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Abstract Humeral shaft fractures are very infrequent in children constituting only 2–5% of all pediatric fractures. They are predominantly seen in children aged less than 3 years or more than 12 years. Fractures of humeral shaft are the result of direct force during a direct impact, traffic accidents or crush injuries. Indirect forces such as fall on elbow or extended arm or strong muscular contractions. The most frequent site of the fracture is between the middle and the distal third of the humerus. The humeral shaft extends from the pectoralis major insertion to the supracondylar ridge. In this interval, the cross-sectional shape changes from cylindrical to narrow in the anteroposterior direction. The vascular supply to the humeral diaphysis arises from perforating branches of the brachial artery with the main nutrient artery entering the medial humerus distal to the midshaft. The simplest classification of humeral shaft fractures is based on the location of the fracture site in the humeral diaphysis (proximal, middle and distal), alignment of fragments and appearance of the fracture line. Radial nerve injury is the most commonly associated injury due to the close proximity of this nerve, particularly in middle-third fractures. Diaphyseal fractures of the humerus in children can most often be treated nonoperatively by functional bracing. Functional bracing is frequently indicated for stable fractures with adequate alignment. The disadvantages include patient noncompliance and limited fracture stabilization. The inability to maintain an acceptable reduction, open fractures, particularly with significant soft tissue injury, concomitant ipsilateral forearm fractures (floating elbow), closed head injury , and polytrauma with lower extremity fractures necessitating early upper extremity weight bearing have been the relative indications for operative treatment. A variety of surgical treatment methods exist, including external fixation and internal fixation. External fixation achieves fracture stability with minimal hardware placement within the patient. The advantages of external fixation in pediatric fracture management include minimal hardware placement in contaminated wounds, direct access to open wounds for their care or soft tissue coverage and early joint range of motion. The disadvantages of external fixation include pintract infection, the need for pin care by the patient’s family, potential muscle scarring around pin sites, potential fracture risk through previous pin sites, and temporary cosmetic concerns by the patient. Numerous internal fixation techniques exist, including plating, rigid intramedullary nailing, and flexible intramedullary nailing. Rigid plate osteosynthesis, the most widely accepted operative method, carries several documented disadvantages, including extensive soft tissue trauma, significant blood loss, increased operative time and the risk of intraoperative radial nerve injury, more so during elective plate removal. Several series of intramedullary stabilization of humeral fractures (Rush rods and Ender nails) have been reported in the literature. Problems of shoulder impingement and adhesive capsulitis of the shoulder were the significant problems in these series, because most of the nails were inserted antegradely through a small incision in the rotator cuff. Since the publication of outcomes by Spanish and Nancy groups in the early 1980s, elastic stable intramedullary nailing (ESIN) has become a well-accepted method of surgical treatment of long bone fractures in children and adolescents. The reasons for this acceptance include the absence of postoperative additional casting in most cases, primary bone union with avoidance of growth plate injury, rapid recovery of joint motion and return to physical activities, minimally invasive surgery allowing small and aesthetic scars, low infection rate, and shortened hospital stays. Titanium elastic nail fixation is an ideal procedure for treating humeral shaft fractures in children in the 6-16 years age group and has many advantages over the use of plates and external fixators which have few indications for their use in this age group. The use of a single intramedullary elastic retrograde nail for fixation of closed, 1st and clean 2nd degree open diaphyseal fractures of the humerus proved to be an adequate fixation technique with a very low complication rate and a favorable final clinical outcome after a short period of follow-up. When using a single nail instead of two nails; the operative time was decreased, less radiological exposure was ensured, the cost was lowered, less incidence of irritation at the insertion site of the nail, simple both the insertion and removal procedures and nevertheless, the final outcome was not compromised. In addition, there was no need for a second entry from the medial or the lateral side and so less incidence of iatrogenic nerve injury and less incidence of iatrogenic distal humeral fracture. Furthermore, no nail twisting or winding over each other took place when using a single elastic nail. |