Introduction

Treatment for distal third shaft fractures of humerus is very challenging. They are commonly treated with plating. Plating has complications of iatrogenic radial nerve palsy. We report our case series of distal third fractures of humerus treated with retrograde Halder Humeral Nail.

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail.

We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy.

Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation.

This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group.

Aim

Treatment for distal third shaft fractures of humerus is very challenging especially if its comminuted and bone is osteopenic. They are commonly treated with plating. Plating has complications of iatrogenic radial nerve palsy. We report our case series of distal third fractures of humerus treated with retrograde Halder Humeral Nail.

The results of displaced three part fracture of the proximal humerus treated by retro grade nailing +/− cannulated cancellous screws for fixation of the greater tuberosity was analysed.

Displaced three part fractures of the humerus are unstable and difficult to fix. Different methods of operative treatment available for this type of fracture are Kirschner wires, tension band wiring, hemiarthroplasty and open reduction and internal fixation with plate and screws.

The Halder Humeral Nail was introduced through the olecranon fossa into the head of the humerus, to stabilize the neck of humerus fracture. The displaced greater tuberosity was reduced with a minimal stab incision and fixed with cannulated screws. Compared to other open procedures the proximal exposure was minimal.

47 Patients with displaced three part proximal humeral fractures have been surgically treated since January 1995. 22 Were treated with proximal screws and 25 without proximal screw fixation. There were 32 females and 15 males. The average age was 67.68 years.

Early passive movements were encouraged in the shoulder. Pain was relieved in almost all the patients. 41 Fractures united. 3 Patients had a malunion, 2 had humeral head collapse, and 1 developed AVN of the humeral head.

The authors concluded that displaced three part proximal humeral fractures can be treated using the Halder Humeral Nail, and that this is a simple method of treatment which avoids major surgical exposures.

Non-operative treatment is usually employed in the treatment of femoral fractures in young individuals. Malunion, delayed union, joint stiffness, limb length discrepancy, psychological problems and delay in functional recovery are well known complications of conservative treatment. The length of hospital stay that will be a part of non-operative treatment will add to the cost of the treatment.

We report our experience with intramedullary nailing of closed femoral shaft fractures with a new femoral nail in adolescent patients with an open physis. We treated 13 patients between 1995 and 2004 aged between 8–16 years (8 males and 5 females) with a new femoral nail for closed femoral shaft fractures using the tip of the greater trochanter as the entry point. 11 of the 13 patients had removal of the femoral nail.

The mechanism of injury, length of hospital stay, patient mental well-being, surgical technique, requirement of secondary surgical procedures, associated complications, post-operative mobility, return to pre-injury status, range of movement at the hip and knee are discussed

At follow up ranging from few months to 7 years, we found no leg length discrepancy, rotational deformity, limp, problems with physis and all patients had a full range of movement at the hip and knee.

External fixation, elastic intramedullary nails, plate and screw fixation are other surgical options available to treat femoral shaft fractures. Children poorly tolerate external fixators and plate fixation can be associated with a high incidence of complications. Flexible intramedullary fixation of femoral shaft fractures is an attractive option, but is technically difficult and is associated with a learning curve. In our view, intramedullary nailing is a simple, safe, efficient and effective method of treatment of femoral shaft fractures in adolescent patients with open physis.

Introduction and Aims: The purpose of this study was to analyse the results of a new intramedullary retrograde humeral nail used for fixation of difficult fractures of humerus.

Method: In Airedale NHS Trust and Calderdale hospitals, 282 patients were treated for displaced humeral fractures. The new nail called Halder Humeral Nail (HHN) was inserted from the olecranon roof proximally towards the head of humerus. It had a specialised locking system by opening of a trio wire at the proximal head of humerus and distally near the elbow the nail was locked with the help of a screw on a plate. Patients were mobilised immediately after surgery in a polysling.

Results: At six weeks, 95% of patients were pain free and could perform daily activities comfortably. Average post-operative Constance score was 74.7. Complications included proximal migration of the nail and the trio wire in seven cases; six patients had non-union and one patient had infection. Breakage of trio wire was seen in five cases. This resulted in modification of the nail by introducing an additional screw to lock at proximal humerus around the trio wires.

Conclusion: We concluded that stable internal fixation and a good fracture union could be achieved by this new HHN, especially in a displaced humeral fracture, even in poor quality bone with fracture at different level. Pain-free movements, and early recovery was possible without damaging the rotator cuff and risking the axillary nerve.

Aim: Distal extra articular fractures of femur and tibia are difþcult to treat by conventional nails because of inability to use distal locking screws. The aim of this study is to analyse the effectiveness of this new I.M. Nail that does not require the use of distal locking screws for rotational stability. Methods & Material: Since 1994 we have treated a total of 68 such cases. Of these 40 were fractures of distal tibia and 28 were that of femur. Age range was from 11– 92. After insertion of the nail in the usual way, a ÒTrio WireÒ was introduced through the nail. This wire fans out in the distal segment which maintains rotational stability. Patients were mobilised with partial weight bearing within 3 weeks. Results: Most of the fractures were united without any signiþcant problem. Delayed union occurred in 2 cases. Breakage of the trio wire occurred in one case and 1 patient with supra-condylar fracture of femur needed revision for persistent varus deformity. Conclusion: We conclude that this I.M. Nail can be used effectively for þxation of these difþcult fractures. This is does not require X-ray exposure for distal locking. Operative time is thus minimised. This also saves surgeonñs hands from direct exposure to radiation. The þxation also allows for dynamisation of the fracture to promote early union.

Aims: Distal humeral shaft fractures are difficult to treat by antegrade humeral nails. In this study we have used a new retrograde nail to treat these fractures. Methods and Material: Since 1997 we have treated 15 extra articular fractures using this device. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. Results: In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. Conclusion: This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations.

Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid axillary nerve and rotator cuff damage. This nail also allows stable fixation of these distal fractures via a plate welded its distal end, which maintain the rotational stability.

Since 1997 we have treated 15 displaced extra particular fractures using this device. 12 of them were widely displaced fractures, some comminuted, and 3 were pathological fractures. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate.

In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees

This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations.

We review the results of the Gamma nail fixation to elucidate its effectiveness in the treatment of peritro-chanteric and subtrochanteric fractures of the neck of femur.

We report the result of 718 cases of Gamma nail fixation in all such cases presenting at our institution since 1988. 573 cases of peritrochanteric and 145 cases of sub-trochanteric fractures were treated by means of standard and long Gamma nail. Age groups of the patients are from 33 to 99 years. No distal locking screw was used in cases of standard nails. All grades of surgeons were involved. Full weight bearing was allowed on the first post operative day. Cases were followed up for one year.

No intraoperative iatrogenic fracture was encountered. Minimal post operative pain was experienced and mobility was regained early. All fractures healed satisfactorily except the following: 51 cases developed coxa vera deformity; 37 cases of undisplaced fractures of base of greater trochanter were noticed at 6 weeks follow up - all healed spontaneously; 1 case of external rotational deformity occurred in a long nail where no distal locking screw was used. 2 cases of deep infection were treated successfully by removal of nail and antibiotic treatment; 4 cases of fracture at the level of the distal end of the prosthesis, presented at 6 weeks to 2 year period following a subsequent trauma, were treated with exchange of device with long nail. Upward penetration of hip screw 22. No case of metal failure observed.

Gamma nail provides a stable fixation in both simple and complex fractures of proximal femur with a much less invasive tehcnique which allows minimal disturbance of fracture haematoma, less incidence of wound infection and less amount of postoperative pain. Early mobility is regained with immediate and unrestricted weight bearing. Biomechanically also Gamma nail produces a better means of osteosynthesis.