2. Objectives
• Identify several acceptable treatment strategies for
humeral diaphyseal fractures
• Learn the operative indications for humeral diaphyseal
fractures
• Understand the benefits and limitations of the various
treatment strategies
3. Humeral shaft fractures
• Humeral shaft fractures account for approximately 1–3%
of all fractures [Beaty 1996, Zuckerman, 1996]
• Usually the result of blunt trauma such as a fall or from
high-energy trauma including motor vehicle accidents
and gunshot injuries
• Fracture displacement is the result of muscular forces
4. General considerations
•
•
Energy of injury?
Associated injuries?
(isolated vs polytrauma)
Status of soft tissues?
Radial nerve function?
Patient factors?
•
•
•
-
-
Obesity
Expectations
•
•
Stable vs unstable?
Need upper extremity
weight bearing?
Open or closed?
Exploration?
Nonoperative treatment?
Do patients demand or
expect perfect x-rays?
•
•
•
•
13. Nonoperative treatment
Sarmiento, et al (2000) J Bone Joint Surg Am
• Followed 620 patients with humeral shaft fractures treated
with cast bracing
Non-union rate: < 2% of closed fractures
Refracture rate: 1% between 2 and 8 weeks post cast
removal
Radial Nerve Palsy: 11%
Most common was varus angulation (16%) with 10°–20° of
angulation
•
•
•
•
26. Humeral shaft fractures—implants
• Broad 4.5 large fragment plate
• Small bone individuals:
-
-
Narrow large fragment plate
Small fragment plate 3.5
30. Intramedullary fixation—flexible nails
• Multiple, flexible,
retrograde IM nails
• Early weight bearing
allowed on upper extremity
• Callous at 4 weeks
postoperative
Nancy nails
32. Intramedullary fixation—flexible nails
Brumback, et al (1986) JBJS
• 63 fractures, 58 followed up
• Both antegrade and retrograde
• 94% union rate
• Retrograde insertion proximal to olecranon fossa gave
excellent results
33. Humeral shaft fractures—antegrade
locked IM nails
• Pathological and
osteopenic fractures
• Good rotational/length
control
• Good healing rates
• Often allows weight
bearing
34. Humeral shaft fractures—antegrade
locked IM nails
Concerns:
•
•
• Insertion often damages rotator
cuff tendons
Inrtamedullary canal narrows
distally
Neurovascular injury at
interlocking sites
X
35. Open reducation internal fixation ORIF vs
intramedullary nailing
• Two randomized prospective studies published compare ORIF to IM
nailing
• Chapman et al (2000) concluded that “neither method was shown to be
markedly superior to each other although nails were associated with a
higher incidence of shoulder discomfort.”
• McCormack et at (2000) suggested that “DCP fixation should continue to be
regarded as the best treatment for fractures of the humeral shaft which
require surgical stabilization.”
36. Humeral shaft fractures—locked IM nails
Design modifications to avoid
shoulder problems:
• More lateral entrance site
• Retrograde insertion
37.
38. Stannard et al (2003) J Bone Joint Surg Am
• 42 consecutive patients
• 95% union rate
• All nonunions (2) occured with 7.5 mm
nail
• 10% shoulder pain
• 24% some loss of motion
• All patients with loss of motion and
shoulder pain had RETROGRADE nails
39. Humeral shaft fractures—retrograde IM
nailing
• Interlocked nails may also be inserted through distal site
• Care to avoid fracture at entrance site
40.
41. Humeral shaft fractures—radial nerve
palsy
•
•
•
•
Incidence 1.8–24 %
Most are a neuropraxia
> 70–90% recover spontaneously
EMG (electromyography) if no evidence of recovery at
6–12 weeks
42. Humeral shaft fractures—radial nerve
palsy
• Associated fracture
patterns
• Transverse mid third
- Usually neuropraxia
• Spiral distal third
-
-
Holstein-Lewis fracture
Higher risk of laceration
or nerve entrapment
44. Summary
• Most humeral shaft fractures can be treated successfully
with a functional brace
• Flexible nails are an effective treatment method
• Plates and nails have “similar” union rates, but nails
have more complications
• Plates are preferable