FRACTURES OF SHAFT HUMERUS
P.G in M.S. (Ortho)
Gandhi Medical College
Accounts for 1 to 3% of all fractures
Most are treated conservatively (easiest of all long bones )
Minimal functional deficit even without anatomical
reduction provided by
wide range of motion provided at shoulder
and elbow joints
Extends from the upper border of the insertion of the
pectoralis major proximally to the supracondylar ridge
Proximally, the humerus is roughly cylindrical in cross
section, tapering to a triangular shape distally.
The medullary canal of the humerus tapers to an end
above the supracondylar expansion.
The humerus is well enveloped in muscle and soft
tissue ( good prognosis ).
Divided into ant & post compartments by
lateral inter muscular septi.
The anterior compartment contains
ulnar nerve passes from the anterior to
the posterior compartment as it travels from proximal
to distal and enters the cubital tunnel.
The posterior compartment contans
radial nerve &
profunda brachii artery run together all
Radial nerve then passes to ant compartment by piercing
MECHANISM OF INJURY
In majority of cases
simple fall or twist in older people
high energy trauma in young people.
Fractures in trivial trauma suspect pathological fracture
(metastatic or osteoporosis )
Mismatch between mech of injury and fracture pattern
suspect domestic abuse
By clinical examination and imaging studies
After resuscitation and stabilizing the patient injured limb
should be looked for
crepitus and abnormal mobility
Look for any
external wounds and classify as per gustillo`s classification
and lastly distal neurovascular deficit.
Examination of the shoulder and elbow joint is mandatory.
PLAIN RADIOGRAPH -- in both A-P &lateral views
including shoulder and elbow joint is sufficient for
diagnosing fracture level and its pattern.
CT SCAN –fractures with intra articular extension.
to know rotation mal alignment.
ANGIOGRAM – for any vascular injury
There is no universally accepted system for humoral shaft
They can be classified according to
fracture pattern transverse
fracture level upper, middle, lower third
soft tissue injury Gustillo`s system
Finally pathological and peri prosthetic
NON OPERATIVE TREATMENT
Union rate 80 to 90%
Factors favoring conservative management are
well covered with muscles
Rich blood supply
does not bear weight,
Mininal functional limitation after considerable malunion
also favours non operative treatment.
Methods of conservative treatment are
abduction casting and splinting,
hanging arm cast,
FUNCTIONAL BRACING :
developed by SERMIENTO
works on the principles of
the hydraulic effect of the brace,
active contraction of the muscles,
beneficial effect of gravity.
Union rates with functional bracing are 96 to 100%.
It is considered as “gold standard” for nonoperative
allowance of shoulder and elbow motion,
Guidelines for acceptable reduction are
shortening < 5 cm
rotation of < 30 degrees.
angulation <20 segrees
Some other indications for operative management are
chronic fracture problems like
Antero lateral /lateral approach
Antero medial approach
Modified Posterior Approach (Triceps-Reflecting)
Antero lateral approach
Preferred for middle and proximal third humeral shaft
fractures that require plate fixation.
Extension : proximally coracoid process, distally ant
margin of supra condylar ridge.
Courses through deltoprctoral groove and lateral border
of biceps brachii.
Biceps retracted anteriorly and triceps posteriorly
Brachialis is splitted to expose humerus
Antero medial approach
Provides exposure to the brachial artery and median
and ulnar nerves.
Begins distally at the medial epicondyle and extends
proximally along the posterior edge of the biceps brachii
After splitting of the superficial fascia, the ulnar nerve is
identified and retracted posteromedially.
The median nerve and brachial artery are identified and
Advantages of this approach are the excellent exposure of
the neurovascular structures medially.
The scar is cosmetically appealing.
Neurovascular injury is a major complication.
Proximal extension is very difficult.
Flexible nails rush nails (rotational instability )
Interlocking nails (preferred)
Self locking expandable nails (technically demanding)
Anterograde technique Rretrograde technique
Disadvantages are post op shoulder pain
axillary n injury
radial n injury
It is avoided in cases with
pre existing shoulder pathology
who demands upper limb wt bearing for ambulatio
Entry point – 2cm above/at superior aspect of olecrenon
fossa in midline
Before closing thorough washing to be done to prevent
heterotrophic calcification around elbow
Intramedullary nailing is indicated for
segmental fractures for proximal–middle
third junction fractures
fractures with poor soft-tissue coverage
fractures in obese patients
Intramedullary nailing is avioded in narrow diameter (<9
mm) canals .
Plate osteosynthesis is the “gold standard” of fixation for
humeral shaft fractures.
Advantages of plating over other techniques are
minimal shoulder or elbow morbidity,
high union rates,
low complication rates,
average union rate of 96.7%.
can be used for fractures with both proximal and
MIPO technique is advocated for shaft humerus fractures
but associated with radial nerve injuries
Pronation of forearm brings nerve close to plate
So fixation done in forearm in supination
Used as temporary method for fractures with
contraindications to plate or nail fixation.
Frankly infected fractures
Fractures with poor soft tissues (such as burns)
Rapid stabilization as in damage-control orthopaedics
It carries high complication rates like
pin tract infection
Post operative care
If follow-up radiographs show maintenance of the
light weights are allowed at 6 weeks
Regular weights at 12 weeks.
Heavy work at 16 weeks.
Sporting activities, such as tennis and golf, can
also be started about 4 months after surgery.
Humerus shaft fracture with Radial Nerve Palsy
Most commonly injured with fractures of the humeral shaft
its spiral course at the back of humerus
its relatively fixed in distal arm as it penetrates the
lateral intermuscular septum.
Mostly the radial nerve injury is a neurapraxia, with
recovery rates of 100% in low-energy injuries and 33% in
Treatment strategy is
INITIAL OBSERVATION AND LATE EXPLORATION
Recovery after nerve injury mostly spontaneous and should
show signs of recovery in 3 to 4 months
ENMG and NCS should be conducted at 6 and 12 weeks
Exploration done when no recovery even after 4 to 6
Ultrasonography can beuseful in diagnosing entrapped or
lacerated radial nerves.
By this indications for nerve exploration would be more
Closed inter locking nailing is preferred method
less chances of infection
wound complications after radiation
Open reduction is preferred only when tissue biopsy to
be taken, and fixed with bone cement, auto/ allograft.
Metaphyseal fractures best treated with excision and
Radial nerve injury
selecting wrong implant
poor bone quality
If infection sets culture to be taken i.v antibiotics to be started
If the fixation rigid enough left in place
If not remove it ,debride and ex fix to be applied
After controlled, reoperation
Role of illizarov is limited