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Management of closed shaft of humerus fractures in non admitted adult patients in a tertiary care hospital

Proximal fractures are more common in elderly and are commonly attributed to low-energy falls, they make up to 5% of all fractures and 25% of humerus fractures, middle fractures about 60% and distal fractures contribute to the remaining fractures. Fractures shaft of humerus account for approximately 3% of all fractures encountered by the orthopedic surgeons (Christensen, 1967). 1 Treatment of these injuries continues to evolve as advances are made in both operative and non-operative management. There is a wide range of good options available for their treatment and controversy over the best methods for different situations (Chapman, 2003). 2 Conservative treatment consists of adequate analgesia and a period of immobilization. Early physiotherapy commencing within two weeks from injury has been associated with better functional outcome than prolonged immobilization (Lefevre-Colau MM 2007). 3 Conservative treatment has shown very good results in most of humeral shaft fractures. Upper limb Anatomy need to be understood properly before deciding among the operative versus non-operative options.


INTRODUCTION
Proximal fractures are more common in elderly and are commonly attributed to low-energy falls, they make up to 5% of all fractures and 25% of humerus fractures, middle fractures about 60% and distal fractures contribute to the remaining fractures. Fractures shaft of humerus account for approximately 3% of all fractures encountered by the orthopedic surgeons (Christensen, 1967). 1 Treatment of these injuries continues to evolve as advances are made in both operative and non-operative management. There is a wide range of good options available for their treatment and controversy over the best methods for different situations (Chapman, 2003). 2 Conservative treatment consists of adequate analgesia and a period of immobilization. Early physiotherapy commencing within two weeks from injury has been associated with better functional outcome than prolonged immobilization (Lefevre-Colau MM 2007). 3   Total 32 There were 6 (20%) male and 24 (80%) female. The age of the patients rang from 18-80 year. A fracture of the humeral shaft was defined as a fracture occurring below the surgical neck and above the epicondyles.

Figure 1 (A-F): Standard Method of application of U-slab with achievement of acceptable reduction.
The application method of the "U" shaped coaptation slab was standard. The patient was seated on a stool or table with backrest, leaning to the injured side to expose the axilla. Keeping the elbow at 90 degree flexion and assistant holding it a single layer of cotton from the shoulder to four inches distal to the elbow was applied.
The arm was encased in six inch, eight layers slab that passed from the midclavicular region around the shoulder, down the arm, under the elbow and up the medial aspect of the arm just below the axilla. Roll bandage was used to retain the slab and to mold it to the contours of the arm (Figure 1 A-F). No anesthesia was used and the treatment was on outpatient basis.
All patients were assessed the following day for the proper fitting plaster, position of the limb, neurovascular status was checked and the humeral shaft radiologically examined. Then the patients were discharged and followed at regular intervals till union.

RESULTS
In our study 26 fractures (86.7%) had complete union without any complications. No correlation was found between sex, or type of fracture and the effect of manipulation and the rate of union. Three fractures in chronic smoker male patients more than 30 year progress to delayed union and the fracture took 16 weeks to get safe union clinically and radiologically. So the incidence of delayed union was 10%. One fracture in a chronic smoker male patient progress to non union with fracture line visible even at 20 weeks after cast application. So the incidence of nonunion was 3.33% ( Figure 2). Function: (Table 2): Grading was done using Hunter Scale (Hunter, 1982). 6 In assessing the function 18 fractures (60%) had grade V function and 9 fractures (30%) had grade IV function. Only 3 fractures (10%) had grade III function especially the shoulder joint and elbow joint (H/O Smoking was present in all of them).

DISCUSSION
Appreciable results can be obtained with nonoperative treatment of patients with humeral shaft fractures. 7 Our treatment considerably improved the fracture in view of deformities of angulation. The U slab and the POP cast act as a dynamic rather than a static splint, correcting angulation to less than 30° in coronal plane and less than 20° in sagittal plane. All our fractures except one resulted in union with three fractures taking more than usual time for union, our study showed the same results as shown by previous study by Winfield  In our study we observed that achieving Perfect anatomical reduction was not found to be necessary for best functional outcome, this lends support to what Kennermann noted as good functional results in the presence of residual coronal and sagittal plane angulation, providing the deformity did not exceed 30°. 10 Heim et al and associates in their study reported 127 patients with humeral shaft fractures also stabilized using plates and screws. Patient age averaged 51 years. Nineteen patients had associated radial nerve palsy; an additional four patients developed palsies after fracture manipulation. Of the 127 patients, 102 were available for follow-up 1 year after fracture. Eighty-nine patients (85%) had full functional recovery of their upper extremity. Two patients had postoperative radial nerve palsy, four developed a postoperative infection, five had early fixation failure and two developed a nonunion. 11  12 Therefore we should not operate on fractures of the shaft unless there is clear indication (Table 3).
Chronic heavy smoking appears to have negative effect on fracture healing in shaft Humerus fractures as in our study all the patients who were chronic smokers I.e. more than 20 cigarettes daily since last 20 years presented with delayed union(10%) or non-union(3%). This is a well known fact that smoking delays soft tissue healing and fracture healing as already proven in their study by Giannoudis and Jerjes. 13

CONCLUSION
Conservative treatment is the most effective way of treatment and the operative treatment can have adverse effect on the outcome in case of bad judgment and should be limited as much as possible to these indications (Table  3). From this study we also conclude that smoking has a negative effect on fracture healing as all the patients who presented with non-union and delayed union were chronic smokers.