الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
Humeral shaft fractures are very infrequent in children constituting
only 2–5% of all pediatric fractures. They are predominantly seen in children aged less than 3 years or
more than 12 years. Fractures of humeral shaft are the result of direct force during a
direct impact, traffic accidents or crush injuries. Indirect forces such as
fall on elbow or extended arm or strong muscular contractions. The most
frequent site of the fracture is between the middle and the distal third of
the humerus. The humeral shaft extends from the pectoralis major insertion to the
supracondylar ridge. In this interval, the cross-sectional shape changes
from cylindrical to narrow in the anteroposterior direction. The vascular
supply to the humeral diaphysis arises from perforating branches of the
brachial artery with the main nutrient artery entering the medial humerus
distal to the midshaft. The simplest classification of humeral shaft fractures is based on the
location of the fracture site in the humeral diaphysis (proximal, middle
and distal), alignment of fragments and appearance of the fracture line. Radial nerve injury is the most commonly associated injury due to
the close proximity of this nerve, particularly in middle-third fractures. Diaphyseal fractures of the humerus in children can most often be
treated nonoperatively by functional bracing. Functional bracing is frequently indicated for stable fractures with
adequate alignment. The disadvantages include patient noncompliance
and limited fracture stabilization. The inability to maintain an acceptable reduction, open fractures,
particularly with significant soft tissue injury, concomitant ipsilateral
forearm fractures (floating elbow), closed head injury , and polytrauma
with lower extremity fractures necessitating early upper extremity weight
bearing have been the relative indications for operative treatment. A variety of surgical treatment methods exist, including external
fixation and internal fixation. External fixation achieves fracture stability with minimal hardware
placement within the patient. The advantages of external fixation in pediatric fracture
management include minimal hardware placement in contaminated
wounds, direct access to open wounds for their care or soft tissue
coverage and early joint range of motion. The disadvantages of external fixation include pintract infection, the
need for pin care by the patient’s family, potential muscle scarring around
pin sites, potential fracture risk through previous pin sites, and temporary
cosmetic concerns by the patient. Numerous internal fixation techniques exist, including plating, rigid
intramedullary nailing, and flexible intramedullary nailing. Rigid plate osteosynthesis, the most widely accepted operative
method, carries several documented disadvantages, including extensive
soft tissue trauma, significant blood loss, increased operative time and the risk of intraoperative radial nerve injury, more so during elective plate
removal. Several series of intramedullary stabilization of humeral fractures
(Rush rods and Ender nails) have been reported in the literature. Problems
of shoulder impingement and adhesive capsulitis of the shoulder were the
significant problems in these series, because most of the nails were
inserted antegradely through a small incision in the rotator cuff. Since the publication of outcomes by Spanish and Nancy groups in
the early 1980s, elastic stable intramedullary nailing (ESIN) has become
a well-accepted method of surgical treatment of long bone fractures in
children and adolescents. The reasons for this acceptance include the absence of postoperative
additional casting in most cases, primary bone union with avoidance of
growth plate injury, rapid recovery of joint motion and return to physical
activities, minimally invasive surgery allowing small and aesthetic scars,
low infection rate, and shortened hospital stays. Titanium elastic nail fixation is an ideal procedure for treating
humeral shaft fractures in children in the 6-16 years age group and has
many advantages over the use of plates and external fixators which have
few indications for their use in this age group. The use of a single intramedullary elastic retrograde nail for fixation
of closed, 1st and clean 2nd degree open diaphyseal fractures of the
humerus proved to be an adequate fixation technique with a very low
complication rate and a favorable final clinical outcome after a short
period of follow-up. When using a single nail instead of two nails; the operative time was
decreased, less radiological exposure was ensured, the cost was lowered,
less incidence of irritation at the insertion site of the nail, simple both the
insertion and removal procedures and nevertheless, the final outcome was
not compromised. In addition, there was no need for a second entry from
the medial or the lateral side and so less incidence of iatrogenic nerve
injury and less incidence of iatrogenic distal humeral fracture.
Furthermore, no nail twisting or winding over each other took place when
using a single elastic nail.