Humeral Shaft Fractures

Anatomy

Spiral Groove

  • Radial nerve crosses humerus midpoint 14cm proximal to lateral epicondyle

Lateral Intermuscular Septum

  • 7-10 cm above lateral epicondyle

Anterolateral Approach

  • Best for proximal 2/3 fractures

Posterior Approach

  • Best for distal 1/2 humerus

Non-Surgical Management

  • Most common deformity is varus
  • Acceptable deformity:
    • 30 degrees in coronal plane - varus is worse as it reduces shoulder abduction
    • 20 degrees in sagittal plane
    • cm shortening

Treatment

  • Coaptation splinting in a U slab for comfort
  • Or collar and cuff initially
  • Application of functional brace at 1 week
  • Serial brace tightening to prevent slipping

Results

  • 2% (closed) and 6% (open) non-union rate - Sarmiento JBJSam 2000
  • Mild deformity does not affect functional outcome
  • Bracing worked as well for all types and location of fracture

Operative Treatment

Indications (All Relative)

  • Even open fractures have been managed non-operatively

Indications for Surgery

  • Inability to maintain closed reduction within acceptable parameters, especially varus
  • Open fracture
  • Simple fracture patterns, especially transverse and short oblique
  • Polytrauma
  • Floating elbow

Overall Results

  • Surgery has a lower malunion and non-union rate

Method of Fixation

Ex Fix

  • Indicated for polytrauma or gross contamination

Safe Zones

  • Proximal 1/3:
    • Through the anterolateral fibers of deltoid – avoid axial nerve and LHB
  • No safe zone in middle 1/3
  • Distal 1/3:
    • Posterior, posteromedial, or posterolateral above olecranon fossa

Plate

  • Large fragment plate
  • 8 cortices either side of fracture traditionally
  • 6 cortices if good lag screw
  • If bridge plating, consider working length rather than the absolute number of screws

IM Nailing

  • Problem: shoulder pain and cuff damage
  • Risk of nerve and vascular injury during locking

Plate vs. Nail

  • Meta-analysis Mo Bandhari Acta Orthopedica 2010:
    • Complication rate with IM nailing is higher:
      • Shoulder pain
      • Re-operation
      • Delayed but not non-union

Radial Nerve Palsy

  • Systematic review of 4000 patients Gianoudis JBJSBr 2005:
    • 11% risk of radial nerve palsy
    • 24% for distal 1/3 fractures
    • Higher in spiral and transverse fractures
    • Spontaneous recovery in 70% at a mean of 7 weeks (longest 6 months)
    • EMG at 6 weeks if no recovery at all:
      • Look for fibrillations and sharp waves
      • Repeat at 3 months
      • If no activity at 3 months, refer to specialist unit
    • Exploration should not be delayed beyond 6 months in the presence of no activity

Indications for Exploration

  • Open penetrating or high energy injury with palsy (higher incidence of laceration)
  • Nerve deficit after reduction and a Holstein-Lewis fracture is a soft indication (not proven beneficial in the literature)

Non-Union

  • Work up patient to identify cause:
    • Smoking
    • Infection
  • Requires ORIF, bone grafting, and compression plating
  • Compression plating alone suffices if it is a hypertrophic non-union
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