Fri., 10/9/09 Upper Extremity, Paper #50, 11:51 am OTA-2009
Anterior Sub-Muscular Plating of the Humerus
Bruce H. Ziran, MD1 (4, 5A-Stryker, Synthes; 5A-Force Medical); Wade R. Smith, MD2 (n);
Gabrielle Peacher, BS2 (n);
1Atlanta Medical Center, Decatur, Georgia, USA
2Denver Health Medical Center, Denver, Colorado, USA
Purpose: Recent work has demonstrated that submuscular plating of the humerus may be feasible. While mixing the principles of external fixation with internal fixation remains controversial, the method appears to be feasible in the preliminary studies. The present study evaluates the outcome of submuscular plating of the humerus with a modification of the original method of Belangero that uses locking screws, minimal insertion portals, and specialized tactics to facilitate reduction and placement.
Methods: Inclusion criteria were patients who had clinical indications for operative humeral fixation (polytrauma or multiple fractures). Our first modification of the original technique used a temporary medium external fixator to maintain a closed reduction maneuver (similar to use of a femoral distractor in lower extremity). The pins were place anterolaterally in the proximal humerus and posterolaterally in the distal humerus to avoid neurovascular structures. A 10- to 12-hole plate was centered directly anteriorly over the fracture span. The antebrachial cutaneous and radial nerve and pectoralis muscle were always identified. The plate was inserted below the brachialis muscle and over the periosteum. Provisional fixation and verification was performed, after which unicortical screws were exchanged for 2 bicortical locking screws on each end of the plate. Patients were allowed ad lib weight and motion of the extremity. Outcome measures included radiographic and clinical healing as well as the Constant score. Study end points were failure and healing with outcome measures.
Results: Of 34 total cases, 32 patients had complete follow-up. All but 1 patient healed by the 18-week office visit. Follow-up ranged from 4 to 36 months. The mean Constant score was 89. Median active arc of elbow motion was 135° flexion/extension and 160° pronation/supination for forearm. Median shoulder forward elevation was 156°, external rotation was 90°, and internal rotation to T12. There were no elbow complaints and minor shoulder dysfunction occurred only in patients with ipsilateral shoulder injuries. Two patients had preoperative radial nerve palsies. One patient suffered a postoperative radial nerve palsy after a prolonged and difficult closed reduction. Complete motor and sensory function returned within 7 days.
Conclusions: Percutaneous submuscular anterior humeral plating can be done with minimal biologic impact and acceptable early results. We modified the technique of Belangero to allow an easier and more reliable method of bridging plate fixation with use of mini-incisions to obtain a stable, locked internal fixator that results in indirect bone healing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant