Humeral Shaft Fractures Chris Oliver DM FRCS(Tr & Orth) FRCP Consultant Trauma Surgeon Edinburgh Orthopaedic Trauma Unit www.trauma.co.uk

Most Humeral Shaft Fractures unite if left alone in the same room!

Humeral Shaft # treatment previously poor operative results high reported complications appreciation of the literature is critical to the development of an appropriate treatment plan for humeral shaft #

previously poor operative results

high reported complications

appreciation of the literature is critical to the development of an appropriate treatment plan for humeral shaft #

Humeral Shaft # Classification low-energy v high-energy soft-tissue injury open fracture grading associated neurovascular injury co-morbidity associated injury AO A, B, C

low-energy v high-energy

soft-tissue injury

open fracture grading

associated neurovascular injury

co-morbidity

associated injury

AO

A, B, C

Humeral Shaft # Epidemiology Edinburgh, 249 consecutive # over 3 years AO type A in 63.3%, B in 26.2%, C in 10.4% 60% middle third of the diaphysis 30% proximal, 10% distal third < 10% fractures were open bimodal age distribution peak third decade ~ moderate to severe injury: men larger peak seventh decade ~ simple fall: women The epidemiology of humeral shaft fractures. Tytherleigh-Strong G, Walls N, McQueen MM. J Bone Joint Surg Br 1998 Mar;80(2):249-53

Edinburgh, 249 consecutive # over 3 years

AO type

A in 63.3%, B in 26.2%, C in 10.4%

60% middle third of the diaphysis

30% proximal, 10% distal third

< 10% fractures were open

bimodal age distribution

peak third decade ~ moderate to severe injury: men

larger peak seventh decade ~ simple fall: women

The epidemiology of humeral shaft fractures. Tytherleigh-Strong G, Walls N, McQueen MM. J Bone Joint Surg Br 1998 Mar;80(2):249-53

Clinical & radiographic examination Humeral Shaft# direct or indirect forces pain, swelling, deformity, shortening, abnormal motion radial nerve palsy compartment syndrome two full-length views of the entire humerus, at 90 degrees to each other, with clear delineation of the shoulder and elbow joints

direct or indirect forces

pain, swelling, deformity, shortening, abnormal motion

radial nerve palsy

compartment syndrome

two full-length views of the entire humerus, at 90 degrees to each other, with clear delineation of the shoulder and elbow joints

Humeral Shaft # Conservative treatment Hanging Cast 3/52 then humeral brace union 3/12 Accept 20 ° anterior angulation 30 ° varus 1 inch of shortening 98% rate of union 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.

Hanging Cast

3/52

then humeral brace

union 3/12

Accept

20 ° anterior angulation

30 ° varus

1 inch of shortening

98% rate of union

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.

Indications for surgical intervention Humeral Shaft # (1) failure closed treatment loss of reduction poor patient tolerance/compliance open fractures vascular injury/neurologic injury segmental fractures floating elbow associated intra-articular fractures associated injuries to the brachial plexus

failure closed treatment

loss of reduction

poor patient tolerance/compliance

open fractures

vascular injury/neurologic injury

segmental fractures

floating elbow

associated intra-articular fractures

associated injuries to the brachial plexus

Indications for surgical intervention Humeral Shaft # (2) delayed union, non-union/malunion infection bilateral fractures of the humerus pathologic fractures Parkinson's disease polytrauma head injuries burns chest trauma multiple fractures

delayed union, non-union/malunion

infection

bilateral fractures of the humerus

pathologic fractures

Parkinson's disease

polytrauma

head injuries

burns

chest trauma

multiple fractures

Humeral Shaft # with Associated Radial Nerve Palsy 1.8% to 24% of shaft fractures nerve contusion ~ neuropraxia spontaneous recovery of nerve function is about 70% at 3/12 EMG little acute value transverse #middle third neuropraxia spiral # distal third laceration/entrapment

1.8% to 24% of shaft fractures

nerve contusion ~ neuropraxia

spontaneous recovery of nerve function is about 70% at 3/12

EMG little acute value

transverse #middle third

neuropraxia

spiral # distal third

laceration/entrapment

Immediate surgical intervention for Humeral Shaft # associated with radial nerve palsy open fractures secondary palsies developing after closed reduction Holstein-Lewis distal-third spiral fractures entrapment medial intramuscular septum

open fractures

secondary palsies developing after closed reduction

Holstein-Lewis distal-third spiral fractures

entrapment medial intramuscular septum

Surgical Treatment Humeral Shaft # plate osteosynthesis intramedullary fixation external fixation no support for stabilization of the humeral shaft by screw fixation alone

plate osteosynthesis

intramedullary fixation

external fixation

no support for stabilization of the humeral shaft by screw fixation alone

ORIF Humeral Shaft # Plate

ORIF Humeral Shaft # Plate: Results union rates average 96% complications ranging from 3% to 13% posterior approach gives direct exploration of the radial nerve record where nerve crosses plate shaft wide 4.5mm DCP

union rates average 96%

complications ranging from 3% to 13%

posterior approach gives direct exploration of the radial nerve

record where nerve crosses plate

shaft wide 4.5mm DCP

3B open shaft + C3.3 s/c elbow

Prograde Humeral Nail prograde adhesive capsulitis rotator cuff dysfunction

prograde

adhesive capsulitis

rotator cuff dysfunction

Retrograde Humeral Nail retrograde iatrogenic distal shaft fracture clumsy proximal locking

retrograde

iatrogenic distal shaft fracture

clumsy proximal locking

AO Retrograde Humeral Nail

Humeral Shaft# Plate versus Nails PRCT 44 patients with # shaft humerus, IMN or DCP ~ FU 6/12 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 shoulder impingement 1 DCP ~ 6 IMN (5 antegrade) complications 3 DCP ~ 13 IMN secondary surgery 1 DCP ~ 7 IMN group ORIF with a DCP remains the best treatment for unstable fractures of the shaft of the humerus IMN technically demanding and higher rate of complications 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

PRCT 44 patients with # shaft humerus, IMN or DCP ~ FU 6/12

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

shoulder impingement 1 DCP ~ 6 IMN (5 antegrade)

complications 3 DCP ~ 13 IMN

secondary surgery 1 DCP ~ 7 IMN group

ORIF with a DCP remains the best treatment for unstable fractures of the shaft of the humerus

IMN technically demanding and higher rate of complications

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

Flexible Humeral Shaft # Nails Rush rods Ender rods Hackethal stacked nails Marchietti Nail All high secondary complication rates insufficient rotatory stability

Rush rods

Ender rods

Hackethal stacked nails

Marchietti Nail

All high secondary complication rates

insufficient rotatory stability

Indications External fixation Humeral Shaft # severe open fractures with extensive soft-tissue injury or bone loss, associated burns, or infected non-unions temporary Ex-Fix polytrauma muscle or tendon impalement safe zones for pin placement open insertion techniques meticulous pin care

severe open fractures with extensive soft-tissue injury or bone loss, associated burns, or infected non-unions

temporary Ex-Fix

polytrauma

muscle or tendon impalement

safe zones for pin placement

open insertion techniques

meticulous pin care

Humeral Shaft# Complications malunion non-union infection

malunion

non-union

infection

Humeral Shaft# Learning Points most treated non-operatively some operative exceptions literature poor plates better overall for diaphyseal humeral shaft # than nails

most treated non-operatively

some operative exceptions

literature poor

plates better overall for diaphyseal humeral shaft # than nails