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Humerus Triptych: Fracturing & Fixing

22 Aug

I just can’t seem to help myself.  No sooner do I find out that I’d previously (and unknowingly) fractured a number of my ribs over a period of years, do I go and fracture my right humerus in the early evening sun of a peaceful July night.  It was, of course, shortly accompanied by the familiar wash of painkillers that helped numb the pain somewhat.  I’ve mentioned the humerus fracture a number of times in recent blog entries but I have not, until now, managed to obtain copies of the X-rays to highlight the break itself, and the subsequent surgical procedure that I underwent to fixate it.  With thanks to modern technology, I present to you below my right humerus in post-accident pre-surgery and post-accident post-surgery poses, if you will.  As White and Folkens (2005: 312) highlight fractures normally occur ‘as a result of abnormal forces of tension, compression, torsion, bending, or shear applied to the bone’, and they are often described by the features of the break itself (i.e. transverse, oblique, spiral etc).

I have long feared fracturing any of my bones in either upper arms (brachium), forearms (antebrachium) or hands (manus), even though I’ve had a somewhat turbulent history of pathologically fractured bones in my lower limbs.  Alongside this I have also undergone a fairly extensive list of elective surgery to fixate the femora and right tibia due to the effects of McCune Albright Syndrome (including improving the angle of the so-called shepherd’s crook deformity of the femoral neck).  Thus where a natural fracture or planned surgical procedure on the lower limbs may mean I cannot use my crutches for a few months, I can still use the wheelchair to maintain physical independence.  This is not so with a fractured upper limb, where healing will take many months.

To return to the common name usage, I rely on my arms not just for holding or grasping objects but for the locomotion of my manual wheelchair.  As such they are my legs for daily mobility.  I use them also to partially bear my weight when I use my crutches to walk, so a fractured upper limb bone would mean walking is out of the question as well.  I have fractured a humerus only once before, aged 13 at school.  An ill-advised arm wrestle resulted in my friend looking at my pale and quickly draining face in horror as I cradled my snapped right humerus in shock.  It is safe to say that my friend won that match, and I’ve been wary of competing in arm wrestles ever since!  The result of that match was a lengthy spell in plaster (or some variation thereof as, after few months, plaster gave way to support splint, and splint gave way to a laughable plastic guard).

right humerus fracture 2014 july

X-ray of my brachium (upper arm) with the transverse (possibly oblique) fracture of the right distal humerus in a cast before surgery (far left), the post-surgery fixation with a titanium plate and screws (centre), and finally a view of the brachium that highlights the plate and the depth of the screws (right), which help to keep the fixation and fracture site stable by equally distributing stress.  The tell-tale signs of the ‘ground glass’ appearance of polyostotic fibrous dysplasia (as a part of the McCune Albright Syndrome that I have) can also be seen in the X-rays, as can the evidence of a previous fracture and natural bowed shape of the humerus.

In truth the recent humeral fracture was the result of my impatience, gained as a result of quickly bouncing off a curb to catch a waiting taxi, and coming off worse for wear as the wheelchair tipped and I instinctively shot out my right arm to stop myself.  The pain from a fracture comes not from the bone breaking but from the damage to the soft tissues that surround the bone.  The periosteum, a tough connective tissue that nourishes and covers all outer external surfaces of the bones barring articular surfaces of the long bones, is home to nerves that the bones themselves are not (White & Folkens 2005: 42).  A fracture of the bone often damages the periosteum tissues (which causes pain) and leads to swelling of local tissues.  The periosteum, and associated endosteum membrane (located on the inner surface of bones), are also one of the origins where the precursor bone cells develop into chondroblasts and osteoblasts, which are essential for helping the bone fracture heal successfully (White & Folkens 2005: 43).

A small but significant benefit of having polyostotic Fibrous Dysplasia is the fact that the pathological fracture patterns tend to be transverse breaks due to the weak structure of the bone architecture, which tends to limit injury to both the nerves and the soft tissues surrounding the fracture area (Marsland & Kapoor 2008: 121).  However, due to the pathological bone porosity and the often high bone cell turnover rate as a part of the overall syndrome, there is the prospect of extensive bleeding during surgical procedures.  This can lead to extensive blood loss during major operations (such as during osteotomy procedures and/or internal and external fixations to help improve the bowing of a limb or to correct pathological fractures).  As such the patient’s blood is often cross matched beforehand with suitable blood groups, for infusion during major surgical procedures to combat excessive blood loss.

In the immediate aftermath of the fracture I was given heavy painkillers and taken to hospital where, after a light sleep overnight, my arm was put into a cast before I underwent surgery later in the week in a hospital nearer my hometown.  The decision was taken not to reduce the bone before the surgery and just to rest it.  On weight bearing bones (such as the tibia or femur) or load bearing bones (such as the mandible in adults), it is important that the bone is reduced quickly and properly to minimise complications and induce good healing (Marsland & Kapoor 2008: 120).  The humeral fracture was openly reduced and fixated under general anesthetic with a titanium locking plate, as can be seen in the above X-ray, and the surgeon achieved a good fix and stability of the distal humerus with the plate.

Curiously, even though the fracture was trauma induced, it was less painful than the fracture that had occurred when I was 13.  The arm still feels heavy and slightly cumbersome, but there is no doubt that the internal fixation is preferable to the months in the plaster cast.  It will still take many months for the bone to heal properly as it is still in the early stages of the primary bony callus, a process where woven bone bridges the initial fibrous connective tissue callus that responds to a fracture in the first few days.  This woven bone is, after a few months, later converted to lamellar bone and the fracture site will be further remodelled.  Eventually, if a fracture site is initially kept stable by immobilization or by fixation as in my case, the bone can remodel so completely as to eliminate any trace of the original fracture (White & Folkens 2005: 48).

Traumatic fractures are found in all periods of human and hominin history, and it is likely that you yourself have suffered a fractured bone of some description, perhaps even unknowingly (Marsland & Kapoor 2008: 121).  They can be devastating, requiring many years of surgery or physiotherapy to gain and improve movement as the sociologist Ann Oakley highlights in her 2007 book Fracture: Adventures of  Broken Body, a personal account detailing the social and professional impact of a fractured right humerus accident which had impinged on nerves, leading to reduced function and feeling.  Fracture treatment has been practiced for thousands of years and it has long been known that, with the reduction of the break and stabilization of the limb, good results can be achieved (Marsland & Kapoor 2008).  The study of fractures in populations can also highlight trends in the attention received as Meyers (2012) has highlighted in an entry on the differences of fracture treatment between Iron Age and Romano-British populations in Britain.

fractured right tibia digistied diseases 0365

The right tibia of an adult, courtesy of the free online resource Digitised Diseases. Notice the well healed mid-shaft oblique fracture in the (a) anterior view, (b) is the posterior view and (c) is the close up posterior view, where right is proximal and left distal. The callus is fully remodelled with smooth bone over the fracture site, where the end is displaced laterally and proximally. Image credit: Digitised Diseases 2014 (Master Record Number 0365).

Still this entry’s approach is focused on the personal, not at the population level.  Another part of my body has broken and it is once again held together by titanium, likely to be a permanent addition to my skeleton.  The movement at the glenohumeral joint (otherwise known as the shoulder) is normal while movement at the elbow joint (comprised of the humeroulnar, humeroradial and superior radioulnar joints) is almost back to normal.  There is still a lack of full extension of the joint, with noticed tension in the biceps brachii muscle as it acts as the antagonist to the triceps brachii muscle during forearm extension, although daily physiotherapy should help to regain full movement.  I am no stranger to the strength of the metal in my body and I remain impressed by its capability in the use of orthopaedic fixation.  The use of metallic implants to fixate fractures is nothing new as Lane (1895) and Uhthoff et al. (2006) attest.  Whilst the use of casts to set fractures continues, it is the increase in the use and versatility of technology and materials to give nature a helping hand that remains the next big step in treating bone fractures (Bali et al. 2013).

Metal plates have been in use for over a hundred years where early pioneers such as Lane (1895), Lambotte (1909) and Sherman (1912) first introduced plates to help stabilize fracture sites and help mobilize patients faster than plaster casts could allow (Uhthoff et al. 2006: 118).  Although these early plates suffered from corrosion problems it soon became apparent that internal plate fixation could provide a safe and efficient way for patients to heal, whilst also regaining some form of movement.  Various plate designs improved on earlier designs, allowing for micromotion at the fracture site and compensation for bone resorption during the healing process.

Uhthoff et al. (2006: 124) contend that there are still problems in the form of internal plates, where compression and stress shielding can still lead to bone necrosis and cortical porosis.  In their conclusion they argue that there still needs to be a fine balance attained between a plate design that managed to reduce stress shielding and allows adequate micromotion at the site of a fracture, both which they concur would help mimic biological healing.  There also drawbacks that can include plate palpability, risk of infection, temperature sensitivity and possible growth restriction with metallic implants (Bali et al. 2013: 167).   Ultimately however the body still has to heal the fracture itself over a matter of weeks and months (White & Folkens 2005: 48).

It is interesting to note that Sir William Lane himself, writing in the late 19th century and primarily focusing on lower limb fractures, indicates the marked differences between upper and lower limb fracture treatment.  He states that although the upper limb does not take the weight of the body:

… in the arm very considerable alterations may occasionally develop, and are more marked and depreciating to the value of the individual as a machine in proportion as changes have already taken place in the particular joint or joints from the prolonged pursuit of a laborious occupation.” (Lane 1895: 861).

Deciding that fractures of upper limb need not be set directly in their original anatomical form, whereas lower limb bones should be set as close to as originally constituted due to their weight-bearing nature.  Furthering this view, in the same letter to the British Medical Journal in 1895, he highlights that:

One cannot but feel that the perpetuation of methods of treatment which have been in use up to the present time must depend on the fact that surgeons have not taken such trouble to inquire into the subsequent life-history of these patients as they have done in other departments of surgery.” (Lane 1895: 863).

There have been some distinct advances in using biodegradable plates in non-weight bearing locations, such as in the maxillofacial region, a position where many would like to avoid the intrusive nature of a temporary or permanent metal plate.  A study by Bali et al. (2013: 167) has highlighted the value of using biodegradable material to help fixate trauma-induced facial fractures, reporting that each individual in the small study cohort (N=10) of varying ages, reported good reduction of fracture and evidence for the total biodegradation of the plate after two years.

They also reported that no further surgical procedures were needed on their test cohort, a significant finding as metallic implants often either need removing if they are temporary or debriding if they become infected, both quite serious surgical procedures (Bali et al. 2013: 170).  Unfortunately the study highlights that biodegradable implants are unlikely to be currently safe to use in weight-bearing or load bearing bones.  Bali et al. (2013:171) conclude by stating that further studies are needed but biodegradable plates and screws can provide satisfactory, if expensive, stabilization as internal fixations for mid-face fractures.

Medical science and engineering has certainly come a long way since Lane first introduced the internal fixation plate, yet humans are as prone as ever to fracturing their bones.  As a person with McCune Albright Syndrome I may know the pain of breaking a bone, but I can be thankful that I live at a time and in a place where fractures can be confidently treated.

Further Information

  • I’ve written in more detail on polyostotic Fibrous Dysplasia and McCune Albright Syndrome here, which details the way in the which the disease has affected my skeleton.  Also, on that particular post, are a host of medical, palaeopathology and osteology related articles to do with McCune Albright Syndrome and Fibrous Dysplasia in general.  Alternatively search the blog for the keywords and numerous posts in which I’ve highlighted the syndrome and the bone disease will appear.
  • A previous post on 3D printing in orthopaedic surgery can be found here, and an entry giving a quick overview of some of the problems and approaches used in studying physical impairment and disability in archaeological contexts can be found here.


Bali, R. K., Sharma, P., Jindal, S. & Gaba, S. 2013. To Evaluate the Efficacy of Biodegradable Plating System for Fixation of Maxillofacial Fractures: A Prospective Study. National Journal of Maxillofacial Surgery4 (2): 167-172. (Open Access).

Digitised Diseases. 2014. Master Record Number 0365. Accessed 18/08/14.

Lane, W. A. 1895.  Some Remarks on the Treatment of Fractures. British Medical Journal1 (1790): 861–863. (Open Access).

Marsland, D. & Kapoor, S. 2008. Rheumatology and Orthopaedics: Crash Course 2nd Edition. London: Mosby Elsevier.

Meyers, K. 2012. Break a Leg! Fracture Treatment in Iron Age and Roman Britain. Bones Don’t Lie. Accessed 11th August 2014. (Open Access).

Oakley, A. 2007. Fracture: Adventures Of A Broken Body. Bristol: Policy Press.

Uhthoff, H. K., Poitras, P. & Backmann, D. S. 2006. Internal Plate Fixation of Fractures: Short History and Recent Developments. Journal of Orthopaedic Science. 11 (2): 118-126.  (Open Access).

White, T. D. & Folkens, P. 2005. The Human Bone Manual. London: Elsevier Academic Press.

Bone Benefits of 3D Printing

24 Mar

Recently there has been some extraordinarily interesting articles in the press on the value of 3D printing in surgical procedures.  In particular the United Kingdom seems to be leading the way in producing and using 3D printed implants for use in reconstructive surgeries, as recent articles in the BBC, the Daily Telegraph and The Independent publications highlight.

Mr Craig Gerrand, a consultant orthopaedic surgeon in an NHS hospital in Newcastle-Upon-Tyne, England, recently announced the success of producing and fitting half of a 3D printed titanium hip into an unnamed patient who was suffering from chondrosarcoma.  Chondrosarcoma is a cancer of the cartilage cells and typically tends to affect the axial skeleton.  In this case the unnamed patient suffered severe damage to one half of his hip due to the effect of the destructive cancer.  In an effort to stop the spread of the cancer, which rarely responds to radiotherapy or chemotherapy, the surgeon was forced to remove half of the patient’s hip (termed an hemipelvectomy, which can be external or internal dependent on if the leg is to be amputated as well).

Before this, however, Mr Gerrand was able to construct and print a 3D titanium half model of the patient’s  hip which, along with the added attachment of a hip socket replacement, he was then able to implant into the patient following the removal of the chondrosarcoma affected bone.  The fake hip was based on scans and x-rays of the patient’s own hip for anatomical reasons and was fully produced using a 3D printer.  The printer used lasers to fuse together titanium powder, which slowly built up a model of the hip layer by layer.  The fake hip was then coated in a mineral into which the remaining bone in the patient’s healthy hip could fuse with, providing long-term stability during recovery and mobility.  Although the news articles on the case were only recently produced, the actual surgery itself was carried out over 3 years ago.  Wonderfully the patient continues to manage to walk with mobility aids, something that would be unthinkable if the surgeon had not been able to print and implant the titanium hip.

In other news recently, as reported by the BBC, the Welsh victim of a vicious motorcycle accident was able to benefit from the 3D printing of custom parts for use in maxillofacial reconstruction.  The use of 3D printing was used at each stage of the procedure, including the planning of the surgery and the reconstruction itself, by using titanium parts to stabilise or replace parts of the patient’s own facial bones.

Following the motorcycle accident, which severely damaged both of the patient’s zygomatic bones as well as sustaining damage to the maxilla, frontal and nasal bones, the patient’s face was reconstructed in a series of operations.  To achieve the aim of improving the patient’s face to almost pre-accident standards the surgeons scanned the skull of the individual using a CT scanner and printed the results using a 3D printer, the results of which helped to produce a symmetrical model of his skull to help plan the surgery in detail.  By using cutting guides and by being able to measure the facial skeletal anatomy directly, they managed to print titanium plates to match the symmetry of the patient’s face originally, and likely minimised the time the patient spent under anesthetic.  In the article the patient, from the city of Cardiff in Wales, movingly states how he now looks as he did before the motorcycle accident, adding that he was able to go out in public once again following the reconstructive surgery.


A model example of how the surgeons helped plan the surgery to improve the motorcycle accident man’s face with 3D printed titanium implants. The image shows the left zygomatic arch with the titanium implants in white against the model of the cranium. (Image credit: The BBC 2014).

The two innovative procedures above are fine examples of the value of integrating the latest technology into the operating theatre, but they also highlight some themes of the body and surgical intervention that interest me.  The benefits of being able to 3D print specific and specially made parts offer a ‘continuation’ for the patient of their own bodies, even with the distinct disconnect (and often intrusive procedures) between the effect of the trauma or disease process and the reconstructive attempts at re-structuring the body, as highlighted in the above orthopaedic cases.

3D printing is a fast-moving technology in the medical world, where even the possibility of being able to bioprint human organs and tissue is fast becoming a possibility for the future.  Perhaps most significantly it offers the option for the patient to use their own bodies (or, more specifically, their cells) to help cultivate a ‘second chance’ organ or tissue in the lab using artificial scaffolds to grow the tissue needed.  To a small degree this has already been carried out with certain tissues, but further work is needed to be able to bioprint human organs properly.  But back to the use of 3D printing in orthopaedic surgery.

Reconstructive orthopaedic surgery generally aims to improve the quality of life for the individual through physical manipulation and internal or external fixation of an implant onto, or into, the bone directly.  The benefits of this are not just anatomical but often also psychological, perhaps more so in maxillofacial procedures.  The patient may feel that their appearance has improved dramatically, or that they have been made to look more normal.  This can increase the positive social perception of the patient themselves and boost self-confidence.  Of course there are always risks associated with reconstructive orthopaedic surgery, the first and foremost being the fact that more damage may occur as a result of the often intrusive procedures, particularly the risk of implant fatigue and possibility of macro/micro fracture of surrounding bone material.

Internal and external fixations also often run the risk of infection, more so when there is the risk of repeated surgical interventions.  Internal fixation (such as intramedullary rodding) has the possibility of deep bone infection, whilst external fixation (such as the use of the Ilizarov frame) often results in small localised infections.  Nevertheless the risk of infection by implant is often controlled for by using clean surgical rooms, sterilised medical equipment and the infusion of antibiotics during and post-surgery.  Further to this, antibiotic laden cement is also often used during the surgical fixation of an implant as an added protector against infection through the introduction of foreign bodies.

I am also interested in the after effects of surgery in the perception of the self.  Titanium implant parts are typically manufactured for general use, although there is a dizzying variety of screws, plates and rods available to the orthopaedic surgeon.   Of course they are also shaped and made to fit the patient to a certain degree.  Titanium is a fairly hefty metal, with the patient often being able to tell that something heavy has been implanted into the body upon awakening from surgery.  It also often hammered or screwed into the bone, sometimes causing the bone to fracture or microfracture during the process, or afterwards as the patient starts to weightbear.  (As a side note orthopaedic surgeons are often built like rugby players because of the demanding physical aspect of orthopaedic surgery).

The new generation of 3D printed parts are often made of different materials than purely consisting of titanium.  Importantly there is the option to help improve the post surgical integration of existing bone and ceramic implants (such as hip replacements, which often use ceramic femoral heads) through the ability to print intricate designs to help meld with bone, and the ability to seed the ceramic scaffolds with the patients own cultured cells to promote  healthy bone growth (Seitz et al. 2005).  This is purely speculation and conjecture, but I wonder if the newer materials used, are of a much lighter material than titanium and are, as a result, less intrusive to the person undergoing the surgery?

What the 3D printing of implants offer is the opportunity to make identical and specifically made models of the  patient for their own use (Fedorovich et al. 2011), by either basing the custom build on an existing bone of the patient or by specifically making a part to improve what has either been lost to a disease process or a traumatic incident, to name the two main causes for orthopaedic reconstructive surgery.  There are also opportunities to help promote wound healing and prevent infection during and post-surgery (Lee et al. 2012), a step that is needed considering the rise of drug resistant germs, the general decline in pharmaceutical companies producing new antibiotics, and the widespread misuse of antibiotics in general (Mayo Clinic release).  3D printing then, I believe, is an important step in advancing and improving the techniques, approaches and materials used in orthopaedic surgery.

Learn More

  • Watch Ben Garrod’s Secrets of Bones BBC TV series to learn more about just how wonderful the skeleton is.  Learn more about the remarkable 3D print of his skull here.
  • Kristina Killgrove, over at Powered by Osteons, has a series of posts on her attempts to integrate 3D printing with teaching human osteology, check it out here.
  • The frankly amazing news of the Netherlands surgeons who were able to produce a 3D model of a patient’s cranium which was then successfully implanted can be found here, although there has been a lack of evidence for this procedure in other mainstream or medical publications.


Fedorovich, N. E., Alblas, J., Hennink, W. E., Oner, F. C. & Dhert, W. J. A. 2011. Organ Printing: The Future of Bone Regeneration? Trends in Biotechnology29 (12): 601-606.

Lee, J-H., Gu, Y. Wang, H. & Lee, W. Y. 2012. Microfluidic 3D Bone Tissue model for High-Throughput Evaluation of Wound-Healing and Infection-Preventing Biomaterials. Biomaterials. 33 (4): 999-1006.

Seitz, H., Rieder, W., Irsen, S., Leukers, B. & Tille, C. 2005. Three-Dimensional Printing of Porous Ceramic Scaffolds for Bone Tissue Engineering. Journal of Biomedical Materials Research Part B: Applied Biomaterials. 74B (2): 782-788.