh et al., the mean UCLA score was 34 at the end of 12 months of follow-up which is comparable to our study as we had just 6 months of follow-up.
The previous studies suggest that, in cases of plating, the rate of nonunion is about 5%, infection about 2%–4%, and radial nerve palsy about 2%–5%. Delayed union was noted in 9 of our patients which comprises 30% which is quite high as compared to other studies. Singh et al. found that Group B had delayed union in 8.18%, while Ghosh et al. noted it in 13.3% of patients. Another comparative study done by Singisetti and Ambedkar showed a higher rate of excellent and good results and a tendency for earlier union with the patients who underwent plating.
As stated before, the incidence of iatrogenic radial nerve palsy in plating for diaphyseal fracture as per literature is 2%–5%. Our study had a case of iatrogenic radial nerve palsy which subsequently recovered fully during the course and did not require any active intervention.
There were no reports of superficial infection, deep infection, implant failure, or nonunion in any of our patients.
In conclusion, internal fixation of comminuted diaphyseal humeral fractures with locking plates described in this study allows an intensive program of rehabilitation immediately after surgery and is associated with a high union rate. When elbow and shoulder rehabilitation can be pursued postoperatively, restoration of painless and satisfactory joint function can be expected. The clinical success of locking plates is likely the result of no or minimal periosteal stripping as well as stable mechanical construct, thus improving union rates even in comminuted and osteopenic fractures.
Lack of uniform criteria for functional evaluation of results in different series makes it difficult to compare the results claimed by different series. The comparison of results, furthermore, in different series is extremely difficult as different fracture types, levels, patients age, energy of trauma, preexisting comorbidities, and associated injuries have an important bearing on the prognosis.
The literature does not have reports in our knowledge of humerus diaphyseal comminuted fracture management with locking plates. Hence, our study is one of its first to be done for the comminuted fracture of humerus diaphysis. Our outcome has been compared to the previous studies which were done for humerus diaphyseal fracture with locking plates irrespective of the type of fracture pattern.
Recently, a trend toward increasing number of studies on locking plates is seen. At the present time, there is some preliminary evidence that the improved fixation seen with this device may be advantageous in the humeral shaft., The strength of our study is that it was a prospective study that allowed the assessment of the functional status.
Limitation of the study
- The number of patients, i.e., the sample size in this study is small
- The duration of the study is small
- In view of the absence of studies on humerus diaphysis comminuted fracture management with locking plates, the outcome could not be compared with literature
- We did not have a control group for comparison or another group treated with some other techniques of humeral diaphyseal comminuted fracture fixation.
| Conclusions|| |
In our study, the results of comminuted humeral shaft fractures have given excellent results without any implant-related complications. We recommend using a limited compression plate for these fractures because of its consistent results with respect to fracture union, stability across the fracture site, and early mobilization for better functional shoulder and elbow ROM.
Patient declaration statement
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Houwelingen AV, McKee MD. Management and complications of humeral shaft fractures. Univ Toronto Med J 2004;81:96-102.
Igbigbi PS, Manda K. Epidemiology of humeral fractures in Malawi. Int Orthop 2004;28:338-41.
Ruedi T, Moshfegh A, Pfeiffer KM, Allgower M. Fresh fractures of the shaft of the humerus--conservative or operative treatment? Reconstr Surg Traumat 1974;14:65-74.
Ulrich C. Surgical treatment of humeral diaphyseal fractures. Musculoskeletal trauma series: Humerus. Butterworth Heinemann; 1996:129-43.
Wagner M, Frigg R. Concepts of fracture fixation. AO Manual of Fracture Management: Internal Fixators. Ch. 1.2. Davos: AO Publishing; 2006. [Last accessed on 2006 Jun 14].
Baumgaertel F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury 1998;29 Suppl 3:C3-6.
Dickson KF, Munz JW. Locked plating: Biomechanics and biology. Technol Orthop 2007;22:4.
Wagner M, Frenk A, Frigg R. Locked plating: Biomechanics and biology and locked plating: Clinical indications. Technol Orthop 2007;22:4.
Lloyd GJ, Wright TA. Self-compressing implants in the management of fractures. Can Med Assoc J 1977;116:626-8.
Hoerdemann M, Gédet P, Ferguson SJ, Sauter-Louis C, Nuss K.In vitro
comparison of LC-DCP- and LCP-constructs in the femur of newborn calves – A pilot study. BMC Vet Res 2012;8:139.
Xiong Y, Zhao YF, Xing SX, Du QY, Sun HZ, Wang ZM, et al.
Comparison of interface contact profiles of a new minimum contact locking compression plate and the limited contact dynamic compression plate. Int Orthop 2010;34:715-8.
Xiong Y, Zhao Y, Wang Z, Du Q, Chen W, Wang A, et al.
Comparison of a new minimum contact locking plate and the limited contact dynamic compression plate in an osteoporotic fracture model. Int Orthop 2009;33:1415-9.
Gardner MJ, Nork SE, Huber P, Krieg JC. Stiffness modulation of locking plate constructs using near cortical slotted holes: A preliminary study. J Orthop Trauma 2009;23:281-7.
Fitzpatrick DC, Doornink J, Madey SM, Bottlang M. Relative stability of conventional and locked plating fixation in a model of the osteoporotic femoral diaphysis. Clin Biomech (Bristol, Avon) 2009;24:203-9.
Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998;80:249-53.
Shetty MS, Kumar MA, Sujay K, Kini AR, Kanthi KG. Minimally invasive plate osteosynthesis for humerus diaphyseal fractures. Indian J Orthop 2011;45:520-6.
] [Full text]
Singh AK, Narsaria N, Seth RR, Garg S. Plate osteosynthesis of fractures of the shaft of the humerus: Comparison of limited contact dynamic compression plates and locking compression plates. J Orthop Traumatol 2014;15:117-22.
Ghosh S, Halder TC, Chaudhuri A, Datta S, Dasgupta S, Mitra UK. Comparative study of operative treatment of mid shaft fracture of humerus by locking plate versus intramedullary interlocking nail. Med J DY Patil Univ 2013;6:390-4. [Full text]
Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: A prospective comparative study. Int Orthop 2010;34:571-6.
Sommer C, Gautier E, Müller M, Helfet DL, Wagner M. First clinical results of the locking compression plate (LCP). Injury 2003;34 Suppl 2:B43-54.
Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res 2004;425:50-4.