Internal fixation of fractures of long bones with plates & screws as a mode of treatment has come a long way[1]. In olden days, surgeons merely used to fix two bone fragments in an approximate alignment which resulted in mechanical failures owing to metal reaction as well as inadequate design of screws and plates. In today’s scenario evolution of plates has taken place, reflecting clinical usage and developments in engineering and material science[2].

For thousands of years, only option for management of fractures was some form of external splintage. Egyptians used palm bark and linen bandages 5000 years ago. Clay, wood and also lime mixed with egg white were used over ages. Wood is still used for native splintage. in many parts of the world it has been incorporated into more scientific form as functional bracing, using shaped bamboo boards for tibial fractures[3-4].

The blood supply of the adult humerus is seen by injecting radio opaque contrast medium into the brachial artery of cadavers and taking radiographs. The largest artery supplying the humerus was termed as the main nutrient artery[5]. Accordingly, the main nutrient artery arises in most cadavers from the brachial artery and from the profunda brachi artery in the remaining. The entry point of main nutrient artery to the humerus is a restricted area, beginning on the medial side of the distal 1/3 and spiraling upwards and medially to the dorsal surface of the middle 1/3 of the shaft.

Studies also revealed that 2/3 of the humerus had single nutrient foramen and the mean position is distal to the midpoint of humerus and distal to deltoid insertion. 3/4 of the foramen are found on the medial border of anteromedial surface[6].

The blood supply of the adult humerus is seen by injecting radio opaque contrast medium into the brachial artery of cadavers and taking radiographs. The largest artery supplying the humerus was termed as the main nutrient artery. Accordingly, the main nutrient artery arises in most cadavers from the brachial artery and from the profunda brachi artery in the remaining. The entry point of main nutrient artery to the humerus is a restricted area, beginning on the medial side of the distal 1/3 and spiraling upwards and medially to the dorsal surface of the middle 1/3 of the shaft. Studies also revealed that 2/3 of the humerus had single nutrient foramen and the mean position is distal to the midpoint of humerus and distal to deltoid insertion. 3/4 of the foramen are found on the medial border of anteromedial surface[7-9].

Study Design: Observational Study.

This is study of Adult patients admitted in Orthopaedic ward, visiting Orthopaedic OPD and trauma centre having fracture shaft of humerus were included in the study. All patients were given lateral decubitus position with affected limb supported on arm rest. Draping was done involving shoulder girdle and elbow, exposing whole of the arm.

Surgery on humerus was done with keen observance of the following:

• Preserving and protecting neurovascular structures around bone.
• Minimal soft tissue stripping.
• Adequate fixation of fracture.

Fracture anatomy was determined radiologically by plain x-rays of humerus, in antero-posterior and lateral planes including shoulder and elbow joints. Fractures were classified according to AO classification system for descriptive purposes. Patients were provided with U-slab and cuff & collar sling as a temporary mode of immobilization.

Hematological, biochemical and other radiological investigations (if required) were carried out as per the requirement for anesthetic fitness. Patient and relatives were explained about the nature of injury, need for surgery and its complications.

INCLUSION CRITERIA:

1. Participants willing to be part of the study.
2. All adult patients presenting with displaced diaphyseal fracture of shaft humerus 5cm proximal and distal to metaphysis.
3. Age group of 18-60 years.
4. Closed fractures.
5. Failure to obtain and maintain adequate close reduction.

EXCLUSION CRITERIA:

1. Pathological fractures.
2. Segmental fractures.
3. Poor skin condition.
4. Any medical contraindication to surgery.
5. Patients unwilling to participate in study.

This study showed preponderance of males suffering from fracture of humeral shaft, vehicular accidents and industrial trauma being the common culprit.

Table No. 1: Sex distribution

Road traffic accidents and cases of assault to the limb were include in high energy impact which accounted for 23 cases,  whereas 07 cases of direct fall were noted as low energy impact.

Table No. 2: Mode of trauma

Fractures occurring in the proximal and distal part of humeral diaphysis were taken as fractures of proximal and distal third, a total of 13 cases. Whereas those occurring in the middle part of shaft were denoted as middle third fractures. This accounted for 17 cases (56.7%), making it the most common region prone for fracture in this study.

Table No. 3: Level of Fracture

Average duration for beginning of radiological fracture union was between 10-12 weeks. 16 out of 30 fractures showed signs of fracture union in this time duration, whereas 10 were in between 13-15 weeks. This accounted for around 90% fractures uniting in good time. Fractures that failed to show union even after 18 weeks were 02 in number. Rest 02 united in between 16-18 weeks.

Table No. 4: Fracture union

Functional outcome was assessed according to Rodriguez Merchan EC criteria which include parameters like radiological bony union, joint movements, any change of occupation, infection and radial nerve palsy. Based on the outcome results were designated as excellent, good, fair and poor.

Table No. 5: Functional Outcome

RODRIGUEZ MERCHAN EC CRITERIA

So according to Rodriguez Merchan criteria maximum number of patients (90%) had excellent – good outcome, as compared to the rest (10%). Nonunion and radial nerve palsy were cause for poor result.

The present study showed an obvious male predominance, out of thirty patients 22 where males (73.3%) and 08 females(26.7%). Similar results are seen in other studies too with males outnumbering the females[10]. Road traffic accidents (RTA) were the commonest cause of fracture humerus. In all the above mentioned studies they were common culprit. In our study they accounted for 22 of 30 cases, a total of 73.3%. Out of thirty cases operated, 28 were good in overall union with 93.3% showing signs of union before 16 weeks[11]. Two fractures failed to unite. But both of the patients remained symptomless with good range of movements during follow up period and denied secondary procedure. Our results of fracture union are comparable to the above mentioned studies.

General merits of open plating are :- proper view of the fracture anatomy, adequate compression at the fracture site which enhances union, rotational stability often not very well achieved with other modalities, decreased chances of shortening, angulation, provision for bone grafting in the required cases, neurovascular clearance in case of compromise at the fracture site, a few to name[12]. This holds true for humeral shaft fracture too and as the implant is deep below the skin chances of implant prominence and skin tenting are never seen. In fixing mid shaft fracture of transverse or short oblique variety generally  six – eight hole DCP is adequate, this is much away from both shoulder and elbow joints so problems related to postoperative physiotherapy are less as compared to nailing techniques. Due to stable fixation post-operative immobilization is generally not required and range of motions can be started early. Return to previous activities & even strenuous work is not an issue, though return to normalcy may require patience[13]. 

Looking at the overall results, complications & patient satisfaction, plate osteosynthesis technique though not a new modality can be regarded as the gold standard procedure for humeral shaft fractures[14].

Plate osteosynthesis is an effective method for treating adult diaphyseal fractures of the humerus, with good to excellent functional outcomes according to Rodriguez-Merchan EC criteria in 27 patients (90%). Oblique and spiral fractures were the most common pattern (66.6%). Full range of motion was achieved in 28 patients (93.3%), while only 2 patients had restricted elbow movements. Complications were minimal, with 1 case (3.3%) of superficial infection and 3 cases (9%) of radial nerve palsy, of which two recovered completely. Overall, plate osteosynthesis provided reliable fracture union with satisfactory functional recovery and low complication rates.

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