Session VI Upper Extremity

A Comparison of Intramedullary Fixation Techniques for Humeral Shaft Fractures in the Multiply Injured Patient

Mitch S. Wagner, MD, Paul Gregory, MD, Thomas DiPasquale, DO, Roy Sanders, MD, Dolfi Herscovici, DO

The Florida Orthopaedic Institute, Tampa, Florida

Hypothesis: Use of retrograde Ender nails for intramedullary fixation of humeral shaft fractures in the multiple trauma patient offers potential advantages over the use of antegrade, interlocked, unreamed, intramedullary nails.

Materials and Methods: Between January 1989 and March 1996, 133 humeral shaft fractures in 131 patients were treated at a regional Level I trauma center. A subset of 83 humeral shaft fractures in 82 multiply injured patients was identified. All fractures were displaced and/or comminuted and required operative intervention based on standard orthopaedic trauma protocols. Thirty-one fractures in 30 patients were treated with compression plates, external fixators, or antegrade Ender nails and were eliminated from the study. This left a total study group of 52 fractures of the humeral shaft in 52 multiply injured patients that were treated with either retrograde Ender nails or antegrade, interlocked, intramedullary nails. Group I consisted of 21 patients with 21 fractures treated with retrograde Ender nails. Group II consisted of 31 patients with 31 fractures treated with antegrade, interlocked, intramedullary nails. The decision to use antegrade, interlocked nails versus retrograde Ender nails was based on surgeon preference. All patients were followed until the fracture united or until they were lost to follow-up. For the purpose of this study a nonunion was defined as a fracture that had not healed clinically or radiographically 9 months after the index procedure. Follow-up included clinical and radiographic evaluation to determine healing, function, and pain.

Results: Complete radiographic and clinical follow-up was possible in 14/21 patients (67%) in Group I at an average of 27 months (4-89). Radiographic follow-up was possible in 23/31 patients (74%) in Group II at an average of 26 months (448). Complete clinical follow-up at the time of final review was only possible in 20/31 (65%), 3 patients having been lost following complete healing. No infection developed in either group. No loss of fixation or nail migration occurred. Seven patients who were treated with an antegrade, interlocked, intramedullary nail (35%) developed some shoulder dysfunction, generally characterized by pain with overhead activity. Rehabilitation was significantly impaired in these patients, and treatment required prolonged analgesic use, subacromial injection, or removal of the implant. No shoulder problem was noted in the retrograde nail group. One patient treated with Ender nails developed significant elbow stiffness, but he had also sustained an ipsilateral elbow injury which appeared to be the main contributing factor. There were 3 nonunions in the 23 patients (13%) with antegrade nails who had radiographic follow-up. One nonunion healed after exchange nailing, 1 required plate fixation and bone grafting to achieve union, and 1 patient is currently being treated with an electrical stimulator. No nonunion was noted in any patient treated with retrograde Ender nails. Interestingly, no malunion occurred in either group despite the fact that the Ender nails could not be statically locked. There was one iatrogenic radial nerve palsy noted in each group; both had resolved at final follow-up.

Conclusion: The treatment of humeral shaft fractures in our group of multiply injured patients with retrograde Ender nails resulted in better functional outcome and fewer complications compared with antegrade, interlocked, intramedullary nails. Specifically, nonunions and shoulder problems were only observed in the group that received antegrade nails. Based on this data we recommend consideration of the use of retrograde Ender nails for humeral shaft fractures in the multiply injured patient.