Intramedullary Nailing Versus Plating in Shaft Humerus Fractures: A Prospective Comparative Study

Dr. Ramavtar Saini ¹, Dr. Anshu Sharma ², Dr Karia Anand Janakbhai ³*.
 

1. Prof and Unit head Department of Orthopedics, GMCH, Udaipur

2. Assistant Prof, Department of Orthopedics, GMCH, Udaipur

3. PG Resident, Department of Orthopedics, GMCH, Udaipur

Corresponding Author: Dr Karia Anand Janakbhai, PG Resident, Department of Orthopedics, GMCH, Udaipur

Copy Right: © 2022 Dr Karia Anand Janakbhai, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: April 03, 2022

Published Date: April 10, 2022

Introduction

Fracture of humerus shaft is commonly encountered by orthopaedic surgeons. (1,2)It mainly includes group of fractureswhere main fracture line lies distal to surgical neck of humerus and proximal to supracondylar ridge distally. Generally, it accounts for approximately 3% of all fractures of bone. (3) 5% of injuries were associated with open wound, 63% were of simple fracture pattern.Radial nerveis at significant risk of injury in association with humeral shaft fracture in up to 18% of the closed injuries. (4)

Successful treatment of a humeral shaft fracture demands a holistic approach that involves knowledge of anatomy, surgical indications,surgical techniques,implants, patient’sfunctions, and expectations. Good results achieved in most cases of the diaphyseal fracture managed conservatively. (5)

Many of these shaft humerus fractures will heal with appropriate conservative treatment, but a consistent number will require surgical intervention for better outcomes. In recent time, significance has been changed from splinting and prolongedimmobilization to internal fixation and early mobilization, with early return to normal function.

Uncomplicated humerus shaft fractures are treated conservatively by reduction and subsequent immobilization with splinting , 90% successful union occurs(6,7,8).By the time both operative and non-operative methods for the humerus shaft fracture advances, initially hanging casts, cuff-collar slings, then functional cast bracing, U casts, shoulder spica were used for this fracture with improved results but it was not suited in long duration of treatment with adverse effect  and was not economical(9). ‘Chanley’, pioneer surgeon of orthopaedicsfavours conservative method. Loss of reduction in plaster castcan leads to malunion. In past operative treatment for humerus shaft fracture has usually been reserved for cases of delayed union, non-union, or malunion following conservative management [10]. Advantage of operative management is early mobilization, patient comfort and early return to normal activity.

In recent times poly trauma due to road traffic accidents, obese patients, elderly with osteoporotic bones, Segmental fracture, fracture with more than 50% of comminution all require operative treatment. Operative treatment is now the first choice of treatment because offailure of conservative treatment and non-compliance of patient to U cast and increased chance ofshoulder and elbow restriction.

So, with recent advancement in fracture fixation technique and biomaterial, success of improved surgical treatment, low complication rates, and better efficacy of managing complication, now-a-day surgical management of humeral shaft fracture is potential option, which is under acceptance as first choice of treatment.

Surgical stabilizationof fracturecan be accomplished with different type of implants and techniques.Two most common modalities areopen reduction with plate fixation or closed stabilization with interlocking intramedullary nails. Both techniques have certain mechanical and anatomical advantages and disadvantages [10].Plating gives good results in terms of fracture fixation and fracture union but disadvantages that it requires extensive dissection and radial nerve protection [11]. According to fracture pattern, indicationsfor interlocking nail are the simple transverse fracture and segmental fracture. ($) So according to that fracture type 12-A3 and 12-C2 are best treated with interlocking nail.Main advantages of intramedullary nails are closed insertion techniques, intact periosteal blood supply, and load-sharing mechanical properties [10].In some cases, intramedullary nail is associated with post-operative shoulder pain, shoulder impingement,decreased shoulder ROM & non-union.

The two most used modalities of internal fixation in fracture shaft of humerus are plate osteosynthesis and intramedullary nailing. With dynamic success of intramedullary fixation of fractures of femur and tibia, there was speculation that this technique might be more appropriate for humerus shaft fracture than plating [10].

The purpose of this study is to compare clinical,functional, and radiological outcomes of each method of fixation. (Plate osteosynthesis and interlocking nailing) forfracture shaft of humerus.

Materials and Methods

AIM: To compare themanagement of humeral shaft fractures by interlocking intramedullary nail fixation or plate osteosynthesis.

Primary Objective:

• To compare functional outcomes, union in patients treated with locked intramedullary nailing or plate osteosynthesis for humeral shaft fractures

Secondary Objective:

• To study the intra-operative and post-operative complications.
• Intra-operative complications (soft tissue damage, neurovascular status, bleeding, anatomical reduction.)
• Post-operative complications (infection, joint stiffness, muscle stiffness)
• To study the intra-operative time for both the technics.

The present study was conducted between January 2020 to June 2021. 40 patients with shaft humerus fracture diagnosed after x-ray arm, admitted in Department of Orthopaedics at a tertiary care center in Southern, Rajasthan, and planned for surgery with treatment modality either intramedullary interlocking nail or plate osteosynthesis.

A) Study Area: -

Patients presenting with shaft humerus fracture to Department of Orthopedics at a tertiary care center in Southern, Rajasthan,

B) Study Duration

All patients of shaft humerus fracture will be treated with either with intramedullary nailing or plate in Department of Orthopaedics at a tertiary care center in Southern, Rajasthan, undergoing from January 2020 to June 2021.

C) Study Design

A prospective comparative study

D) Study Sample 

The inclusion and exclusion criteria were as follows –

Inclusion Criteria

1. All patients with shaft humerus fractures (closed & open to grade IIIB)43

2. All skeletal mature patients (≥18years)

3. Patients willing to give consent

Exclusion Criteria

1. Pathological fractures

2. Associated injury on same limb

3. Neurovascular injury (gradeIIIC)43

Study Population

All patients with shaft humerus fracture treated with either intramedullary nailing or plate in Department of Orthopaedics at a tertiary care center in Southern, Rajasthan, from January 2020 to June 2021.

Study Intervention: -

Patient were assessed clinically and radiologically and graded as per AO Classification.39 Considering inclusion and exclusion criteria consented patients were operated witheither closed interlock intramedullary nailing technique or open reduction and internal fixation with plate osteosynthesis with due optimization.

Data Collection Technique and Tools:

Data was collected prospectively at the time of follow up at 6 weeks, 3 months, 6 months and was noted as per proforma.

Outcome Measures: -

For functional outcome measurement dash score was used. Radiological assessment was done with X ray of humerus (anteroposterior and lateral view), periodically for 6 weeks, 12 weeks, 24 weeks follow up in view of malunion, delayed union and non-union of fracture.

Fracture healing was assessed by sequential radiographs. Union was considered when bridging callus was seen(3 cortices) inboth AP and LATERAL views. Malunion was defined as more than 5° of angular deformity or 10° of rotational deformity.44

Complications like iatrogenic fractures, implant failure, shoulder or elbow morbidity, radial nerve palsy, compartment syndrome, etc. were recorded.

American Academy of Orthopaedic Surgeons developed Dash score38. For assessment of functionof upperlimb, it is very useful.Thirty self-rated questions are there in it, answers of all of them are graded between 1 - 5 points. Score varies from 0-100. As the score is high more is disability.In DASH scoring system‘n’ is number of completed responses. In this ‘0’ is the best score, and '100' is the worst score.With increasing final score, functional outcome decreases. Finally, result then graded asfollow: -

Excellent: - 0 to 20 points

Good: - 21 to 40 points

Fair: - 41 – 60 points

Poor: - ≥ 61

METHOD OF COLLECTION OF DATA: -

CLINICAL EVALUATION: -

PRE-OPERATIVE EVALUATION

Clinical and radiological assessment

A careful and detailed history was taken about the mechanism of injury and severity from patients and from attenders. Then clinical evaluation of the patient is carried out (general condition of patient and any systemic injury (head, chest, abdominal injury, etc.)  according to Advanced Trauma Life Support (ATLS) protocol guidelines. Vital signs were documented. Examination for associated injuries were also carefully done.

Examination of affected arm is done once patient is stable. Local examination of the affected site was done for signs of fracture like, swelling, crepitus, deformity, and tenderness. Evaluation of both the joints (shoulder & elbow) was done. Purposeful abnormal mobility of fracture is generally not elicited due to acuteness of the fracture. Abrasions, lacerations, or puncture wounds on arm should raise suspicion of an open injury which require management on emergency basis. Associated neurovascular examination was done and recorded.

Plain Radiographs of affected arm including both the joints (shoulder&elbow) were taken in antero-posterior and lateral views. Radiographs were carefully studied, and technical aspects of surgicalintervention were planned.  U-slab was applied for temporarily immobilized with collar and cuff sling. For pain relief analgesics were given.

Necessary blood investigations (complete blood count, blood urea, serum creatinine, blood sugar, HIV, HBSAg), ECG and chest X-ray were done. For operative procedurespre-anaestheticevaluation was done. In diabetic patient’s surgical intervention has been carried out once blood sugar level controlled.

 After explaining details of operative procedure,an informed and written consent was taken. All cases were operated either by intramedullary interlocking nailing or plate osteosynthesis

METHOD FOR TREATMENT OF SHAFT HUMERUS FRACTURES

(A) Non-Operative Treatment

 Following are the nonoperative treatment optionsfor humeral fractures

1. Velpeau bandage

2. Sling and body bandage

3. Abduction cast or splint

4. Coaptation splint or u-slab

5.  Hanging arm cast, and functional bracing.

6.  Functional bracing as described by sarmiento

(B) Operative Treatment

The principles of operative treatment are to maintain axial alignment, anatomical restoration of articular surface, proper length, early mobilization of joints and stable fixation of fractures. Velocity of injury, fracture pattern, age of patient, condition of soft tissue injury and comorbid condition like DM are determining factors for operative treatment.

In our study patient were treated either by intramedullary nail or plate osteosynthesis.

INTRAMEDULLAY INTERLOCKING NAIL
(A) Nail Design

(B) Characteristics Of Interlockednailing:

1. Rotational stability achieved by distal locking.

2. For reducing hoop stress formation by smallcalibre, cannulated implant insertion after reaming

3. Stability is increased with reamed technique

4. Universal nail for right & left humerus.
 

(C) Surgical Technique

Position:        

Patient was placed on beach chair position on edge of radiolucent table. To expose humeral head from beneath acromion, shoulder should extend to 30°.

Approach:

The antegrade approach (Deltoid-splitting)

Incision is generally given anterolateral to acromion. Too Lateral or posterior placement of incision increases risk of fracture of proximal end of humerus on nail insertion.

Entry Point: -

The entry point is markedthrough image intensifierwith K-wire just medial to greater tuberosity and in area at junction between articular surface of  head and greater tuberosity. An awl is introduced.  It is directly in line with intramedullary canal.It should be confirmed by fluoroscopy.

The posterior cortex should not be breached out at any cost, while reaming medullary canal.

Serial reaming to be done up to one size above desired nail.

C-arm is used for confirming the distal end of nail.

Distal locking screws applied under C-arm guidance.

With help of jig two locking screws inserted at proximal part.

Closure done in layers and sterile dressing applied.

(D) Post-Operative Protocol

• Wound inspection and dressing done on 2ndpost op day.

• Post-operatively parenteral Antibiotics were given up to 5 post-operative daysin case of compound injury and in other cases only for 2 days.

Post-operatively hypoglycaemic drugs given for patient having diabetes and regular monitoring and sugar control was done.

• Passive and active range of motion exercises for shoulder and elbow were started on next day once pain level decreases under physiotherapist guidance and tolerability of patient.

Active guided mobilization of shoulder was startedwhich includes pendular motion exercises, supported and active abduction exercises , circumduction exercise for shoulder and flexion exercises involving elbow.

Patients were usually discharged on 3rdpost-operative day for close injury, for open injury patients discharge an average of 8 days or till no sign of infection perceived.

Postoperatively Patient’s follow-up done at 2ndweek, 6th week, 12th week and thenat 6th month.

•  On 14th post-op daySuture removal was done on outpatient basis.

(II) PLATES AND SCREWS

(A) Plate design
4.5 mm  DCP

SURGICAL APPROCH FOR HUMERUS SHAFT PLATE FIXATION

There are 3 different surgical approaches for shaft humerus.

Posterior

Anterior

Antero-lateral

In our study we carried out shaft humerus fixation through posterior approach:

Position: -

There are two positions for this approach.

1.Patient is placed either in lateral position with affected side uppermost.

2. Prone position with arm 90° and elbow allowed to bend and forearm to hang over side of table.

Incision: -

Longitudinal incision given in midline of posterior aspect of arm, from 8 CMS below acromion to olecranon fossa.

Internervous Plane

There is no true internervous plane; dissectionmainly involves separating heads of triceps brachii muscle.

Dissection: -

Superficial dissection

The deep fascia should be incised in line with skin incision.

To identify gap between two heads of triceps(lateral and long heads), begin proximally, above point at whichtwo heads fuse. Interval should be developed between heads by blunt dissection on proximal side. Lateral head should be reflected laterally and long head medially. Along line of skin incision distally muscle will need to be divided. Radial nerve identified, isolated & protected. Small blood vesselsneed to be coagulated individually at this level.

Deep Surgical Dissection

Incise medial head in midline, continuing dissection up to periosteum of humerus. By epiperiostealdissectionstrip muscles off bone. To avoid damaging ulnar nerve, plane of operation must remain in an epiperiosteal location. It pierces medial intermuscular septum as it passes in an anterior to posterior direction in lower third of arm. To preserve blood supply to zone of injury very minimal soft tissue detached.

Fracture reduction and plate placement: -

Fracture site identified & exposed. Syringe wash given; fracture end cleaned. Now fracture ends hold with bone clamps, reduction achieved &temporarilyfixed by K-WIRE. Now plate applied taking care of radial nerve and screws applied. Wash taken and closure done in layers over suction drain. Dressing done and above elbow slab applied.

Post-Operative Protocol

In all cases immediately after surgery splintage was applied.

Post-operatively broad-spectrum prophylactic antibiotics were given in all closed cases. In open fracture, local site samples collected, and postoperative antibiotics management was done according to culture & sensitivity report.

In patients with diabetes mellitus, regular sugar monitoring was done. Good glycaemic control was achieved with dietary regulations and hypoglycaemic drugs.

Patients were usually discharged on 3-5thpost-operative day for close injury, for open injury patients discharge depending on wound condition.

Passive & active shoulder& elbow ROM exercises were started as early as possible once pain level decreases and if fracture is stable and construct is rigid under physiotherapist guidance and tolerability of patient.

Patient’s follow-up done at 2ndweek, 6th week, 12th week and thenat 6th month.

On 14th day suture removal was done on outpatient basis.

Discussion

The surgical treatment of humerus shaft fracture is the subject of continuous debate.Most surgeons agree that intramedullary nailing is notbest fixation for humerus shaft as compared to tibia and femur shaft fracture. Plate osteosynthesis requires extensive soft tissue dissection with risk of radial nerve damage and infection.45

Absolute indications for open reduction and internal fixation of acute fractures of humeral shaft are open fractures, fractures associated with vascular or neural injuries.

We observed these findings in our study.

The mean age in the present study was 43.52years. Majority of cases were in age group of 40 – 49 years (30%) as being working age group with higher risk of fractures and falls, followed by 50-59 years of age group with 25% of patients, 30-39 years of age with 20%, 20-29 years of age with 17.50% and 7.50% in age group more than 60 years of age.

Similar finding to our study were observed by Pansey N. K. et al (2017)24, who reported that mean age was 42 years.

Out of total 40 patients surgically treated, 20 (50%) cases were operated by plate fixation and 20 (50%) with intramedullary interlock nail insertion. Age of patients in plating group ranged from 22 to 75 years with a mean age 47.28 years and in interlocking group age range was from 23 to 76 years with a mean age 45.05 years.

Similar findings to ours were observed by Naga Raju26, who reported that out of total 38 patients treated surgically, 18 (47%) cases were operated by plate fixation and with intramedullary interlock nail insertion 20 (53%) were treated. Age of patients in plating group ranged from 22 to 60 years and in  interlocking group age range was from 23 to 70 years. Mean age was 37.27 years in plating group and 35.05 years in nailing group.

In present study plating group 16 (80%) patients were male and 4 (20%) were females. In nailing group, 13 (65%) cases were male and 7 (35%) were females.

Naga Raju reported26 in their study that in plating group 13 (72.2%) patients were male and 5 (27.8%) were female. In nailing group, 14 (70%) cases were male and 6 (30%) were female.

In our study road traffic accident (RTA) was most common mode of injury in both groups 34(85%) patients and followed by FALL from height and domestic fall in 6 (15%)patients.

Naga Raju26 reported similar results to ours. In their study Road traffic accident (RTA) was most common mode of injury in both groups with n = 11 (61.1%) and n = 16 (80%) cases in plating and IMN groups respectively followed by fall from height, domestic and others.

In our study right-side involvement was in 33 (55%) compared to left side 18 (45%). In both groups, majority of subjects were males 29 (72.50%).

Naga Raju26 reported in their study that right side 23(60.5%) was most involved compared to left side 15 (39.5%). In both groups, most subjects were males 27(71.1%).

In our study, according to AO Group classification system, 19 (47.50%) patients had Type A fracture, 18 (45%) patients had type B and 3 (7.50%) patients presented fracture type C.

Our study was in congruence with study of Naga Raju26 series. In their series according to AO Group classification system, n = 20 (52.63%) patients had Type A fracture, n = 12 (31.57%) patients had type B and n = 6 (15.78%) patients presented fracture type C.

Gallusseret al36 stated that according to fracture pattern, main indications for interlocking nail are the simple transverse fracture, severally comminuted fractures, and segmental fracture.

Walker et al37 stated that in wedge fracture or oblique/ spiral patterned fractures, plate osteosynthesis provide maximize inter-fragmentary compression and simplify the fracture when used with lag screw.

According to AO classification, out of 40 patients, 19 patients belong to group-A (simple fracture AO 12A) and majority of these were treated with interlocking nail. 18 patients classified as group-B (wedge fracture AO 12B) and mostly treated with plate osteosynthesis. 03 patients belong to group-C (complex fracture AO 12C) and among them 02 patients (complex spiral fracture) were treated with plate osteosynthesis, and 01 patient (segmental fracture) treated with interlocking nail.

Inpresent studymean surgery time for plating was significantly more than nailing modality. Mean surgery time for nailing 82 ± 11.74 mins as compared to plating was 94.80 ± 7.90 mins.

Pansey N. K. et al (2017)24reported in their study thatmean surgical time was 68 minutes in cases with the nailing and 115 minutes in cases with plating.

In present study fracture union in plating group was seen at 15.30 weeks and in nailing group 14.45 weeks. Average time taken for radiological union was 14.87 weeks and range was 8 - 34 weeks. Healing rate was relatively faster in nailing group compared to  plating groupbut it is statically not significant.

Kesemenli and Subasi et al19 studied 60 patients with fractures of shaft of humerus, 33 fixed with interlock nailing and 27 with dynamic compression plating. They showed that healing did not differ in both groups, but non-union rate was higher with interlock nailing. Similar results were obtained in our study.

Naga Raju26 showed similar findings in their study. Facture union in plating group was seen at 16 weeks and in IMN group 14 weeks. Average time taken for radiological union was 15 weeks. In plating group, average time taken for fracture union was 16.06 weeks, and in IMN group, average was 14.05 weeks. Healing rate was relatively faster in IMN group compared to plating group.

S Raghvendra and Bhalodiya20 followed up 36 patients with fractures of shaft of humerus in a prospective study. Eighteen patients each underwent open reduction and internal fixation with compression plating and antegrade interlock nailing. Though there was no significant difference between plating or nailing in terms of time to union. Compression plating is preferred method in majority of fractures of shaft of humerus with better preservation of joint function and lesser need for secondary bone grafting for union.

For functional outcome assessment, we used DASH scoring system. DASH scores 0 - 20 points rated as excellent, 21 – 40 points as good, 41-60 points as fair and ≥ 61 points as poor. The mean DASH score in whole series was 22.27 / 100 (lower the score better the function). Average DASH score in plating group was 20.63, and in interlocking nailing group, it was 23.92.

In our study 26 (65%) patients had Dash score as excellent, followed by 8 (20%) as Good and 5 (12.50%) as fair score. Only in 1 (2.50%) patient Dash score was categorized as poor.

Functional results of our study were comparable to study by Singisetti and Ambedkar21. In 2010 in a prospective, comparative study of management of acute humeral shaft fractures treated by antegrade interlocking nail fixation and dynamic compression plating over a period of 3 years. In their study plating has been shown to have better overall results compared to interlocking nails in treatment of closed humeral shaft fractures.

Naga Raja et al26 in their study showed among n = 38 subjects, n = 10(26.31%) cases showed excellent results, n = 12 (31.57%) good, n = 10 (26.31%) fair and n = 6 (15.78%) showed poor results. Among n = 10 subjects with excellent results, n = 8 (44.44%) cases were of plating group and n = 2 (10%) were interlocking nailing group. In patients treated by intramedullary nailing, n = 6 (30%) patients showed good results, n = 8(40%) patients showed fair results and n = 4 (20%) poor results. In patients treated by plate fixation, n = 6 (33.33%) cases showed good results, n = 2 (11.11%) fair and n = 2 (11.11%) cases showed poor results.

In present study in shoulder pain 4 (20%) was main complication observed in cases of nailing. There was one case with delayed union in nailing. Inplating group 19 (95%) patients recovered completely and 1 (5%) had superficial infection that was treated with regular dressing and oral antibiotics.

In a study by Putti et al27, 34 patients with humeral shaft fractures were randomized to undergo locked antegrade intramedullary nailing (n = 16) or dynamic compression plating (DCP, n=18). All patients were followed up for a minimum of 24 months. In the respective IMN and DCP groups, the mean ASES scores were 45.2 and 45.1 (P = 0.69), the complication rates were 50% and 17% (P = 0.038). They concluded that the complication rate was higher in the IMN group, whereas functional outcomes were good with both modalities.

McCormack et al46 performed a prospective randomized study of 44 patients with fracture shaft humerus fixed with dynamic compression plate and intramedullary interlock nailing. Patients were followed up for a minimum of six months. They concluded that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of shaft of the humerus. Fixation by IMN may be indicated for specific situations but is technically more demanding and has a higher rate of complications. Our results were comparable with this study, and we also found plating was better than nailing for fracture shaft humerus.

Jinn47 collected data on 48 acute humeral shaft fractures in 48 patients treated with humeral locked nails and compared with retrospective data on 25 fractures in 25 other patients treated with dynamic compression plates. They concluded that humeral locked nailing offered a less invasive surgical technique and more favourable treatment results than did plate fixation.

Comparative studies between plate fixation and intramedullary locked nailing have given contradictory results. Plate fixation, however, has been associated with an extensive soft tissue exposure, longer operating time, higher iatrogenic nerve palsy rate, possibly an increased infection rate, an increased need for blood transfusion, and prolonged hospital stay but associated with good shoulder range of motion & less chance of delayed or non-union.

Intramedullary nailing is becoming popular among surgeons because of the advantages like minimal soft tissue dissection, preservation of fracture hematoma,less chances of infection.Also, intramedullary nailing allows for early postoperative motion and rehabilitation because of its superior biomechanical properties (load sharing properties)48 but shoulder pain is main complication with the intramedullary nail, and it is technically more demanding.

Summary and Conclusion

This was a prospective comparative study in which 40 patients were treated witheither interlocking intramedullary nailing or plate osteosynthesis, 20 patients in each group.

• The mean age in the present study was 43.52years. Majority of cases were in the age group of 40 – 49 yrs. (30%) as being the working age group with higher risk of fractures and falls, followed by 50-59 years of age group with 25% of patients, 30-39 years of age with 20%, 20-29 years of age with 17.50% and 7.50% in age group more than 60 years of age.
• In our study total 29 patients were Male and 11 patients werefemale.
• Out of 40 patients, right side involvement was seen in 20 cases and left side in 18 cases.
• Most common MOI in the study was RTA (34 patients) followed by FALL (06 patients).
• According to AO classification, out of 40 patients, 19 patients belong to group-A (simple fracture AO 12A) and majority of these were treated with interlocking nail. 18 patients classified as group-B (wedge fracture AO 12B) and mostly treated with plate osteosynthesis. 03 patients belong to group-C (complex fracture AO 12C) and among them 02 patients (complex spiral fracture) were treated with plate osteosynthesis, and 01 patient (segmental fracture) treated with interlocking nail.
• Mean surgery time for plating was significantly more than nailing modality. The mean surgery time for plating was 94.80 ± 7.90 mins as compared to nailing 82 ± 11.74 mins.
• The mean time taken for radiological healing is little less in nailing (14.45 weeks) than plating (15.30 weeks), though this is statistically not significant.
• Dash score was almost similar in both the genders when compared with nailing and plating.
• Shoulder pain 4 (20%) was the main complication observed in cases of nailing. There was one case with delayed union in nailing and one case with superficial infection in plating.
• The mean Dash score for nailing was 23.92 ± 13.73 and for plating was 20.63 ± 10.72.
• Maximum patients had Dash score of 26 (65%) as excellent followed by 8 (20%) as Good and 5 (12.50%) as good score. Only in 1 (2.50%) patient the Dash score was categorized as poor.
• There was very minimal soft tissue exploration during locked nailing but it is technically more demanding whereas for plate osteosynthesis application there were more soft tissue explorationthatled to loss of fracture hematoma, prolongs the surgical time, and can lead to surgical site infections and radial nerve injury.

• As nails are biomechanically weight sharing devices and there is very minimal soft tissue disruption hence, post-operatively early shoulder ROM was initiated.

  Shoulder pain of mild to moderate severity was observedin few patients treated with intramedullary nail but can be prevented by precise surgical technique, correct nailing direction and meticulous rotator cuff repair.

  Union time was shorter with nailing group as compared with the plating group. One case of delayed union observed in nailing group, but100% union achieved in both the groups.

  Functional DASH scores were better in plating group compared to nailing group, but it is statistically not significant.In most of the subjects, functional outcome was satisfactory.

  So, we are of the opinion that both intramedullary nailing and plating offer good clinical and functional outcomes in shaft humerus fractures and mainly depends upon right selection of patient (Fracture pattern, radial nerve status and co-morbid conditions like diabetes mellitus), correct surgical technique, proper knowledge of implant and expertise of operating surgeon.

  The results and observation obtain during the study indicate that both modalities of treatment deserve a place in treatment of humerus shaft fracture with very minimal complications if performed meticulously & scientifically.

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  19. Kesemenli CC, Subasi M, Arslan H, Necmioglu S, Kapukaya A. Comparative study of fracture shaft of humerus managed by dynamic compression plating and interlock nailing. Acta OrthopTraumatolTurc. 2003; 37: 120-5.

  20. Raghavendra S, Bhalodiya HP. Internal fixation of fractures of the shaft of the humerus bydynamic compression plate or intramedullary nail:A prospective study. Indian J Ortho 2007; 41:214-8.

  21. Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: a prospective comparative study. International orthopaedics. 2010 Apr 1;34(4):571-6.

  22. Rupesh Kumar, Pankaj Singh, Lal Jee

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