Humeral Shaft Fractures

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Humeral Shaft Fractures

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Humeral Shaft Fractures

  1. 1. Humeral Shaft Fractures Chris Oliver DM FRCS(Tr & Orth) FRCP Consultant Trauma Surgeon Edinburgh Orthopaedic Trauma Unit www.trauma.co.uk
  2. 2. Most Humeral Shaft Fractures unite if left alone in the same room!
  3. 3. Humeral Shaft # treatment <ul><li>previously poor operative results </li></ul><ul><li>high reported complications </li></ul><ul><li>appreciation of the literature is critical to the development of an appropriate treatment plan for humeral shaft # </li></ul>
  4. 4. Humeral Shaft # Classification <ul><li>low-energy v high-energy </li></ul><ul><li>soft-tissue injury </li></ul><ul><li>open fracture grading </li></ul><ul><li>associated neurovascular injury </li></ul><ul><li>co-morbidity </li></ul><ul><li>associated injury </li></ul><ul><li>AO </li></ul><ul><ul><li>A, B, C </li></ul></ul>
  5. 5. Humeral Shaft # Epidemiology <ul><li>Edinburgh, 249 consecutive # over 3 years </li></ul><ul><li>AO type </li></ul><ul><ul><li>A in 63.3%, B in 26.2%, C in 10.4% </li></ul></ul><ul><ul><li>60% middle third of the diaphysis </li></ul></ul><ul><ul><li>30% proximal, 10% distal third </li></ul></ul><ul><ul><li>< 10% fractures were open </li></ul></ul><ul><li>bimodal age distribution </li></ul><ul><ul><li>peak third decade ~ moderate to severe injury: men </li></ul></ul><ul><ul><li>larger peak seventh decade ~ simple fall: women </li></ul></ul><ul><li>The epidemiology of humeral shaft fractures. Tytherleigh-Strong G, Walls N, McQueen MM. J Bone Joint Surg Br 1998 Mar;80(2):249-53 </li></ul>
  6. 6. Clinical & radiographic examination Humeral Shaft# <ul><li>direct or indirect forces </li></ul><ul><li>pain, swelling, deformity, shortening, abnormal motion </li></ul><ul><li>radial nerve palsy </li></ul><ul><li>compartment syndrome </li></ul><ul><li>two full-length views of the entire humerus, at 90 degrees to each other, with clear delineation of the shoulder and elbow joints </li></ul>
  7. 7. Humeral Shaft # Conservative treatment <ul><li>Hanging Cast </li></ul><ul><ul><li>3/52 </li></ul></ul><ul><ul><li>then humeral brace </li></ul></ul><ul><ul><li>union 3/12 </li></ul></ul><ul><li>Accept </li></ul><ul><ul><li>20 ° anterior angulation </li></ul></ul><ul><ul><li>30 ° varus </li></ul></ul><ul><ul><li>1 inch of shortening </li></ul></ul><ul><li>98% rate of union </li></ul><ul><li>Diaphyseal fractures of the humerus: Treatment with prefabricated braces Zagorski JB, Latta LL, Zych GA, et al:. J Bone Joint Surg 1988;70A:607-610. </li></ul>
  8. 8. Indications for surgical intervention Humeral Shaft # (1) <ul><li>failure closed treatment </li></ul><ul><ul><li>loss of reduction </li></ul></ul><ul><ul><li>poor patient tolerance/compliance </li></ul></ul><ul><li>open fractures </li></ul><ul><li>vascular injury/neurologic injury </li></ul><ul><li>segmental fractures </li></ul><ul><li>floating elbow </li></ul><ul><li>associated intra-articular fractures </li></ul><ul><li>associated injuries to the brachial plexus </li></ul>
  9. 9. Indications for surgical intervention Humeral Shaft # (2) <ul><li>delayed union, non-union/malunion </li></ul><ul><li>infection </li></ul><ul><li>bilateral fractures of the humerus </li></ul><ul><li>pathologic fractures </li></ul><ul><li>Parkinson's disease </li></ul><ul><li>polytrauma </li></ul><ul><ul><li>head injuries </li></ul></ul><ul><ul><li>burns </li></ul></ul><ul><ul><li>chest trauma </li></ul></ul><ul><ul><li>multiple fractures </li></ul></ul>
  10. 10. Humeral Shaft # with Associated Radial Nerve Palsy <ul><li>1.8% to 24% of shaft fractures </li></ul><ul><li>nerve contusion ~ neuropraxia </li></ul><ul><li>spontaneous recovery of nerve function is about 70% at 3/12 </li></ul><ul><li>EMG little acute value </li></ul><ul><li>transverse #middle third </li></ul><ul><ul><li>neuropraxia </li></ul></ul><ul><li>spiral # distal third </li></ul><ul><ul><li>laceration/entrapment </li></ul></ul>
  11. 11. Immediate surgical intervention for Humeral Shaft # associated with radial nerve palsy <ul><li>open fractures </li></ul><ul><li>secondary palsies developing after closed reduction </li></ul><ul><li>Holstein-Lewis distal-third spiral fractures </li></ul><ul><ul><li>entrapment medial intramuscular septum </li></ul></ul>
  12. 12. Surgical Treatment Humeral Shaft # <ul><li>plate osteosynthesis </li></ul><ul><li>intramedullary fixation </li></ul><ul><li>external fixation </li></ul><ul><li>no support for stabilization of the humeral shaft by screw fixation alone </li></ul>
  13. 13. ORIF Humeral Shaft # Plate
  14. 14. ORIF Humeral Shaft # Plate: Results <ul><li>union rates average 96% </li></ul><ul><li>complications ranging from 3% to 13% </li></ul><ul><li>posterior approach gives direct exploration of the radial nerve </li></ul><ul><li>record where nerve crosses plate </li></ul><ul><li>shaft wide 4.5mm DCP </li></ul>
  15. 15. 3B open shaft + C3.3 s/c elbow
  16. 16. Prograde Humeral Nail <ul><li>prograde </li></ul><ul><ul><li>adhesive capsulitis </li></ul></ul><ul><ul><li>rotator cuff dysfunction </li></ul></ul>
  17. 17. Retrograde Humeral Nail <ul><li>retrograde </li></ul><ul><ul><li>iatrogenic distal shaft fracture </li></ul></ul><ul><ul><li>clumsy proximal locking </li></ul></ul>
  18. 18. AO Retrograde Humeral Nail
  19. 19. Humeral Shaft# Plate versus Nails <ul><li>PRCT 44 patients with # shaft humerus, IMN or DCP ~ FU 6/12 </li></ul><ul><li>No significant differences in the function of the shoulder and elbow, American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity </li></ul><ul><li>shoulder impingement 1 DCP ~ 6 IMN (5 antegrade) </li></ul><ul><li>complications 3 DCP ~ 13 IMN </li></ul><ul><li>secondary surgery 1 DCP ~ 7 IMN group </li></ul><ul><li>ORIF with a DCP remains the best treatment for unstable fractures of the shaft of the humerus </li></ul><ul><li>IMN technically demanding and higher rate of complications </li></ul><ul><li>Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH J Bone Joint Surg Br 2000 Apr;82(3):336-9 </li></ul>
  20. 20. Flexible Humeral Shaft # Nails <ul><li>Rush rods </li></ul><ul><li>Ender rods </li></ul><ul><li>Hackethal stacked nails </li></ul><ul><li>Marchietti Nail </li></ul><ul><li>All high secondary complication rates </li></ul><ul><li>insufficient rotatory stability </li></ul>
  21. 21. Indications External fixation Humeral Shaft # <ul><li>severe open fractures with extensive soft-tissue injury or bone loss, associated burns, or infected non-unions </li></ul><ul><li>temporary Ex-Fix </li></ul><ul><ul><li>polytrauma </li></ul></ul><ul><li>muscle or tendon impalement </li></ul><ul><ul><li>safe zones for pin placement </li></ul></ul><ul><ul><li>open insertion techniques </li></ul></ul><ul><ul><li>meticulous pin care </li></ul></ul>
  22. 22. Humeral Shaft# Complications <ul><li>malunion </li></ul><ul><li>non-union </li></ul><ul><li>infection </li></ul>
  23. 23. Humeral Shaft# Learning Points <ul><li>most treated non-operatively </li></ul><ul><li>some operative exceptions </li></ul><ul><li>literature poor </li></ul><ul><li>plates better overall for diaphyseal humeral shaft # than nails </li></ul>

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