|Year : 2015 | Volume
| Issue : 1 | Page : 154-161
Minimally invasive plate osteosynthesis versus open reduction and plate fixation of humeral shaft fractures
Mahmoud Mohamed Hadhoud MBBCh , Amr Eid Darwish, Mustafa Mohamed Kamel Mesriga
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||13-May-2014|
|Date of Acceptance||24-Aug-2014|
|Date of Web Publication||29-Apr-2015|
Mahmoud Mohamed Hadhoud
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Sabery Abo-Allam Street, Shebin Al-Kom, Menoufia
Source of Support: None, Conflict of Interest: None
This study compared clinical outcomes and complications in patients with humeral shaft fractures treated using two methods of fixation by means of plating.
Plate osteosynthesis has been the treatment of choice for humeral shaft fractures when operative treatment is required. However, plate osteosynthesis of comminuted humeral fractures is a challenging operation, which requires surgical experience and meticulous attention to soft tissue. Minimally invasive plate osteosynthesis (MIPO) is an emerging procedure for the treatment of humeral shaft fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing.
Patients and methods
Thirty patients were analyzed and divided into two groups. Group 1 (n = 15) patients were treated with MIPO and group 2 (n = 15) with open reduction and internal fixation (ORIF). The major characteristics of the two groups in terms of age, sex, mode of injury, fracture location, and associated injuries were similar.
Primary union was achieved in all patients in the MIPO group and in 14 of 15 in the ORIF group. The mean time to union was similar in the two groups. The mean operation time in the MIPO group (80 min) was shorter than that in the ORIF group (125 min) (P < 0.0001). Bone grafting was performed in one patient in the ORIF group, but in no patients in the MIPO group. There was one case of deep infection in the ORIF group. There was one case of postoperative radial nerve palsy in the MIPO group and two cases in the ORIF group. Functional outcome was satisfactory in both groups.
The MIPO technique achieves comparable results with the ORIF method in simple and complex fractures of humeral shafts. Although MIPO potentially has a radiation hazard, it reduces perioperative complications with shortened operation time and minimal soft tissue dissection.
Keywords: Humerus shaft fracture, minimally invasive plate osteosynthesis, open reduction
|How to cite this article:|
Hadhoud MM, Darwish AE, Mesriga MM. Minimally invasive plate osteosynthesis versus open reduction and plate fixation of humeral shaft fractures. Menoufia Med J 2015;28:154-61
|How to cite this URL:|
Hadhoud MM, Darwish AE, Mesriga MM. Minimally invasive plate osteosynthesis versus open reduction and plate fixation of humeral shaft fractures. Menoufia Med J [serial online] 2015 [cited 2020 Apr 4];28:154-61. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/154/155974
| Introduction|| |
Various methods are used to treat humeral shaft fractures. Most of the fractures can be effectively treated conservatively ,. Operative intervention is indicated in special circumstances including failure of closed reduction, intra-articular extension, neurovascular compromises, floating elbow, pathological fractures, open fractures, bilateral humeral shaft fractures, and polytraumatized patients . These fractures can be surgically treated by means of plating osteosynthesis ,, intramedullary nails, or external fixation (5-8). Open reduction and internal fixation (ORIF) continues to be considered the gold standard for surgical treatment. The advantages include anatomical reduction of fractures and less interference to elbow and shoulder function ,. The major disadvantages of this technique are extensive soft tissue stripping and disruption of periosteal blood supply, which increase the risk of nonunion and iatrogenic radial nerve palsies ,,. It has been reported that humeral shaft fractures can be successfully treated with minimally invasive plate osteosynthesis (MIPO) ,,,,. This technique has advantages of less soft tissue dissection and avoids the need to expose the radial nerve; thus, there is also low risk of iatrogenic radial nerve palsies and deep infection . The purpose of this study was to compare the clinical results and functional outcomes of two groups of patients: those treated with MIPO and the other treated with ORIF.
| Patients and methods|| |
Thirty patients with humeral shaft fractures were included in this study. They were randomly divided into two groups:
- Group 1 : This group comprised 15 patients with humeral shaft fractures treated surgically with MIPO.
- Group 2 : This group comprised 15 patients with humeral shaft fractures treated surgically with ORIF.
The patients were admitted to the Orthopedic Department, Menoufia University Hospital, during the period from March 2012 to April 2014, with a follow-up period of 6-10 months.
Written informed consent was taken from all patients.
Criteria of inclusion
Patients aged greater than 20 years old with closed and first degree open fracture were included in this study.
Criteria of exclusion
Patients with second-degree or third-degree open fractures, those with high-velocity gunshot injuries, or with pathological fractures were excluded.
(a) Group 1: There were nine male and six female patients with an average age of 39 years (range 20-67 years).
The fracture was on the right side in nine cases and on the left side in six cases.
The mechanism of injury was road traffic accident (RTA) in eight cases and fall from height in seven cases.
Fractures were classified according to the AO classification of humerus shaft fractures: four cases were A1, two cases were A2, three cases were A3, one case was B1, two cases were B2, two cases were C1, and one case was C2.
(b) Group 2: There were 11 male and four female patients with an average age of 35 years (range 20-65 years).
The fracture was on the right side in seven cases and on the left side in eight cases.
The mechanism of injury was RTA in eight cases and fall from height in seven cases.
Fractures were classified according to the AO classification of humerus shaft fractures: four cases were A1, one case was A2, five cases were A3, two cases were B1, two cases were B2, and one case was C3.
Technique of minimally invasive plate osteosynthesis
Position of the patient
The patients were placed supine on the operating table and the arm to be operated on was carefully supported on the table with the arm abducted to 90° and the forearm in full supination.
First, the interval between the lateral border of the proximal part of the biceps and the medial border of the deltoid muscle was palpated; a 3 cm proximal incision was made ~6 cm distal to the anterior part of the acromion process.
Distally, a 3 cm incision was made along the lateral border of the biceps muscle ~5 cm proximal to the flexion crease of the elbow.
The biceps was retracted medially to expose the musculocutaneous nerve lying on the brachialis. The brachialis was then split longitudinally. The musculocutaneous nerve was retracted together with the medial half of the split brachialis, while the lateral half served as a cushion to protect the radial nerve.
Application of the plate
A sub-brachialis extraperiosteal tunnel was then created. A narrow or broad locked compression plate was passed deep to the brachialis from the distal to the proximal incision. The plate position and reduction was visualized on the image intensifier. Manual traction was applied to restore length and correct varus or valgus angulation and rotation. The plate was temporarily fixed to the bone with 2-mm K-wires. Ensuring that the position of the plate on the distal fragment was central, it was fixed with a locking screw and, similarly, the proximal fragment was also fixed. After confirmation of the reduction alignment on the image intensifier other screws were inserted to complete the fixation.
Exploration of the radial nerve in the minimally invasive plate osteosynthesis technique in cases associated with preoperative radial nerve palsy
The radial nerve was exposed between the brachialis and brachioradialis muscles through an oblique incision ~5-8 cm long at the junction of the middle and distal thirds of the arm. After identifying the nerve it was freed from its distal part proximal to its emergence from the lateral intermuscular septum, which was released.
Technique of open reduction and internal fixation
Position of the patients
The patient was placed in the supine position for the anterolateral approach. The arm to be operated on was carefully supported on the table. The lateral position was adopted for the posterior approach.
Application of the plate
Plate location: For proximal fractures an anterolateral plate location and anterolateral surgical approach were adopted. For midshaft and distal fractures a posterior plate location was chosen through the posterior approach.
Plate fixation: No periosteal stripping was performed for both plate fixation and screw placement, but there was adequate soft tissue exposure to provide sufficient area for the plate. The plate was positioned over the fracture so that three to four screws were used in each of the proximal and distal segments. Drilling for placement of the first screw was carried out, followed by attachment of the plate with one screw to the predrilled fragment. The second screw was inserted eccentrically and then the screws were tightened to compress the fracture. The lag screw was then inserted if needed. Before tightening the lag screw fully the axial compression was released slightly to allow additional interfragmentary compression. The loosened screw was retightened after tightening of the lag screw. The remaining screws were then inserted. Screws closest to the fracture site were inserted first. Alignment of the humerus and reduction of the fragments were confirmed with fluoroscopy.
In both methods, the patient's arm was supported in a sling for 3-5 days postoperatively. Shoulder and elbow ranges of motion were initiated as soon as possible. The patients were instructed to move the shoulder and elbow and to use the operated limb to perform daily activities (eating and personal hygiene). Stitches were removed after 2 weeks, Follow-up visits by clinical examination and anteroposterior and lateral radiography were performed monthly for 3 months and then every 3 months until bony union was achieved.
The operative time, intraoperative radiation exposure, intraoperative blood loss, union time, postoperative complications, and shoulder and elbow functions were recorded. Shoulder function was assessed by the UCLA scoring system , and elbow function was assessed by the Mayo elbow performance index . Operative time was defined as the time from skin incision to closure. Union was defined as the absence of pain and the presence of bridging callus in three of the four cortices on anteroposterior and lateral radiographic views of the humerus. Nonunion was defined as the absence of fracture union at 6 months postoperatively. Postoperative complications were categorized as infection, nonunion, and radial nerve injury.
Statistical analysis was performed using SPSS software, version 20. The demographic characteristics and AO fracture classification of the two treatment groups were compared using the Mann-Whitney U-test, and operative characteristics of two groups were compared using the Student t-test, the Mann-Whitney U-test, and the c2 -test. For functional outcome the Student t-test was used, and for assessment of complications the Mann-Whitney U-test was used.
| Results|| |
Thirty patients with humeral shaft fractures were included in this study. They were divided into two groups:
- Group 1: This group comprised 15 patients with humeral shaft fractures treated surgically with MIPO.
- Group 2 : This group comprised 15 patients with humeral shaft fractures treated surgically with ORIF.
[Table 1] illustrates the sociodemographic pattern of patients with humeral shaft fractures who had been admitted to Menoufia University Hospital during the period of the study and treated with either MIPO or ORIF techniques. There was no significant difference between the mean ages of the two groups (P > 0.05). Ages of MIPO patients ranged between 22 and 67 years, with a mean value of 39.7 ± 12.7 years, and in the ORIF group the ages ranged between 20 and 65 years, with a mean value of 36.1 ± 12.8 years. The same result was found for sex-related differences (P > 0.05) [Figure 1].
|Figure 1: Patients' characteristics as regards age, sex, mechanism of injury, and side of injury.|
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|Table 1: Characteristics of the studied cases as regards age, sex, mechanism of injury, and side of injury|
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A nonsignificant relation was also found between the two groups with respect to mechanism of injury (either road traffic accident or fall from height) and side of injury (right or left) (P > 0.05).
[Table 2] and [Figure 2] demonstrate the AO grading of both MIPO and ORIF cases, revealing a nonsignificant difference between the two groups (P > 0.05).
|Figure 2: AO grading of humeral shaft fractures treated with either minimally invasive plate osteosynthesis (MIPO) or open reduction and internal fixation (ORIF) techniques.|
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[Table 3] illustrates the difference in operative characteristics between the two groups. As regards operative time (in min), there was a highly significant relation (P < 0.001). Operative time in the MIPO group ranged between 65 and 90 min, with a mean value of 80.7 ± 7.8 min, whereas in the ORIF group it ranged between 110 and 140 min, with a mean value of 125.3 ± 8.3 min.
With regard to intraoperative radiation exposure, the difference between the two groups was highly significant (P < 0.001). All patients in the MIPO group were exposed to radiation, whereas only 33.3% in the ORIF group were exposed [Figure 3].
|Figure 3: Intraoperative radiation exposure in both groups; all patients in the minimally invasive plate osteosynthesis (MIPO) group were exposed to radiation, in contrast to patients in the open reduction and internal fixation (ORIF) group (33.0 3%).|
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A highly significant relation was found between the two groups as regards intraoperative radiation time (P < 0.001). The mean intraoperative radiation time in the MIPO group ranged between 60 and 90 s, with a mean of 72 ± 7.7 s, whereas it ranged between 10 and 15 s, with a mean of 12 ± 6.03 s, in the ORIF group.
In contrast, a highly significant difference (P < 0.001) was found between the two groups with regard to intraoperative bleeding; in the MIPO group the amount of blood loss ranged between 70 and 120 ml, with a mean of 92.7 ± 15.3 ml, whereas the amount of bleeding in the ORIF group ranged between 300 and 450 ml, with a mean of 366.8 ± 52.3 ml.
[Table 4] reveals a nonsignificant relation between the two groups with respect to classification of patients as per the MEPI scoring system (P > 0.05). In the MIPO group eight patients showed excellent results, six showed good results, one showed fair, and no patient showed a poor result. In contrast, in the ORIF group there were seven excellent cases, six good cases, one fair case, and one poor case [Figure 4].
According to the UCLA scoring system, a similar result was found. In the MIPO group five cases showed excellent results, nine cases showed good results, one patient had a fair result, and no patient had a poor result. In the ORIF group, there were five excellent cases, eight good cases, one fair case, and one poor case [Figure 5].
[Table 5] illustrates a nonsignificant relation (P > 0.05) between the two groups as regards postoperative complications such as infection, radial nerve injury, nonunion, delayed union, and bone graft.
On examination of the cases in the follow-up period, a nonsignificant relation was found as regards union time (in weeks) between the two groups (P > 0.05).
| Discussion|| |
Plate osteosynthesis has been the treatment of choice for humeral shaft fractures when operative treatment is required ,,,. However, complications such as healing problems, infections, and iatrogenic radial nerve palsy have been reported ,,. Therefore, plate osteosynthesis of comminuted humeral fractures is a challenging operation, which requires surgical experience and meticulous attention to the periosteum, muscles, and nerves. MIPO is an emerging procedure for the treatment of humeral shaft fractures ,. One of the main advantages of MIPO is that it preserves soft tissue and the periosteal circulation, which promotes fracture healing .
In this series, the mean operative time was 80.7 min (range 70-90 min) in the MIPO group and 125.3 min (range 110-140 min) in the ORIF group, which was highly significant [Figure 6] and [Figure 7].
|Figure 6: A 45-year-old woman with a humerus shaft fracture managed with the minimally invasive plate osteosynthesis (MIPO) technique with follow-up radiograph showing full union at 6 months.|
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|Figure 7: A 40-year-old woman with a humerus shaft fracture managed with open reduction and internal fi xation (ORIF) with follow-up radiograph showing full union at 6 months.|
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In all patients in the MIPO group we used intraoperative fluoroscopic control to assess reduction and achieve satisfactory alignment. The mean time of intraoperative radiation exposure was 72 s (range 60-90 s). The C-arm was not routinely used in the ORIF group and the mean exposure time was 12 s (range 10-15 s).
The mean intraoperative blood loss was 92 ml (range 70-120 ml) and 366 ml (range 300-450 ml) in the MIPO group and ORIF group, respectively, which is statistically highly significant.
Oh et al.  while comparing the MIPO technique with ORIF reported a mean operative time of 110 min in the MIPO group and 169 min in the ORIF group. In the MIPO group, the mean intraoperative radiation exposure time was 201 s (range 88-415 s). In the ORIF group, fluoroscopy was not used.
In the MIPO group of this study, all cases achieved primary bony union. There was only one case of delayed union, which united after 40 weeks, and it concurs with reports on MIPO. In the ORIF group, nonunion occurred in one case only, which was managed by bone grafting after 6 months when there was no evidence of progress of bone union. The average union time was 15.3 and 16.5 weeks in the MIPO group and ORIF group, respectively. The union time in group B was longer than that in group A, but the difference was not statistically significant.
An et al.  documented the results of ORIF and MIPO in the treatment of mid-distal humeral shaft fractures. The mean fracture union time was 15.29 weeks in the MIPO group and 21.25 weeks in the ORIF group.
Malalignment is a common complication of MIPO when applied to long bone fractures ,. However, in this study malalignment was not observed in the MIPO group, which concurs with previous reports.
The functional outcomes of shoulders and elbows in this study were satisfactory in both study groups. The mean function of the elbow as assessed by the MEPI score system was 90.3 and 87.7 in the MIPO group and ORIF group, respectively. The mean UCLA score for shoulder function was 32.2 and 30.9 for the MIPO group and ORIF group, respectively.
In the study by An et al.  40 cases of closed mid-distal humeral shaft fractures were surgically treated with MIPO ( n = 19) and ORIF ( n = 21). The mean UCLA shoulder score was 34.78 in the MIPO group and 34.42 in the ORIF group. The MEPI in these two groups was 99.44 and 99.74, respectively.
In this study there was no infection in the MIPO group and there were two infected cases in the ORIF group, most commonly due to extensive soft tissue dissection, which coincides with previous reports. One case was managed by culture-specific antibiotic. The plate was removed later when the wound had become clean with normal levels of erythrocyte sedimentation rate and C-reactive and no discharge. The sinus fracture was fixed by means of a locked plate. The other case was managed by antibiotics prescribed on the basis of culture results and sensitivity until union was achieved, and then the plate was removed.
Concha et al.  studied a series of 35 patients who underwent MIPO for humerus shaft fractures and reported the occurrence of only one deep and one superficial infection, which represents a 6% infection rate. The one superficial infection that occurred resolved with antibiotic treatment. The patient who developed a deep infection responded to serial debridement and irrigation with culture-specific antibiotics. Removal of hardware was not deemed necessary as no signs of loosening were present and progressive bone healing was visible on radiographs. Adequate healing with complete remission of infection was achieved.
In this study, there was only one case of postoperative radial nerve palsy in the MIPO group from retraction to achieve distal exposure. We saw two cases of iatrogenic radial nerve palsy in the ORIF group. All cases of postoperative radial nerve palsy improved without interference on follow-up of the patients. Therefore, we believe that humeral MIPO is a safe method in terms of radial nerve safety, whereas ORIF with longer operative duration has higher possibility of complications. It is attributable to the larger wound exposure with higher risk for radial nerve traction injury.
Pospula and Abu Noor  reported only one case of iatrogenic radial nerve palsy when the MIPO technique was used to treat 12 cases of humeral shaft fractures, whereas Ji et al.  reported one in 23 humeral shaft fractures. Livani et al.  reported good results in 35 cases of mid-distal humeral shaft fractures without iatrogenic radial nerve lesions.
An et al.  reported that there was no case of iatrogenic radial nerve palsy in the MIPO group after surgery; however, five cases of transient iatrogenic radial nerve palsy were identified in the ORIF group after surgery, and the function of the radial nerve recovered in these cases at the last follow-up.
| Conclusion|| |
From the above results it can be concluded that the MIPO technique can be used to treat humerus shaft fractures with many advantages such as short operative time, minimal intraoperative bleeding, and decreased incidence of postoperative infection, rate of nonunion, delayed union, and postoperative radial nerve palsy.
The radial nerve is not at risk as long as the forearm is kept in supination during the procedure, and no screws are inserted into that part of the humeral shaft where the radial nerve runs along the spiral groove.
Performing the procedure slowly and carefully, attending to every detail, and being aware of the possible complications should enable the surgeon to fix the fracture and achieve a satisfactory result.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ekholm R, Tidermark J, Törnkvist H, Adami J, Ponzer S. Outcome after closed functional treatment of humeral shaft fractures. J Orthop Trauma 2006; 20
Toivanen JA, Nieminen J, Laine HJ. Functional treatment of closed humeral shaft fractures. Int Orthop 2005; 29
Schemitsch EH, Bhandari M. Fractures of the humeral shaft. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma: basic science, management, and reconstruction. 3rd ed. Philadelphia: WB Saunders Company; 2003. 1487-1488.
Niall DM, O′Mahony J, McElwain JP. Plating of humeral shaft fractures - has the pendulum swung back?. Injury 2004; 35
Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop 2007; 31
Fernandez FF, Matschke S, Hulsenbeck A, Egenolf M, Wentzensen A. Five years′ clinical experience with the unreamed humeral nail in the treatment of humeral shaft fractures. Injury 2004; 35
Petsatodes G, Karataglis D, Papadopoulos P, Christoforides J, Gigis J, Pournaras J. Antegrade interlocking nailing of humeral shaft fractures. J Orthop Sci 2004; 9
Pogliacomi F, Devecchi A, Costantino C, Vaienti E. Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures. Chir Organi Mov 2008; 92
Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures - a meta-analysis. Acta Orthop 2006; 77
Lim KE, Yap CK, Ong SC, Aminuddin M. Plate osteosynthesis of the humerus shaft fracture and its association with radial nerve injury - a retrospective study in Melaka General Hospital. Med J Malaysia 2001; 56
Paris H, Tropiano P, ClouetD′orval B Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2000; 86
Jawa A, McCarty P, Doornberg J Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am 2006; 88
Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report. Injury 2005; 36
Zhiquan A, Bingfang Z, Yeming W Chi Z, Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007; 21
Ziran BH, Belangero W, Livani B, Pesantez R. Percutaneous plating of the humerus with locked plating: technique and case report. J Trauma Inj Infect Crit Care 2007; 63
Livani B, Belangero W, Andrade K, Zuiani G, Pratali R. Is MIPO in humeral shaft fractures really safe? Postoperative ultrasonographic evaluation. Int Orthop 2009; 33
Ji F, Tong D, Tang H, Wang Q. Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach. Int Orthop 2009; 33
Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. J Bone Joint Surg Am 1986; 68
Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992; 74
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomized trial. J Bone Joint Surg Br 2000; 82
Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY. The results of plating humeral shaft fractures in patients with multiple injuries. The Sunnybrook experience. J Bone Joint Surg Br 1985; 67
Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma 1993; 35
Dabezies EJ, Banta II CJ, Murphy CP, d′Ambrosia RD. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma 1992; 6
Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br, 2005; 87
25. Livani B, Belangero WD. Bridging plate osteosynthesis of humeral shaft fractures. Injury 2004; 35
Oh CW, Byun YS, Oh JK, Kim JJ, Jeon IH, Lee JH, Park KH. Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating. Orthop Traumatol Surg Res 2012; 98
An Z, Zeng B, He X, Chen Q, Hu S. Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique. Int Orthop 2010; 34
Jiang R, Luo CF, Zeng BF, Mei GH Minimally invasive plating for complex humeral shaft fractures. Arch Orthop Trauma Surg 2007; 127
Concha JM, Sandoval A, StreubelP N. Minimally invasive plate osteosynthesis for humeral shaft fractures: are results reproducible? Int Orthop 2010; 34
Pospula W, Abu Noor T. Percutaneous fixation of comminuted fractures of the humerus: initial experience at Al Razi hospital, Kuwait. Med Princ Pract 2006; 1:423-426.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]