Treatment Of Humeral Diaphyseal Fractures In Elderly Using Functional Brace

摘要

Background: Conservative treatment for humeral diaphyseal fractures demands great cooperation by the patient in maintaining a suspended position of arm , sleep in Fowlers semi erect position and start active exercises of the limb. Elderly patient are bereft with a number of medical and surgical problems and humeral diaphyseal fractures in them are difficult to treat. Material and Methods: From March 2004 to December 2005, 44 elderly patients aged 50-75 years( Average 58.6 years) who had closed or type 1 open humeral diaphyseal fractures were treated conservatively in the orthopaedic department of Government Medical college university of Kashmir with a follow up of 12 to 18 months (average 15 months). Among 41patients available for follow up, 28 ( 68.3%) were female and 13 (31.7%) were male patients. Cause of injury was domestic fall in 31(76%), road traffic accident in 7(17%) and direct trauma in 3(7%) patients.4 patients had type 1 open fracture.22(54%) were right and 19(46%) were left sided fractures. There were 9-A1,12-A2,10-A3, 7-B1,1-B2 and 2-B3 fractures. There were 13 distal third,19 middle third and 9 proximal third fractures. Fractures were reduced and stabilized by coaptation splint for 2 weeks when a prefabricated humeral brace was applied with cuff and collar for additional comfort. Results: Results were interpreted in terms of radiological union, clinical outcome ( Severity of pain and Range of motion of shoulder and elbow) and functional outcome ( system of American Shoulder and Elbow surgeons shoulder score). Radio logically ununited fractures were graded as poor results. 14 (34%) patients who showed union within first 3 months of treatment with no pain, grade 1 ROM and ASES score of greater than 45 were graded as excellent. 9 (21%) patients united between 3 to 4 months with mild pain, grade II ROM and ASES score of 35 to 45 and were graded as good. Union was delayed in 6(14%) patients with grade III ROM, severe pain and ASES score of <35 ,were graded as poor result.12(29%) patients failed to show the signs of union and were again grade as poor results. Conclusion: Elderly patients with humeral diaphyseal fractures do not cooperate with difficult rehabilitative program of conservative treatment and using functional brace is fraught with poor results. Further research is needed to come out with best modality of treatment for these fractures in this particular age group. Introduction All of the current modalities have a place in treatment of humeral diaphyseal fractures, but none of the treatments is a panacea and complications may occur with each one of them (AAOS Instructional course lectures trauma Chap.8). Non operative treatment is a rational option for the treatment of isolated humeral shaft fracture with no or minimal displacement 1,13.Closed treatment results in an excellent clinical outcome for most humeral fractures 3 . When choosing conservative methods, functional bracing should be primarily considered in the treatment of humeral diaphyseal fractures because of low complication but very high success rates 8 . Antegrade Interlocking intramedullary nailing leads to less blood loss and provides rotational stability, but injury to rotator cuff with shoulder dysfunction and non union remain problematic. 1,7 .Operative treatment using dynamic compression plate achieves better anatomical reduction but extensive dissection with more blood loss ,risk of infection and iatrogenic radial nerve paralysis are the major disadvantages 4,5 Most of reported series in literature have tried to evaluate and compare the results of non operativ, 8,10,13 and operative treatment( dynamic compression plates 2,6 interlocking nails 5,12 ender nails 4 for humeral diaphyseal fractures. But, no papers have been published to report the results of non operative treatment in a specific age group of elderly patients. Elderly patient are bereft with a number of medical and surgical problems and the goal of treatment remains restoration o