Humerus yüzey anatomisi ve perkütan plak uygulaması: Kadavra çalışması

Öz

Amaç: Humerus kırıklarının minimal invaziv plak osteosentezi sırasında mekanik engel oluşturabilecek kasların yerleşim yerlerinin belirlenmesi amaçlandı.

Çalışma planı: Çalışma, 6 erkek kadavranın 12 üst ekstremitesi üzerinde yapıldı. Kadavraların ortalama yaşı 61.8 (45-72)’di. Tüm piyeslerde büyük tuberkül ile lateral epikondil arasındaki mesafe olarak tanımlanan humerus uzunluğu ölçüldü. 4.5 mm’lik bir plak subbrakiyel olarak açılan bir tünelden yerleştirilirken karşılaşılan mekanik engeller değerlendirildi ve anatomik engellerin lateral epikondile olan mesafeleri ölçüldü.

Bulgular: Kadavraların ortalama humerus uzunluğu 271.8 mm olarak ölçüldü. Uygulamalarda, başta deltoid kasının anterior insersiyosu ile brakialis kasının proksimal kısmı olmak üzere çeşitli anatomik engeller tanımlandı. Lateral epikondil ile deltoid insersiyosunun en proksimal ve distali arasındaki mesafe sırasıyla 188.9 mm ve 138.7 mm; lateral epikondil ile brakialis kasının origosu arasındaki mesafe ise 147.4 mm olarak ölçüldü. Lateral epikondil ile anterior deltoid insersiyosunun proksimali, lateral epikondil ile anterior deltoid insersiyosunun distali ve lateral epikondil ile brakialis kasının origosunun proksimali arasındaki mesafelerin, humerus uzunluğuna oranları ise sırasıyla %69.4, %51 ve %54.2 olarak bulundu. Ölçümler yüksek gözlemciler arası güvenilirlik göstermekteydi (p<0.001).

Çıkarımlar: Humerus anterior yüzüne minimal invaziv plak osteosentez tekniği ile plak yerleştirilebilmesi sırasında deltoid insersiyosu ve brakialis kası origosunun proksimal kısmı gibi mekanik engellerin göz önünde bulundurulması gereklidir.

Anahtar Kelimeler

• Humerus; Minimal invazif plak osteosentezi; kadavra; kırık.

Humeral surface anatomy and percutaneous plate advancement: a cadaveric study

Öz

Objective: The aim of this study was to identify the anatomical obstacles on the humeral surface which can complicate subcutaneous plate advancement during surgical treatment of humeral fractures.

Methods: We dissected twelve upper extremities of six male cadavers, and measured the humeral length, which was defined as the distance between the greater tubercle and the lateral epicondyle. We performed a retrograde advancement of a 4.5 mm plate through the subbrachial tunnel and noted the mechanical obstacles during the procedure. In addition, we recorded the distances between the anatomic obstacles and lateral epicondyle.

Results: The average humeral length was 271.8 mm. We identified anterior insertion of the deltoid muscle and the proximal part of the brachialis muscle as the main anatomic obstacles on the anterior surface of the humerus. The average distances between the lateral epicondyle and the most proximal and distal insertion of anterior deltoid were 188.9 mm and 138.7 mm, respectively. The average distance between the lateral epicondyle and the brachialis origin was 147.4 mm. Proportions of the distances between the lateral epicondyle and proximal of anterior deltoid insertion, the lateral epicondyle and distal of anterior deltoid insertion and the lateral epicondyle and proximal of brachialis origin to humeral length were 69.4%, 51%, and 54.2%, respectively. There was a high interobserver reliability (p<0.001).

Conclusion: The deltoid insertion and proximal attachment of the brachialis muscles were identified as mechanical obstacles when performing the percutaneous plating. These sites caused difficulties with the procedure during the retrograde plate advancement through submuscular tunnel on the anterior surface of humerus. It was also noted that for successful plate advancement, it was necessary to release the anterior part of the deltoid insertion.

Anahtar Kelimeler

• Humerus
• minimal invasive plate osteosynthesis
• cadaver
• fracture

Kaynakça

1. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88:1469-73.
2. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ. Functional treatment of closed humeral shaft fractures. Int Orthop 2005;29:10-3.
3. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.
4. Kobayashi M, Watanabe Y, Matsushita T. Early full range of shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures. J Orthop Trauma 2010;24:212-6.
5. Marsh JL, Mahoney CR, Steinbronn D. External fixation of open humerus fractures. Iowa Orthop J 1999;19:35-42. Lin J, Hou SM. Antegrade locked nailing for humeral shaft fractures. Clin Orthop Relat Res 1999;365:201-10.
6. Ajmal M, O’Sullivan M, McCabe J, Curtin W. Antegrade locked intramedullary nailing in humeral shaft fractures. Injury 2001;32:692-4.
7. Meekers FS, Broos PL. Operative treatment of humeral shaft fractures. The Leuven experience. Acta Orthop Belg 2002;68:462-70.
8. Aksu N, Karaca S, Kara AN, Işiklar ZU. Minimally invasive plate osteosynthesis (MIPO) in diaphyseal humerus and proximal humerus fractures. Acta Orthop Traumatol Turc 2012;46:154-60.

9. Jiang R, Luo CF, Zeng BF, Mei GH. Minimally invasive plating for complex humeral shaft fractures. Arch Orthop Trauma Surg 2007;127:531-5.
10. 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;21:628-33.
11. 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;36:530-8.
12. Apivatthakakul T, Patiyasikan S, Luevitoonvechkit S. Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: a cadaveric study. Injury 2010;41:169-72.
13. Livani B, Belangero WD, Castro de Medeiros R. Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis. J Bone Joint Surg Br 2006;88:1625-8.
14. López-Arévalo R, de Llano-Temboury AQ, SerranoMontilla J, de Llano-Giménez EQ, Fernández-Medina JM. Treatment of diaphyseal humeral fractures with the minimally invasive percutaneous plate (MIPPO) technique: a cadaveric study and clinical results. J Orthop Trauma 2011;25:294-9.
15. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093-110.
16. Ricci AR, Yue JJ, Taffet R, Catalano JB, DeFalco RA, Wilkens KJ. Less Invasive Stabilization System for treatment of distal femur fractures. Am J Orthop (Belle Mead NJ) 2004;33:250-5.
17. Naik MA, Arora G, Tripathy SK, Sujir P, Rao SK. Clinical and radiological outcome of percutaneous plating in extra-articular proximal tibia fractures: a prospective study. Injury 2013;44:1081-6.
18. Livani B, Belangero WD. Bridging plate osteosynthesis of humeral shaft fractures. Injury 2004;35:587-95.
19. Wagner M. General principles for the clinical use of the LCP. Injury 2003;34 Suppl 2:B31-42.
20. Ji F, Tong D, Tang H, Cai X, Zhang Q, Li J, et al. Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach. Int Orthop 2009;33:543-7.
21. Klepps S, Auerbach J, Calhon O, Lin J, Cleeman E, Flatow E. A cadaveric study on the anatomy of the deltoid insertion and its relationship to the deltopectoral approach to the proximal humerus. J Shoulder Elbow Surg 2004;13:322-7.
22. Leonello DT, Galley IJ, Bain GI, Carter CD. Brachialis muscle anatomy. A study in cadavers. J Bone Joint Surg Am 2007;89:1293-7.