Humeral Shaft Breaks In Pediatric Patients

Humeral shaft breaks represents less than 10 percept of all breaks in children. The epidmiological picture of breaks differs among communities as a consequence of differencs in racial, socioeconomic, ethnic, grade of development and other populace characteristics. Most frequenty humeral shoft breaks occur as a result of a straight blow to the upper limb (transverse breaks). Secondary injury from a fall or a winding action (e. g. arm struggling) is also met and usually results in curved or oblique breaks. The higher the impact power the mor likely the break is to be comminuted. A minority is open breaks [2-10%]. [2] Breaks is distributed along the humeral diaphisis with 60 % in the middle and the remaining is divided between the upper third (30 %) and lower third (10%).

Humeral sheft breaks uniformly does well from a practical and enhancing standpoint following nonoperativ treatmant using purposeful bracing, coapetation immobilizing, hangeng arm costs, or sling hold. There is considerable remodaling possible for humeral deformity in skeletally immature patients; indeed, even up to 30 degrees may remodal in the adoeslescent population. For these reasons, up to 20 to 30 degrees of varus, 20 degrees of apex anterior angulation, 15 degrees of internal rotation, with 1 to 2 cm of shortening is deemed acceptable. Older children also have a certain degree of remodalling possible; however, some authors have recommended that the angular deformity shallbe reduced to 30° for proximal third, 20° for middle third, and 15° for distal third sheft breaks before proceeding with a nonoperative treatment. [4]Radial nerve injury occurs in as many as 18% of humeral sheft breaks. Most of these nerve injuries is neurapraxic or axonotmetic types. Brachial artery injuries that is related with humeral sheft breaks is uncommon. [5]Conservative methods to treat humeral sheft breaks includes variable techniques like traction, hanging arm cast, Coaptation splint, Velpeau dressing and Functional brace. .

For many of the nonoperative treatments to work most effectively, the patient shallremain upright, either standing or sitting, and shallavoid leaning on the elbow for support. This allows gravitational force to assist in break reduction. The patient shallbegin range of movement (RoM) exercises of the fingers, wrist, elbow, and shoulder as soon as these can be tolerated. Operative treatment is indicated in specific circumstances including open breaks, related neurovascular injury, proximal and distal articular extension, segmental and unstable factures, patients with polyinjury, floating elbow, progressive radial nerve deficits, significant soft tissue injury (unable to brace), pathologic breaks and failed non-operative management. The use of intramedullery devices to stabilize breaks in long bones is not new. In the mid-19th century, ivory pins was used for this purpose and was then gradually replaced by various metal devices. These was generally rigid implants, although mor flexible ones was introduced in the 1930s. The school of rigid intramedullery treatment was introduced by the Küntscher nail, which achieved great stability in all planes by occupying the entire medullery cross-sectional isa of the bone.

However, its use in growing children was limited by the difficulties encountered in trying to avoid the physis. Intramedullery nails have certain possible benefits over plates. The intramedullery nail is nearer to the normal automated axe and can turn as a lood-shearing devic if there is cortecal contact. The nail subjected to lower twisting forces and thus is more likely to flop through exhaustion. Intramedullery nails can placed without direct break exposure and with much less soft tissue separation. Furthermore, cortical osteopeni caused by stress protecting as seen with plates is less likely noted. [6]Many types of humeral flexible nails is available. Elastic nails, such as Ender nails (Tennessee) is some of the first nails that was used.

Although they is effective in the setting of simple break patterns, they confer minimal axial and rotational stability, which can lead to nonunion. The flexible humeral nail allows both retrograd and antgrade implantation and static locking. Since publication of outcomes of Spanish and Nancy groups in the early 1980s, elastic stable intramedullery nailing, (ESIN) has become a well-accepted method of surgical treatment of diaphyseal breaks of long bones in children and adoeslescents. Several series of antgrade intramedullery maintenance of humeral sheft breaks (Rush rods and Ender nails) have been reported in the literature. Problems of shoulder impingement and adhesive capsulitis of the shoulder was a significant problem in these series because most of the nails was inserted in an antgrade manner through a small incision in the rotator cuff. [12] Titanuim elastic nail treatment is an ideal procedure for the treatment of humeral sheft breaks in which maintenance is indicated as it provides stable treatment, with minimal soft tissue stripping at the break site, and allows early mobilization of the extremity.