A Novel Treatment For Severely Porotic Humerus Non Union With Plate And Rush Pin: A Report Of 2 Cases

摘要

The management of humerus non union in severely porotic bone mainly encountered in the elderly is challenging .The incidence of nonunion is higher in cases involving porotic bones. Non unions can result in significant patient morbidity by limiting activities of daily living due to pain and loss of function especially in the elderly. The literature is replete with studies outlining the various methods of treating humeral shaft non unions with severely porotic bones following primary operative management. However no study describes combining a plate and rush pin together with cancellous bone graft for severely porotic humerus non unions. We have applied this technique in 2 cases of previously plated porotic humerus non unions in the elderly with good results. This technique could be a very useful procedure in underdeveloped countries and rural hospitals where facilities like methylmethacrylate, a plate with a blade and spiked nuts that lock the screws to the plate are not available. Introduction The incidence of nonunion after operative treatment of humeral shaft fractures has been reported to range between 2.5 and 13 percent.1,2,3.The incidence is higher in cases involving porotic bones. Non unions can result in significant patient morbidity by limiting activities of daily living due to pain and loss of function. Revision surgical management is indicated for treatment of non unions following an initial failed surgical procedure. The literature is replete with studies outlining the various methods of treating humeral shaft non unions with severely porotic bones following primary operative management 4,5, 6,7, 8.We hereby describe a technique of combining a plate and rush pin together with cancellous bone graft for severely porotic humerus non unions. We have applied this technique in 2 cases of previously plated porotic humerus non unions in the elderly. Materials and Methods This prospective study was conducted at Presbyterian Church of East Africa (PCEA) Kikuyu Hospital, Orthopedic Unit from October 2007 to April 2008. Two consecutive patients with nonunion of the humeral diaphysis after plating with severe porosis were reviewed and evaluated. A plate and rush pin with cancellous iliac crest bone graft was used to treat the nonunion. The tool for data collection was a predesigned data sheet to collect information on the cases. The questionnaire contained information on age, sex, co-morbid conditions, mechanism of injury, fracture location, initial treatment of the fracture, time from injury to definitive treatment, definitive treatment, time taken to unite, function and complications.In this study, nonunion was defined as absence of radiographic signs of union and persistent pain on clinical examination 6 months after injury 9. A fracture between the superior border of the pectoralis major insertion and 2cm above the olecranon fossa was defined as a diaphyseal humerus fracture 10.Records of patients were reviewed for history, physical examination, operative reports, and all radiographs. Laboratory studies included a hemoglobin level, urinalysis and random blood sugar where indicated. Surgical Technique The patient was put under general anesthesia then prepared and draped in a standard manner as for humerus plating using the approach that was previously used. Prophylactic antibiotics were administered. The radial nerve was identified and protected for the duration of the procedure in posterior or lateral approaches. The previous implants were removed. The intramedullary canal was reconstituted with a drill and bone ends were contoured to provide adequate diaphyseal contact. Once the fracture was reduced, the rush pin that had been cut preoperatively was inserted antegrade from the tip of greater tuberosity into the medullary canal of distal fragment through a 4 cm incision made over greater tuberosity ,lateral to acromion. Then a 4.5mm DCP plate was fixed based on the approach used. The screws were inserted slightly oblique to