This document summarizes the results of treating 25 patients with humeral shaft fractures using an interlocking nail with spreading distal ends. Key findings include: - The majority of fractures were closed fractures in males from road accidents. - Retrograde nailing resulted in significantly faster union time (10.2 weeks) compared to antegrade nailing (14.2 weeks). - According to a standard scoring system, results were excellent in 40% and good in 24% of patients, with antegrade nailing patients having poorer outcomes.

3. PRESENTED TO THE GRADUATE SCHOOL
FACULTY OF MEDICINE, UNIVERSITY OF ALEXANDRIA
In partial fulfilment of the
requirements of the Master Degree
in
Orthopaedic Surgery & Traumatology .
By
Elsheikh taweel salih

4. RESULTS OF TREATMENT OF
HUMERAL SHAFT FRACTURES
USING INTERLOCKING NAIL WITH
SPREADING DISTAL ENDS
(SEIDEL)

6. Relevant Anatomy of the humerus
The humeral shaft extends from the pectoralis major insertion to
the supracondylar ridge.
The arm is divided into anterior and posterior compartments by
the 2 intermuscular septa:( medial and lateral).
The anterior compartment contains the biceps brachii,
coracobrachialis, and brachialis muscles; the brachial artery and
vein; and the median, musculocutaneous, and ulnar nerves.
The posterior compartment contains the triceps muscle and the
radial nerve which passes between the lateral and medial heads of
triceps .
B. SUPPLY :arises from perforating brs. Of the brachial A. The
main nutrient artery enters the shaft at the junction of its middle and
lower thirds
-The periosteum also plays another important source of blood
supply.
INTROUDCTIO
N

7. AO definition of humeral shaft
 The humeral shaft is the area extending from the
surgical neck above to the supracondylar ridge
below.>>>
INTROUDCTIO
N
Radiographs of the humerus , should include the shoulder and elbow joints

8. Fractures of the humeral shaft represent about 3 % of
all fractures.
Mechanism of Injury
Direct trauma is the most common especially RTA.
Indirect trauma such as fall on an outstretched hand.
Pathological fractures.
INTROUDCTIO
N

9. ClassificationClassification
C = Complex fracture
1-AO classification which used in this study1-AO classification which used in this study
A = Simple fracture
B = Wedge fracture
INTROUDCTIO
N

10. ClassificationClassification
2-According to the line of fracture
TransverseTransverse ObliqueOblique SpiralSpiral WedgeWedge SegmentalSegmental
INTROUDCTIO
N

11. Complications of humeral shaft fractureComplications of humeral shaft fracture
1.Neural complications:
 Radial nerve injury : 8- 11%
2. Vascular injury: due to
 Gunshot, entrapment of vessels bet #
ends or occlusion (second
haematoma)
INTROUDCTIO
N

12. 3. Malunion: which defined here as
>20° of anterior angulation
>30° of varus angulation
>3 cm shortening
4. Delayed and Nonunion:
> 6 months
5. Joint stiffness.
Complications of humeral shaft fractureComplications of humeral shaft fracture
INTROUDCTIO
N

13. Treatment options>A-non op. --B- operativeTreatment options>A-non op. --B- operative
A-Non operative treatment:
Has a history of success with union rate up to 95%
INTROUDCTIO
N
2.coaptation splint:
U shaped slab
Includes:
1.hanging cast:

14. Non operative treatment:
4. Body Bandage3.Functional bracing
Treatment:Treatment:
INTROUDCTIO
N

15. Non operative treatment:
Treatment:Treatment:
6. Skeletal traction5. Abduction humeral splint
INTROUDCTIO
N

16. Treatment
B. Operative treatment
Indications for operative management
1. Open fractures
2. Segmental fractures.
3. Floating elbow .
4. Associated neurovascular injury .
5. Pathological fractures .
6. polytraumatized patients .
7.Bilateral humeral fractures .
8.Fractures with unacceptable alignment .
9. Fractures with intra-articular extension.
10. nonunion

17. Treatment
B. Operative treatment:
Methods of surgical fixation:
1. Compression plate fixation
Advantages:
• anatomical reduction
• rigid fixation
• high union rate
• avoidance of shoulder complications
Disadvantages:
• extensive soft tissue exposure
• radial nerve injury
• long operative time
• infection
2. External fixators:
1. Uniplanar , mono planar Ex. fix
INTROUDCTIO
N

18.  3. Intramedullary fixation (2 types nails)
 1-Flexible nails .eg Nancy nails, Rush pins
 2-Rigid interlocked nails.eg
(SEIDEL, Kuntscher, St-pro)
Treatment B. Operative treatment:
INTROUDCTIO
N

19.  Conditions not suitable for IM nailing:
1) Open physeal plates
2) Too proximal or too distal fracture
3) Gross humeral deformity
4) Too narrow medullary canal
5) presence of obstructing implant
6) Infection
INTROUDCTIO
N
Treatment

20.  Complications of IM nailsComplications of IM nails
1. Insertion site morbidity (joints stiffness, loss of motion and pain)
2. Iatrogenic comminution
3. Nonunion
4. Complications from locking screws
5. Infection
INTROUDCTIO
N

21. Medullary canal study:
 The proximal part is wide and rounded
but distally it become narrower and
oval in shape.
 The distal part has ant. Angulation.
 This must be appreciated to determine the linear
relationship between the medullary canal and the
distal humerus .>>>
INTROUDCTIO
N

22. Design of the interlocking humeral nail with distal spreading ends
( modified Seidel nail)
The nail is cannulated, comes in different diameters starting from 7mm and
increased by 1mm, its length starts from 23cm and increased by 1cm.
INTROUDCTIO
N

23. The design of the nail
 Straight and cannulated.
 The nail has one proximal hole .
 The distal end (tip)of the nail is slotted .
 The distal spreading wings protrude just proximal to the dist. End
of the nail.
 Distal locking achieved by clockwise rotation of a distal spreading
bolt, using along screw-driver through the nail (the proximal inner
part is serrated), the bolt then pushes and spreads the distal
flanges of the nail.
INTROUDCTIO
N

25. AIM OF THE WORK
The aim of this work was to evaluate the results of
treatment of humeral shaft fractures using
interlocking nail with spreading distal ends (Seidel
nail).

27.  The study included 25 patients

1- Age of patients
The mean age was 41.92 ± 12.24years and the range was 20-
70years old.
Age No. %
<30 3 12
30 – 39 10 40
40 – 49 7 28
50 + 5 20
Range 20.00-70.00
Mean ±
SD 92. 12.24
The first ten patients had ante-grade nailing method. While the successive
Fifteen patients had retrograde nailing,

28. Gender No %
Male
20 80
Female
5 20
Total
25 100.0
Twenty patients were males (80%) and five patients were
females (20%).
2-Gender

29. The dominant (right) side was affected in ten patients (40%)
and the non dominant (left) side in fifteen patients (60%).
Affected side
No %
Right
10 40
Left
15 60
Total
25 100.0
3- Side affected

30. The commonest mechanism of
trauma was road traffic
accidents (RTA) in 16 patients
(64%). Seven patients (28%) fell
from height (FFH). two patients
(8%) had direct trauma by a blunt
object.
4.Mechanism of trauma

32. Twenty three patients (92%) had
closed fractures, while two
patient (8%) had an open Gustilo
grade I and II fractures.
5.Type of fractures :

33. 6.Level and shape of fracture
Type of fracture No. %
Closed 23 92
Open 2 8
Level of fracture
Lower 1/3 2 8
Middle 1/3 20 80
Upper 1/3 3 12
Shape of
fracture
Oblique 9 36
Transverse 11 44
Spiral 2 8
Spiral wedge 3 12

34. •Three patients (12%) had a radial nerve injury, two of them
(8%) had preoperative injury and one patient (4%) had post-
operative radial nerve paresis.
Radial nerve
affection No. %
No
22 88.0
Yes
3 12.0
Total
25 100.0
7.Associated radial nerve injuries

35. 8.Methods of the nail insertion
Fifteen patients (60%) had retrograde nailing, while ten
patients (40%) had ante-grade nailing method.
ILN insertion method
No %
Retrograde
15 60
Ante grade
10 40
Total
25 100.0

37. @-The operation was performed under general anaesthesia.
@- patients received intravenous antibiotic before surgery
METHODS

38. 1-Antegrade nailing tech.
Patient s were positioned in a beach chair position
METHODS
surgical staff and pt positioningsurgical staff and pt positioning
Nail insertion methodsNail insertion methods

39. Antegrade nailing tech.
The landmarks for the skin incision over the lateral
aspect of the shoulder
METHODS

40.  Incision and exposure
3-4 cm anterolateral to the3-4 cm anterolateral to the
acromionacromion
 Deltoid muscle split in line with itsDeltoid muscle split in line with its
fibers,sub acromial bursa clearedfibers,sub acromial bursa cleared
bluntly. Then the supraspinatusbluntly. Then the supraspinatus
tendon incised.tendon incised.
METHODS

41.  The point of entry:-
Just medial to the greater tuberosity ,an awl was placed and
checked fluoroscopically and advanced to the medullary canal.
METHODS

42.  Reduction of the fracture
 Guide wire insertion and nail length determination
 achieved by gentle traction
and adduction of the limb
METHODS

43.  Reaming
 Usually 1 mm larger than the nail diameter.
 Reaming was avoided across comminuted segments to
avoid complications .
METHODS

44.  Nail insertion
 The nail inserted gently by
hand using insertion guide.
 The Distal locking achieved
by the spreading dist. Wings
which engaged into the distal
cancellous bone)
METHODS

45.  Proximal locking
Drilling using the guide
Proximal locking screw positioning
 Closure of the wound
The incision in the supraspinatus tendon was repaired , the wound
closed in routine fashion .
METHODS

46. 2.Retrograde nailing technique
 Pts were positioned in a Prone
position
 .The landmarks for incision
METHODS
6cm skin incision was made from the tip of the
olecranon proximally

47. Retrograde nailing technique
 The skin incision through triceps-splitting approach.
METHODS

48. METHODS
 Entry portals for the retrograde nailing.
A - supra-condylar access.(large ant
deviation>more prox.entry .
B-access through the upper edge of
olecranon fossa ( small ant
deviation>more distal entry .
 Exposure of the posterior
humerus.

49. Opening medullary canal
and guide rod insertion
 Opening medullary canal

50. The fracture reduction was
maintained while reaming.
METHODS
 Closure of the wound

51.  Post-operative care
&management
 Patients were put in an arm sling immediately
post-operatively.
 examined for vascular and neurological status.
 Post op rehab. tailored to nailing method,fract.
Stability and overall pt health .
 Pts advised to avoid large rotational stresses .
 Follow-up
Check x-rays AP & Lat . Views were obtained after
2wks then monthly till union .
METHODS

52. Fair Activity pain
Loss of between 20ºand 40º of shoulder range of motion in a single direction
and elbow range of flexion and extension
Malunion with an angle more than 10º
Poor Constant pain
more than 40º Loss of shoulder range of motion in a single direction and elbow
range of flexion and extension
Non-union or iatrogenic radial nerve palsy
Good Occasional pain
Less than 20º loss of shoulder range of motion in a single direction and elbow
range of flexion and extension
Malunion with an angle less than 10º
Excellent
No pain
Full range of motion of shoulder and elbow
Good radiological union and alignment
Methods of assessment:
Results were assessed according to Stewart and Hundley’s scoring system
(pain-ROM-union & alignment)
METHODS

54. According to Stewart and Hundley's scoring system, the results obtained
were excellent in ten patients (40%), good in six patients (24%), fair in six
patients (24%), and poor in three patients (12%(.
Result
No. %
Excellent
10 40.0
Good
6 24.0
Fair
6 24.0
Poor
3 12.0
Total
25 100.0
The overall results
RESULTS
Excellent
40.0%
Good
24.0%
Fair
24.0%
Poor
12.0%
(10)
(6)
(6)
(3)

55.  The studied antegrade cases according to the results
 out of 10 patients with antegrade nailing no case was graded as
excellent, 3were good, 5were fair, and 2 were poor.
RESULTS

56. The studied retrograde cases according to the results
out of 15 patients with retrograde nailing 10 were excellent, 3
were good, one was fair, and an other one was poor.
RESULTS

57. Union time (weeks) Number Per cent
6 – 10 12
48%
11 –15 8
32%
16 – 20 4
16%
Non union 1 4%
Range
Mean
S.D.
6- 20
13.11
3.58
 twenty four patients progressed to union in an average union
time of (13.1) weeks, there was one patient with non-united
fracture after 6months.The shortest time to union was 8 weeks,
whereas the longest time to union was 20weeks.
RESULTS

58.  Relationship betweenRelationship between union timeunion time andand shapeshape of fractureof fracture
Union
time(weeks)
Shape of fracture
Oblique
Transvers
e
Spiral
Spiral
wedge
Range
Mean
S.D.
6 – 18
11.20
4.03
9 – 20
15.1
4.07
6 – 15
9.85
3.66
8 – 20
14.65
4.25
F 12.98
p 0.013*
 the mean duration of union was significantly decreased in spiral fracture
(9.85±3.66) weekswhile transverse fracture showed the highest period of union
(15.1±4.07) weeks, indicating a significant increase in union time in transverse
fracture.
RESULTS

59.  Union time and ILN methodUnion time and ILN method
Union time
(weeks)
Retrograde Ante grade
Range
Mean
S.D.
8 – 16
10.21
2.98
12 – 20
14.21
3.25
T
p
2.98
0.013*
Retrograde Ante grade
Union time
0
2
4
6
8
10
12
14
16
Mean
There was statistically significant relation between ILN method and union
time, the mean union time in retrograde method was 10.21±2.98 weeks, while
in antegrade method the mean duration of union time was 14.21±3.25 weeks,
there was a significant increase in union time in antegrade than retrograde
method.
RESULTS

60.  Range of elbow and shoulder motionRange of elbow and shoulder motion
Retrograde Antegrade Total
No. % No. % No. %
Shoulder motion
Full range 14 93.3 0 0.0 14 56
Loss of< 20° 1 6.7 7 70.0 8 32
Loss of < 40° 0 0.0 2 20.0 2 8
Loss of > 40° 0 0.0 1 10.0 1 4
Total 15 100.00 10 100.00 25 100.00
p 0.0001*
Elbow motion
Full range 12 80.0 8 80.0 20 80
Loss < 20° 2 13.3 2 20.0 4 16
Loss of < 40° 1 6.7 0 0.0 1 4
Loss of > 40° 0 0.0 0 0.0 0 0
Total 15 100.00 10 100.00 25 100.00
p 0.65
The shoulder ROM was obviously affected in antegrade cases more than
the retrograde ones, while elbow extension loss was more prominent in
retrograde cases..
RESULTS

61. Shoulder motion:
Fourteen patients (56%) had a full range of motion in all directions.
Nine patients (36%) had loss of less than 20°of shoulder abduction
at the end of follow up, two patients (8%) had loss of more than
40° of shoulder abduction.
Elbow motion:
Twenty patients (80%) had a full range of motion, four patients
(16%) had loss of less than 20 degrees of elbow extension, and
one patient (4%) had loss of more than 40 degrees of elbow
extension.
<<Range of elbow and shoulder motion
RESULTS

62. Pain No. %
No pain 18 72.0
Occasional pain 4 16.0
Activity pain 2 8.0
Constant pain 1 4.0
Total 25 100.00
No pain
72.0%
Occasional pain
16.0%
Activity pain
8.0%
Constant pain
4.0%
 Eighteen patients had no pain at the fracture site, four patients had
occasional pain, two patients had activity pain and one patient had
constant pain
RESULTS
 The studied cases according to painThe studied cases according to pain

63. Factors that may affect the final score:
1.Age:
Age (years)
Result
Excellent Good Fair Poor
No. % No. % No. % No. %
<30 3 30.00 0 0.00 0 0.00 0 0.00
30-39 5 50.00 3 50.00 2 33.33 0 0.00
40-49 2 20.00 2 33.33 3 50.00 0 0.00
50+ 0 0.00 1 16.67 1 16.67 3 100.00
Total 10 100.00 6 100.00 6 100.00 3 100.00
p 0.015*
Range 20.00-42.00 35.00-52.00 33.00-65.00 51.00-63.00
Mean ± SD 33.81 ± 6.11 36.12 ± 6.25 44.66 ± 5.02 53.12 ± 3.66
F
p
9.01
0.0042*
*: Statistically significant at p ≤ 0.05
There was statistically significant relation between age and the
final results, that the younger the patient the more rapid the
fracture healing occurs.
RESULTS

64. 2. Gender
Relation between net results and patients genderRelation between net results and patients gender
Male Female
Gender
0
20
40
60
80
100
120
%
Excellent Good Fair Poor
 There was no difference in relation between the results
and patient gender
RESULTS

65. 3. Level of fracture:
Result
Excellent Good Fair Poor
No. No. % No. % No. % No. %
Level of fracture in antegrade nailing
Lower 1/3 0 0 0.0 0 0.0 0 0.0 0 0.0
Middle 1/3 9 0 0.0 3 100.0 4 80.0 2 100.0
Upper 1/3 1 0 0.0 0 0.0 1 20.0 0 0.0
Total 10 0 0.0 3 100.0 5 100.0 2 100.0
p 0.3652
Level of fracture In retrograde nailing
Lower 1/3 2 1 10.0 1 33.3 0 0.0 0 0.0
Middle 1/3 11 8 80.0 2 66.7 1 100.0 0 0.0
Upper 1/3 2 1 10.0 0 0.0 0 0.0 1 100.0
Total 15 10 100.0 3 100.0 1 100.0 1 100.0
p 0.4526
MCp: p for Monte Carlo test
There was no statistically significant relation between the level of the fracture and the
final score(however the number of pts. With prox and dist 3rd #
was small (5) while pts
with middle 3rd
# was large (20) pts)
RESULTS

66. 4.Nail insertion method
Result
Retrograde ante grade
No. % No. %
Excellent 10 66.67 0 00.0
Good 3 20.00 3 30.0
Fair 1 6.67 5 50.0
Poor 1 6.67 2 20.0
Total 15 100.0 10 100.0
X2
P
12.50
0.005* Excellent Good Fair Poor
Result
0
10
20
30
40
50
60
70
%
Retrograde Antegrade
 There was statistically significant relation between ILN method and the
final score, it was found that there was a significant increase in
excellent and good results in retrograde than antegrade method, while
on the other hand there was a significant increase in fair and poor
results in antegrade method than retrograde one.
RESULTS

67. 5.Mechanism of trauma
Relation between results and mechanism of trauma
Result
Excellent Good Fair Poor
No. % No. % No. % No. %
Trauma mechanism
RTA 4 40.00 4 66.67 6 100.00 2 66.67
FFH 5 50.00 2 33.33 0 0.00 0 0.00
Direct trauma 1 10.00 0 0.00 0 0.00 1 33.33
Total 10 100.00 5 100.00 6 100.00 3 100.00
MCp 0.25
RTA: Road traffic accident
FFH: Falling from height
 There was no statistically significant relation btwn mechanism of
trauma and final score
RESULTS

68. 6.Time lapsed before surgery
Time lapse
Result
Excellent Good Fair Poor
No. % No. % No. % No. %
1-3 days 8 80.0 0 0.0 0 0.0 0 0.0
4-6 days 2 20.0 5 83.3 2 33.3 1 33.3
7 days or more 0 0.0 1 16.7 4 66.7 2 66.7
Total 10 100.00 5 100.00 6 100.00 3 100.00
p 0.013*
 trere was statistically significant relation…that the shorter the time before surgery,
the better the results .
1-3 days 4-6 days 7 days or more
Result
0
20
40
60
80
100
%
Excellent Good Fair Poor
RESULTS

70. Complications encountered in this study
1.Limitation of shoulder motion
 Shoulder range of motion was partially limited in eleven
patients.
 The restricted shoulder motion is obvious after antegrade IM
nailing especially in elderly patients and in the presence of
pain at nail insertion site.
2.Elbow extension loss
 Lack of full extension of the elbow joint was encountered in five
patients. The extension loss was more frequent in retrograde nailing
group.
RESULTS

71. 3.Radial nerve palsy:
 Two patients sustained pre-operative radial nerve injury in this
series, one patient had post-operative radial nerve palsy.
 33 year-old male patient .RTA
 he had a spiral wedge fracture (B1) of the middle third of his right
humerus
 internal fixation using modified Seidel nail was performed through
retrograde fashion
 Post-operatively radial nerve injury was noticed with weak wrist
and fingers extensors
RESULTS

72. Complications
Radial nerve palsy
 nerve conduction study report
conclusion was [definite injury of
the right radial nerve. No
neurotemesis, there is severe axon
loss.. This pattern suggests good
prognosis for regeneration]
 Fortunately there was complete
recovery after 3 months.
RESULTS

73. Complications
Radial nerve palsy
Wrist, elbow and shoulder function at end of follow up
RESULTS

74. Complications.
4.Proximal protrusion of the nail and shoulder impingement.
Shoulder impingement was seen in
one patient and the protrusion of the
nail was the cause. Nail protrusion
into the shoulder was a technical
error due to incomplete insertion of
the nail as it should be 2mm
subchondral.
RESULTS

75. Complications
5.Non union
One fracture failed to unite (4%). Seventy years old female patient sustained
road traffic accident resulted in transverse displaced humeral fracture at the
upper third. The patient was operated two weeks after trauma. After 6 months
the fracture failed to unite so she was planned for bone grafting and plate
fixation
6.Infection
Infection also occurred in one patient, a 35 years old male, had open Gustilo grade II
fracture.
RESULTS

76. cases

77. • A 33 year-old male
• Sustained RTA
• transverse fracture of left humerus ,Offered modified Seidel
nail through retrograde approach
Case 1
CASES

78. CASES
x-rays at end of the follow up
Case 1

79. The final outcome was graded as excellent according to the
evaluation scoring system.
Range of shoulder and elbow motion at the end of follow up
Case 1
CASES

80.  A 25 year-old female
 RTA.
 A short oblique fracture of the left humerus.
 Internal fixation…Retro..app
CASES
Case 2

81.  X rays at the end of follow up(7months)
Case 2
CASES

82. Follow up continued for seven months and the final outcome
was graded as good.
CASES
Case 2

84. •A male patient aged forty five years old.
•RTA-right humerus fracture
•Offered modified Seidel nail through antegrade approach
Case 3
CASES

85.  x-rays at end of follow
up.
CASES
Range of motion at the end of follow up
The final outcome was graded as fair.

86.  A 35 years old male patient.
 had open Gustilo grade I mid shaft fracture of the left humerus
 internally fixed by antegrade intramedullary nail after initial
wound care.
 Three weeks after surgery, he developed wound infection at the
surgical wound site and the open fracture site.
 After a period of wound care and antibiotic therapy, condition
improved and wounds were healed.
 At ninth month of follow up he came with discharging wound
sites. fortunately x-ray showed good callus and union, nail
removal was planned.
CASES
Case 4

87. Case 4
CASES

88. 9 month follow up
The final results were graded as
poor results.
CASES
Case 4

90. 1. The fixation of humeral shaft fractures by Interlocking
intramedullary nail with distal spreading end) is a less invasive
and safe procedure that offers reasonable fixation, short
operative time, short hospitalization, minimal radiation exposure
and least complications.
2. Results were affected significantly by the age of the pts, shape of
fracture, nail insertion method and time lapsed before surgery.
3. The retrograde nailing method gives better final outcome in
contrast to the antegrade one.
CONCLUSIONS

91. 4.The antegrade approach produces shoulder stiffness in most
patients more than the retrograde technique.
5.The final outcome of fixation of humeral shaft fractures using
this nail is comparable to other systems of intramedullary fixation.
6.Correct nailing direction, precise surgical techniques, less bulky
hardware, and stable transfixing screws are the keys for a
successful treatment.
CONCLUSIONS

92. 1.
But some people like u can never
Be left unrememBered
some words can Be
left unsaid
some feelings can Be
left unexpressed