陳書佑 / 吳基銓副部長

Transcription

1 陳書佑 / 吳基銓副部長

2 30 y/o male, TA no radial nerve injury 2

3 s/p splint arrange functional brace 3

4 1 month 4

5 2 months 5

6 3 months 6

7 4 months 7

8 One year 8

9 Conservative Treatment of Humeral Shaft Fractures - Emphasis on the Value of Functional Brace Treatment journal of Orthopedic Surgery Taiwan,1992 Chi-Chuan Wu;Chun-Hsiung Shih;Yeung-Jen Chen;Pin-Yuan Shih Material and methods 142 humeral shaft fracture 104 closed fractures, 28 open fractures 96 transverse, 30 comminuted, 16 spiral U-slab splint: could not sit upright, high level fracture Hanging cast: one inch above fracture site to wrist Functional brace: remove immobilization at 6 weeks, if clinical union (-) Unacceptable alignment: new cast, splint 9

10 Conservative Treatment of Humeral Shaft Fractures - Emphasis on the Value of Functional Brace Treatment journal of Orthopedic Surgery Taiwan,1992 Chi-Chuan Wu;Chun-Hsiung Shih;Yeung-Jen Chen;Pin-Yuan Shih Results Of 142 patients, 104 f/u Union rate: 88.5% (92/104) 70.2%: clinical union at 6 weeks, functional brace (-) Shoulder abduction: 160 degrees Elbow ROM: degrees 6 complete radial nerve palsy spontaneously recovered 10

11 Conservative Treatment of Humeral Shaft Fractures - Emphasis on the Value of Functional Brace Treatment journal of Orthopedic Surgery Taiwan,1992 Chi-Chuan Wu;Chun-Hsiung Shih;Yeung-Jen Chen;Pin-Yuan Shih Complication Nonunion: 12 patientes(12/104) ORIF Malunion: 4 patients (AP > 20 degrees, ML > 30 degrees) Conclusion Conservative treatment for humeral shaft is good method 11

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13 Background Humeral shaft : 1~3% of all fractures Annual incidence» Court-Brown CM, Caesar B. Injury 2006;37(8): / : fifth decade 60 / : 90~ 100 y/o» Ekholm R, JBJS(B) 2006;88(11): % of fractures : trauma, 68% simple fall 8.5% pathologic fractures 1.5% peri-prosthetic fractures» Ekholm R, JBJS(B) 2006;88(11):

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15 Fracture pattern VS mechanism Direct blow: transverse or multiple fragment Twisting injuries Oblique or spiral fracture Fall on elbow with arm in abduction Oblique and transverse» Zafar MS, Trauma 2007;9(4):

16 Treatment nonsurgical Mainstay for treatment of the majority of humeral shaft fracture 90~98% healed» Rutgers M, J Orthop Trauma 2006;20: » Sarmiento A, JBJS-Am 2000;82: » Zagorski J, JBJS-Am 1988;70:

17 Treatment non-surgical 17

18 Treatment non-surgical 18

19 Treatment -surgical Indication Open fractures Polytrauma patients Ipsilateral humeral shaft and forearm fracture Nerve/ vascular injury Failure to tolerate or maintain alignment in conservative treatment» Sarmiento A, Instr Course Lect 2002;51: » Browner BD, Skeletal trauma. Philadelphia: Saunders; 1998.» Epps CH Jr, Rockwood and Green s fractures in adults. 3rd ed. Philadelphia: Lippincott Williams & Williams;

20 Treatment - plate Mainstay of operative management for humeral fracture Direct compression plate Bridge plating Locking plate 20

21 Indication Treatment - nail Pathologic fracture Impending pathologic fracture Segmental fractures Osteopenic bone Contraindication Neurologic deficit Open fracture, type III 21

22 Treatment external fixator Open fracture Infection 22

23 Objectives To assess and compare the effects of surgical versus non-surgical interventions for treating non-pathological fractures of the humeral fracture 23

24 Study methods Inclusion All randomised controlled trials trial that compare surgical with non-surgical interventions for treating humeral shaft fracture Exclusion Primary bone disease ( ex. Fibrous dysplasia) Pathologic fracture Peri-prosthetic fracture 24

25 Search methods Cochrane Bone, Joint and Muscle Trauma Group Specialised Register Cochrane Central Register of Controlled trials Medline EMBASE Current Controlled Trials, Clinicaltrials.gov and WHO International Clinical Trial Registry for ongoing trial 25

26 Results of search 532 citations up to October potentially eligible completed studies 5 retrospective 1 prospective 26

27 Outcome of nonoperative vs operative treatment of humeral shaft fractures: a retrospective study of 213 patients. Orthopedics 2010 Aug 11;33(8) Denard A Jr, Richards JE, Obremskey WT, Tucker MC, Floyd M, Herzog GA. 213 patients, evaluated retrospectively, in two level I trauma center Non-operative VS operative(plating) Nonunion: 20.6% vs 8.7%, p= Malunion: 12.7% vs 1.3%, p= No significant difference in infection rate, radial nerve palsy, time to union, ROM 27

28 51 consecutive closed, extra-articular fracture of humeral shaft, retrospective 40 patients f/u, 19 plating, 21 functional brace Operative(plating) group (19): 1 loss of fixation, 1 post-op infection, 1 still radial nerve palsy, 3 new radial nerve palsy All healed < 10 degrees of angulation 28

29 Non-Operative group(21): Two converted to plate fixation(due to angulation and radial nerve palsy) One malalignment > 30 degrees Two skin breakdown Two lost > 20 degrees of shoulder motion Conclusion Operative treatment : more predictable alignment, but risks of iatrogenic nerve injury and infection Functional bracing Skin problem, ROM loss 29

30 The conservative and surgical therapy of traumatic humeral shaft fractures Chirurg Nov;68(11): Klestil T, Rangger C, Kathrein A, Brenner E, Beck E. Retrospective study 63 patients 27 surgically(plating), 36 conservatively No significant difference of union rate Conservative group : superior mobility of shoulder and elbow 30

31 Comparative results of bracing and interlocking nailing in the treatment of humeral shaft fractures International Orthopaedics. 21(6):374-9, Wallny, T. Sagebiel, C. Westerman, K. Wagner, U A. Reimer, M. retrospective 44 functional brace 86% full ROM of shoulder 2 pseudarthrosis 45 IM nail 47% full ROM of shoulder 2 revision(hematoma, infection) 6 primary radial nerve palsy decompression, 2 residual disturbance Conclusion: Advocate functional brace as first choice if no contraindication 31

32 The treatment of humeral shaft fractures. Results of a prospective AO multicenter study Unfallchirurg. 94(9):447-54, 1991 Sep. Nast-Kolb, D. Knoefel, W T. Schweiberer, L. Prospective multicenter study, German section of the AO 302 humeral shaft fractures 170(56%) operative, 132(44%) conservative Operative : 3.5% infection, 10% paresis Conservative : only one complication, pseudarthrosis 173(57%) patients f/u Both resulted in good to excellent results Operative group : somewhat inferior results, due to local injury and concomitant injury 32

33 Conclusion Failed to identify any randomised controlled trial testing the effects of surgical versus non-surgical interventions for humeral shaft fracture Very challenging to design a randomised controlled trial with enough statistical power 33

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35 Current nonoperative management Mainstay of humeral shaft fracture 98% of closed humeral fracture healed in 922 patients study» Sarmiento A, JBJS-Am 2000;82: Good clinical outcomes with functional brace» Sarmiento A, JBJS-Am 2000;82: » Zagorski J, JBJS-Am 1988;70:

36 Current nonoperative management Immediate immobilization with splint, sling days soft-tissue subsided Functional brace Circumferential soft-tissue compression» Sarmiento A, J BJS-Am 2000;82: » Sarmiento A, J BJS-Am 1977;59: » Koch P, J Shoulder Elbow Surg 2002;11: Avoiding immobilization of shoulder/elbow 36

37 Functional brace Medially 2.5cm below axilla 1cm above medial epicondyle Laterally Below lateral acromion Above lateral epicondyle Active joint motion as soon as tolerate 37

38 Complication of functional brace Malunion 13% varus deformity > 16 degrees 19% anterior angulation > 16 degrees» Sarmiento A, J BJS-Am 2000;82: % Loss of shoulder ROM» Zagorski J, JBJS-Am 1988;70: Acceptable alignment 30 degrees of varus 20 degrees of anterior angulation 3cm shortening» Klenerman L. JBJS-Br 1966;48:

39 Complication of functional brace Radial nerve palsy 18% radial nerve deficit with humeral shaft fracture 70-92% spontaneous recovery in 4 months Indication for nerve exploration Nerve loss after closed reduction 39

40 Limitation of functional brace Open fracture type III High nonunion rate Ipsilateral brachial plexopathies Muscle contractility decrease» Brien W,. J Bone Joint Surg Am 1990;57: Long oblique fracture with proximal extension Soft tissue interposition, deltoid muscle belly 40

41 Intramedullary nail Indication Pathologic fracture Impending pathologic fracture Segmental fractures Osteopenic bone Contraindication Neurologic deficit Open fracture, type III 41

42 Complication of IM nail Antegrade nailing Rotator cuff injury Shoulder dysfunction Retrograde nailing Iatrogenic supracondylar fracture Extension loss of elbow Heterotopic ossfication 42

43 Non-union of IM nail 0~29% nonunion rate after IM nail» Reimer B. Philadelphia:Lippincott; p » Wong MW, Injury 2005;36: No significant difference in union rates or functional outcome compared to DCP» Putti AB, J Orthop Surg (Hong Kong) 2009;17:

44 Open reduction and internal fixation plating( DCP) Gold standard of surgical treatment Union rate 93-96% Radial plasy(2%), infection (2%)» McKee MD: : Rockwood and Green s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, 4.5-mm dynamic compression plate Broad / narrow Pre-bending of plate to avoid gap At least 6-8 cortex on either side 44

45 Open reduction and internal fixation DCP vs. locking plate Locking plate in humeral fracture No biomechanical advantage, torsion, bending, axial stiffness 5 times of cost» O Toole RV, J Orthop Trauma 2008;22: Relative indication of locking plate Osteopenia» Gardner MJ, JBJS-Am 2006;88:

46 Radial nerve palsy Indication of surgical exploration Neurologic compromise after closed reduction Open fracture with radial nerve palsy Radial nerve palsy after penetrating injury Spiral or oblique fracture in middle to distal one-third of humeral shaft NO closed fracture with radial nerve palsy EMG: 6 weeks and 12 weeks 46

47 Thanks for your attention!! 47