From: DR.BASAVARAJ V. B. PATIL. Date: 15.11.2010.
P.G. IN ORTHOPAEDICS.
DEPARTMENT OF ORTHOPAEDICS
VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY.
To THE PRINCIPAL,
VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES,
BELLARY.
THROUGH PROPER CHANNEL
Respected Sir,
Subject: Acceptance of registration and forwarding of my dissertation topic.
With reference to the above subject, I, the undersigned studying post graduate course in M.S. Orthopaedics has been allotted the dissertation topic “A STUDY OF SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES OF HUMERUS IN ADULTS WITH INTRAMEDULLARY INTERLOCKING NAIL BY CLOSED TECHNIQUE - AT VIMS ,BELLARY .”, under the guidance of DR.E.VENKATESHALU ,Professor, Department of Orthopaedics, VIMS, Bellary.
I request you to kindly forward the dissertation topic in the prescribed form to the University for approval.
Thanking you,
Yours sincerely,
Signature of the guide: (DR.BASAVARAJ V. B. PATIL)
P.G.IN ORTHOPAEDICS.
Department of Orthopaedics
(DR.E. VENKATESHULU) VIMS, Bellary
The Professor
Department of Orthopaedics,
VIMS, Bellary
From: Date: 15.11.2010.
THE PROFESSOR AND HEAD OF THE DEPARTMENT,
DEPARTMENT OF ORTHOPAEDICS,
VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY.
To,
THE REGISTRAR,
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.
THROUGH PROPER CHANNEL
Respected Sir,
As per the regulations of the University for registration of Dissertation topic, the following Post Graduate Student in MS Orthopaedics has been allotted the dissertation topic as follows by the Official Registration Committee of all qualified and eligible guides of the Department of
Orthopaedics.
NAME / TOPIC / GUIDEDR.BASAVARAJ V.B.PATIL
Post Graduate Student in
M.S. Orthopaedics,
VIMS, Bellary. / A STUDY OF SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES OF HUMERUS IN ADULTS WITH INTRAMEDULLARY INTERLOCKING NAIL BY CLOSED TECHNIQUE- AT, VIMS, BELLARY. / DR. E. VENKATESHULU
The Professor
Department of Orthopaedics,
VIMS, Bellary.
Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the postgraduate student at an early date.
Thanking you,
Signature of the guide: Yours faithfully,
DR.E. VENKATESHULU DR.D.PRABHANJAN KUMAR
Professor of Orthopaedics, Professor and HOD,
Department of Orthopaedics, Department of Orthopaedics,
VIMS, Bellary. VIMS, Bellary.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
ANNEXURE – II
SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the candidate and Address( In Block letters ) /
DR.BASAVARAJ V.B.PATIL
POST GRADUATE STUDENT IN M.S. ORTHOPAEDICS,VIMS, BELLARY – 583104.
2 / Name of the Institution / VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY
3 / Course of study and subject / M.S. IN ORTHOPAEDICS
4 / Date of admission to the course / 28-04-2010
5 / Title of Topic:
“A STUDY OF SURGICAL MANAGEMENT OF DIAPHYSEAL FRACTURES OF HUMERUS IN ADULTS WITH INTRAMEDULLARY INTERLOCKING NAIL BY CLOSED TECHNIQUE – AT VIMS, BELLARY.”
6. Introduction :
A fracture of the humeral shaft is a common event.This fracture has been treated by closed reduction & cast application with/without cast bracing and open reduction & internal fixation using dynamic compression plate. Many authors have documented the general good outcome that occurs after compression plate fixation, which is still considered the gold standard for operative treatment of acute humeral shaft fractures. Though plate fixation has given high rates of union, it involves extensive soft tissue stripping, potential injury to radial nerve and poor fixation in osteoporotic bone.
Later flexible nails of many varieties were used. The advantages of intramedullary nailing are minimal surgical exposure, better biological fixation, minimal disturbances of soft tissues and early mobilization of neighboring joints2,3.The technique of interlocking nailing represents the newer approach of the treatment of humeral fractures. Interlocking nailing also avoids complications like lack of rotational control, migration of nail and requirement of supplementary bracing1,2,3.
7. Review of Literature :
Diaphyseal fractures of the humerus accounts for 3-5% of all fractures.1, 2, 3 Various treatment modalities are evolving over the period of time. Historically, methods of conservative treatment have included skeletal traction, abduction casting and splinting, Velpeau dressing, and hanging arm cast, each with its own advantages and disadvantages. Sarmiento et al. and Pehlivan reported high union rates with functional bracing of distal-third humeral shaft fractures.5
We currently use a coaptation splint or hanging arm cast for the first 7 to 10 days to allow pain to subside and then convert to a prefabricated functional brace. This has become the “gold standard” for nonoperative treatment.5
The choice of operative treatment for a humeral shaft fracture depends on multiple factors. McKee divided the indications for operative treatment into three categories: (1) fracture indications, (2) associated injuries, and (3) patient indications. The goal of operative treatment of humeral shaft fractures is to reestablish length, alignment, and rotation with stable fixation that allows early motion and ideally early weight bearing on the fractured extremity.5
Plate osteosynthesis by broad dynamic compression plating was promoted by AO/ASIF for fracture stabilization. They noted complication rates of 7% hardware failure, 6%infection, and 5% chances of iatrogenic nerve palsy.5
Flexible nails in multiple numbers can be inserted into humerus from both antegrade and retrograde entry portal. The nails in use are Enders nail, Hackethal nail, 6 Rush nail. Though they are found to have good prognostic outcome, higher complication rates of non union, nail cut through into articular surface are always to be kept in mind.10
Intra medullary inter locking nailing was the obvious sequel for this and the first nail introduced was the seidel’s nail7. Here the distal locking was achieved by expandable fins, which are opened within the barrel. This fell into disrepute due to the complications associated with flange failure.
Newer developments include the Marchetti Vincenzi nail, 9 Russel taylor nail, Synthes design which have lesser complication rates of implant failure, iatrogenic radial nerve palsy and infection than plate osteosynthesis. Recently interlocking nailing has been promoted in the retrograde insertion to prevent shoulder impingement syndrome and is technically more demanding. Inter locking nailing has been found useful in treatment of non union and pathological fractures of the humerus.
8. Objectives of study :
To document the clinical outcome and complications associated with the use of intramedullary interlocking nail in acute diaphyseal fractures of humerus in adults in a consecutive series of patients at VIMS, Bellary during the period of September 2010-August2012.
9. Materials and Methods:
9.1 Source of data :
The Patients admitted to the Department of Orthopaedics at Vijayanagar Institute of Medical Sciences, Bellary with Diaphyseal fractures of Humerus in adults during the period from SEPTEMBER 2010 to AUGUST 2012 are selected. All the patients who will be operated during this period are included in the study. Those patients who are above the age of 18 years and managed surgically are included in the study.
9.2 Method of Collection of Data: ( Including the sampling procedure if any )
The study will be conducted at the Department of Orthopaedics, VIMS, and Bellary during the period from SEPTEMBER 2010 to AUGUST 2012. The complete data is collected from the patients in a specially designed Case Record Form (CRF) by taking history of illness and by doing detailed clinical examination and relevant investigations.
Finally after the diagnosis the patients are selected for the study depending on the inclusion and exclusion criteria. Post operatively all the cases are followed for the minimum period of 6 months.
A) Inclusion Criteria:
· Acute shaft of humerus fractures
· 2cm below surgical neck to 3 cm above olecranon fossa
· Age above 18 years
· Osteoporotic bone
· Segmental diaphyseal fractures
· Pathological fractures
B) Exclusion Criteria:
· Presence of open physis
· Compound fractures of more than Grade-I severity
· Fracture involving proximal 2cms and distal 3cms of the diaphysis
· Age less than 18 years.
· Medically unfit for surgery
· Fractures with neurovascular deficit
9.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
Yes, In our study the following investigations are conducted in each patients. All the patients included in the study are investigated thoroughly with
1. Routine blood investigations ( Complete Blood Count, Random Blood Sugar,
blood urea , Serum Creatinine )
2. Urine routine ( Albumin, Sugar, Microscopy )
3. Radiological examination pre operatively are done.
X-rays of arm with shoulder and elbow joint.
-AP view
-Lateral view
Radiological examination will be repeated post-operatively and at the end of 6 weeks, 12 weeks and 6 months intervals.
Patients will be followed up at 6 weeks, 12 weeks and at 6 months.
9.4 Has ethical clearance been obtained from your Institution in case of 9.3?
YES, Ethical clearance has been obtained from VIMS INSTITUTIONAL ETHICS COMMITTEE, Bellary.
10. References.
1. Schemitsch EH, Bhandari M, Browner BD, Jupiter JB, Levine AM, Trafton PG Fractures of the diaphyseal humerus. Skeletal trauma, 3rd ed. Toronto: WB Saunders; 2001:1481-1511.
2. Praemer A, Furner S, Rice DP. Musculoskeletal conditions in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999.
3. Brinker MR, O'Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a capitated population. J Bone Joint Surg Am 2004; 86:290-297.
4. Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998; 80:249-253.
5. ST Canale, JH Beaty: Campbell's Operative Orthopaedics, 11th ed, 3389-3397.
6. Hackethal KH. Die Budel-Nagelung. Berlin: Springer, 1961:134-45.
7. Seidel H. Humeral locking nail: a preliminary report. Orthopedics 1989; 2:219-26.
8. McKee MD, Miranda MA, Reimer BL, et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996; 10:492-499.
9. Simon P, Jobard D, Bistour L, et al. Complications of Marchetti locked nailing for humeral shaft fractures. Int Orthop 1999; 23:320-324.
10. Farragos AF, Schemitsch ED, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999; 13:258-267.
11 / Signature of the candidate :
12 / Remarks of the guide :
13 / Name and Designation of :
( In Block Letters)
13.1 Guide: / DR. E. VENKATESHULU. The Professor
Department of Orthopaedics,
VIMS, Bellary.
13.2 Signature
13.3 Co – Guide, if any
13.4 Signature
13.5 Head of the Department / DR.D.PRABHANJAN KUMAR
Professor and Head of the Department,
Department of Orthopaedics,
VIMS, Bellary.
13.6 Signature
14 / 14.1 Remarks of Chairman and Principal
14.2 Signature