Humeral shaft fractures can often be treated nonoperatively with a brace, though operative options include plating, flexible nailing, or locked intramedullary nailing. Plates and nails have similar union rates but nails have more complications so plates are generally preferable. Flexible nails are also an effective option. Radial nerve palsy is a risk, especially with distal fractures, and may require exploration. Most humeral shaft fractures heal well with either operative or nonoperative treatment depending on the specific situation and patient factors.

1. AOTrauma Principles Course
Christopher Finkemeier, US
Hank Hanff, US
Humeral shaft fractures

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?

5. Treatment options
Nonoperative:
• Coaptation splint
• Hanging arm cast
• Functional orthosis
Operative:
• Compression plating
• Intramedullary fixation
• Antegrade
• Retrograde
• Interlocking
• Flexible
• External fixation

6. Nonoperative treatment
Indications:
• Isolated injury
• Adequate alignment after splinting
- AP bowing < 20o
- lateral bowing < 300
• Preferred method
• Functional orthosis

7. Nonoperative treatment
Functional orthosis Collar-and-cuff

8. Nonoperative treatment
17-year-old man, isolated
fracture, closed injury from
snowboarding

9. Nonoperative treatment—10 days
postinjury after orthosis

10. Nonoperative treatment—21 days post
injury with orthosis in place

11. Nonoperative treatment—11 weeks
postinjury
15°
varus 12°
anterior angulation

12. Nonoperative treatment
• 15° varus
• 12° anterior angulation

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

14. Humeral shaft fractures—operative
indications
• Open fractures
• Vascular injury
• Radial nerve palsy after
closed reduction
• Floating elbow
• Failure of closed treatment
• Pathologic fractures (bone
metastases)
• Brachial plexus injury

15. Humeral shaft fractures—relative
operative indications
• Polytrauma
• Bilateral humeral
fractures
• Morbid obesity
• Segmental fractures
• Need to use crutches

16. Humeral shaft fractures—operative
options
• Plate fixation
• Interlocked IM nail
• Ender’s nails, rush
rods
• External fixation

17. Humeral shaft fractures—external fixation
• Open fractures
with extensive
soft-tissue injuries
• Severe
contamination

18. Humeral shaft fractures—indications for
plate fixation
• Fractures requiring
nerve or vascular
exploration
• Very distal fractures
• Very proximal
fractures
• Any diaphyseal
fracture

20. Humeral shaft fractures—surgical
approaches
• Anterolateral:
- Proximal and middle third
• Posterior:
- Distal and middle third

21. Humeral shaft fractures—anterolateral
approach
• Supine
• Good for
polytraumatized
patient

22. Humeral shaft fractures—anterolateral
approach
• Deltopectoral approach
proximally
• Interval between biceps
and brachialis
• Split brachialis fibers

23. Humeral shaft fractures—posterior
approach
• Prone or lateral
• Arm draped over padded support

24. Humeral shaft fractures—posterior
approach
• Interval between lateral and
long heads of triceps
• Identify radial nerve
• Split medial (deep) head

25. Humeral shaft fractures—posterior plate
• Tension band
• Placed beneath radial nerve
• Dictate location of nerve

26. Humeral shaft fractures—implants
• Broad 4.5 large fragment plate
• Small bone individuals:
- Narrow large fragment plate
- Small fragment plate 3.5

27. Absolute stability Relative stability

28. Humeral shaft fractures—flexible nails
• Ender nails
• Antegrade or
retrograde
• Rotational control?
• Migration problems

29. Intramedullary fixation—flexible nails
22-year-old with acetabular fracture and closed humeral
fracture

30. Intramedullary fixation—flexible nails
• Multiple, flexible,
retrograde IM nails
• Early weight bearing
allowed on upper extremity
• Callous at 4 weeks
postoperative
Nancy nails

31. Intramedullary fixation—flexible nails
Fracture healed at 3 months

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

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

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

43. Humeral shaft fractures—immediate
radial nerve exploration
• Open fractures
• Distal-third spiral fractures
• Secondary palsy following closed reduction

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