This document provides an overview of humerus shaft fractures, including: - Epidemiology showing they are most common in young males from high-energy trauma and elderly females from low-energy mechanisms. - Classification systems including the AO classification system. - Treatment options of non-operative management with splinting or bracing for most fractures, and operative options including plating or intramedullary nailing for displaced or unstable fractures. - Surgical approaches and techniques for plating and nailing are also described.

1. FRACTURE SHAFT
HUMERUS
Dr. RAMKISHAN
ASSISTANT PROFESSOR
DEPT. OF ORTHOPAEDICS AND
TRAUMATOLOGY
OSMANIA GENERAL HOSPITAL
HYDERABAD

2. FRACTURE SHAFT
HUMERUS
 Introduction
 History
 Epidemiology
 Mechanism of injury
 Classification
 Clinical features
 Investigations
 Treatment
 Complications

3. INTRODUCTION
 3% to 5% of all fractures
 Most will heal with appropriate
conservative care, although a limited
number will require surgery for optimal
outcome.
 Given the extensive range of motion of
the shoulder and elbow, and the minimal
effect from minor shortening, a wide
range of radiographic malunion can be
accepted with little functional deficit

4. GENERAL
CONSIDERATIONS
 Current research -- decreasing the
surgical failure rate through
 New implants and techniques,
 Optimizing the postinjury rehabilitation
programs
 Minimizing the duration and magnitude
of remaining disability.

5. GENERAL
CONSIDERATIONS
Successful treatment demands a
knowledge of :
 Anatomy,
 Biomechanics
 Techniques
 Patient Function and Expectations.

6. HISTORY

7. Sir JOHN CHARNLEY (1911-
1982)
 ―It is perhaps the
easiest of major lonf
bones to treat by
conservative
methods‖

8. SARMIENTO (February 15,
1811 – September 11, 1888)

9. RICHARD WATSON (1737-
1816)

10. EPIDEMIOLOGY
 High energy trauma is more common in
the young males
 Low energy trauma is more common in
the elderly female

11. AGE AND GENDER SPECIFIC
INCIDENCE OF SHAFT
HUMERUS FRACTURE

12. ANATOMY
 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, hence there is a
good prognosis for healing in the
majority of uncomplicated fractures.

13. ANATOMY
 Nutrient artery- enters the bone very
constantly at the junction of M/3- L/3 and
foramina of entry are concentrated in a
small area of the distal half of M/3 on
medial side
 Radial nerve- it does not travel along the
spiral groove and it lies close to the inferior
lip of spiral groove but not in it
 It is only for a short distance near the
lateral supracondylar ridge that the nerve is
direct contact with the humerus and
pierces lateral intermuscular septum

14. ANATOMY

15. RELATIONSHIP OF
NEUROVASCULAR
STRUCTURES TO SHAFT
HUMERUS

16. MECHANISM OF INJURY
 Direct trauma is the most common especially
MVA
 Indirect trauma such as fall on an outstretched
hand
 Fracture pattern depends on stress applied
○ Compressive- proximal or distal humerus
○ Bending- transverse fracture of the shaft
○ Torsional- spiral fracture of the shaft
○ Torsion and bending- oblique fracture usually
associated with a butterfly fragment

17. CLINICAL FEATURES
 HISTORY
 Mode of injury
 Velocity of injury
 Alchoholic abuse, drugs ( prone for
repeated injuries )
 Age and sex of the patient ( osteoporosis )
 Comorbid conditions
 Previous treatment( massages)
 Previous bone pathology ( path # )

18. CLINICAL FEATURES
 Pain.
 Deformity.
 Bruising.
 Crepitus.
 Abnormal mobility
 Swelling.
 Any neurovascular injury

19. CLINICAL FEATURES
 Skin integrity .
 Examine the shoulder
and elbow joints and
the forearm, hand,
and clavicle for
associated trauma.
 Check the function of
the median, ulnar, and,
particularly, the radial
nerves.
 Assess for the
presence of the radial
pulse.

20. INVESTIGATIONS
 Radiographs
 CT scan
 MRI scan
 Nerve conduction studies
 Routine investigations

21. IMAGING
AP and lateral views of the humerus,
including the joints below and above the injury.
 Computed Tomographic (CT) scans of associated
intra-articular injuries proximally or distally.
 CT scanning may also be indicated in the rare
situation where a significant rotational abnormality
exists as rotational alignment is difficult to judge from
plain radiographs of a diaphyseal long bone fracture.
A CT scan through the humeral condyles distally and
the humeral head proximally can provide exact
rotational alignment
 MRI for pathological #

22. CLASSIFICATION
 CLOSED
 OPEN
 LOCATION- proximal, middle, distal
 FRACTURE PATTERN-tranverse, spiral,
oblique,comminuted segmental
 SOFT TISSUE STATUS – Tscherene &
Gotzen
Gustilo &
Anderson

23. AO CLASSIFICATION OF THE
HUMERUS FRACTURE
SHAFT

24. AO CLASSIFICATION
 1 – HUMERUS
 2--- DIAPHYSIS
A – SPIRAL– 1-PROXIMAL ZONE
2- MIDDLE ZONE
3- DISTAL ZONE
B- OBLIQUE
C- TRANSVERSE

25. AO CLASSIFICATION

26. AO CLASSIFICATION
A3

27. AO CLASSIFICATION

28. AO CLASSIFICATION

29. AO CLASSIFICATION

30. AO CLASSIFICATION

31. AO CLASSIFICATION

32. AO CLASSIFICATION

33. ASSOCIATED INJURIES
○ Radial Nerve injury = Wrist Drop =
Inability of extend wrist, fingers, thumb,
Loss of sensation over dorsal web
space of 1st digit
 Neuropraxia at time of injury will often
resolve spontaneously
 Nerve palsy after manipulation or
splinting is due to nerve entrapment
and must be immediately explored by
orthopedic surgery
○ Ulnar and Median nerve injury (less
common)

34. DIAGNOSIS
History
Clinical
examination
imaging

35. TREATMENT
Goal of treatment is to
establish
union with acceptable
alignment

36. TREATMENT OPTIONS
Non operative operative

38. NON OPERATIVE
TREATMENT
 INDICATIONS
Undisplaced closed simple
fractures
Displaced closed fractures with
less than 20 anterior angulation, 30
varus/ valgus angulation
Spiral fractures
Short oblique fractures

39. HUMERAL SHAFT
FRACTURES
 Conservative Treatment
 >90% of humeral shaft fractures
heal with nonsurgical
management
○ 20degrees of anterior
angulation, 30 degrees of varus
angulation and up to 3 cm of
shortening are acceptable
○ Most treatment begins with
application of a coaptation spint
or a hanging arm cast followed
by placement of a fracture brace

40. NON OPERATIVE
METHODS
 Splinting:
 Fractures are splinted with a hanging splint,
which is from the axilla, under the elbow,
postioned to the top of the shoulder .
 The U splint.
 The splinted extremity is supported by a
sling.
 Immobilization by fracture bracing is
continued for at least 2 months or until
clinical and radiographic evidence of fracture
healing is observed.

41. FCB - INTRODUCTION
 A closed method of treating fractures
based on the belief that continuing
function while a fracture is uniting ,
encourages osteogenesis, promotes the
healing of tissues and prevents the
development of joint stiffness, thus
accelerating rehabilitation
 Not merely a technique but constitute a
positive attitude towards fracture
healing.

42. CONCEPT
 The end to end bone contact is not
required for bony union and that rigid
immobilization of the fracture fragment
and immobilization of the joints above
and below a fracture as well as
prolonged rest are detrimental to
healing.
 It complements rather than replaces
other forms of treatment.

44. CONTRAINDICATIONS
 Lack of co-operation by the pt.
 Bed-ridden & mentally incompetent pts.
 Deficient sensibility of the limb [D.M with
P.N]
 When the brace cannot fitted closely
and accurately.
 Fractures of both bones forearm when
reduction is difficult.
 Intraarticular fractures.

45. TIME TO APPLY
 Not at the time of injury.
 Regular casts, time to correct any angular
or rotational deformity.
 Compound # es , application to be
delayed.
 Assess the # , when pain and swelling
subsided
1. Minor movts at # site should be pain free
2. Any deformity should disappear once
deforming forces are removed
3. Reasonable resistance to telescoping.

48. OPERATIVE
MANAGEMENT

49. OPERATIVE TREATMENT
INDICATIONS
 Fractures in which reduction is unable to be
achieved or maintained.
 Fractures with nerve injuries after reduction
maneuvers.
 Open fractures.
 Intra articular extension injury.
 Neurovascular injury.
 Impending pathologic fractures.
 Segmental fractures.
 Multiple extremity fractures.

50. METHODS OF SURGICAL
MANAGEMENT
 Plating
 Nailing
 External fixation

51. ANTERIOR APPROACH
 SUPINEON
THE ARM
TABLE WITH
600
ABDUCTION AT
SHOULDER

52. ANTERO LATERAL
APPROACH
 Incision
 Proximal land mark
– coracoid process
 Distal land mark-
anterior to lateral
supracondylar ridge

53. ANTERO LATERAL
APPROACH
 Proximally, the plane
lies between the
deltoid laterally
(axillary nerve) and
the pectoralis major
medially(medial and
lateral pectoral
nerves).

54. ANTERO LATERAL
APPROACH
 Distally, the plane
lies between the
medial fibers of the
brachialis
(musculocutaneous
nerve) medially and
the lateral fibers of
the brachialis (radial
nerve) laterally.

55. POSTERIOR APPROACH
 Position of the
patient for the
approach to the
upper arm in either
the (A) lateral or (B)
prone position.

56. POSTERIOR APPROACH
 Incision
 Tip of olecranon
distally to postero
lateral corner of
acromion proximally

57. POSTERIOR APPROACH
 Incise the deep
fascia of the arm in
line with the skin
incision.

58. POSTERIOR APPROACH
 Identify the gap
between the lateral
and long heads of
the triceps muscle.

59. POSTERIOR APPROACH
 Proximally develop the
interval between the two
heads by blunt
dissection, retracting the
lateral head laterally and
the long head medially.
Distally split their
common tendon along
the line of the skin
incision by sharp
dissection. Identify the
radial nerve and the
accompanying profunda
brachii artery.

60. INTRA OP PHOTO

61. PLATING - POSTERIOR
APPROACH

62. PLATING
 Plate osteosynthesis remains the criterion
standard of fixation of humeral shaft
fractures
 high union rate, low complication rate, and
a rapid return to function
 Complications are infrequent and include
radial nerve palsy, infection and refracture.
 limited contact compression (LCD) plate
helps prevent longitudinal fracture or
fissuring of the humerus because the
screw holes in these plates are staggered.

63. PLATE OSTEOSYNTHESIS
 There are several practical advantages
to the use of the LCD plates over
standard compression plates: they are
easier to contour, allow for wider angle
of screw insertion, and have
bidirectional compression holes.
 Theoretical advantages include
decreased stress shielding and
improved bone blood flow due to limited
plate-bone contact.

64. PLATE OSTEOSYNTHESIS
 Recently angle stable or locked plating
systems have gained wide popularity.
 By locking the screws to the plate a
number of mechanical advantages are
gained, including a reduced risk for screw
loosening and a stronger mechanical
construct compared with conventional
screws and plates.
 With locking plate systems, the pressure
exerted by the plate on the bone is minimal
as the need for exact anatomical
contouring of the plate is eliminated.

65. PLATE OSTEOSYNTHESIS
 A theoretical advantage of this is less
impairment of the blood supply in the
cortical bone beneath the plate
compared to conventional plates.
 For humeral shaft fractures,MIPO has
been considered too dangerous due to
the risk of neurovascular injuries,
particularly to the radial nerve.

66. DYNAMIC COMPRESSION
PLATE

68. LIMITED CONTACT DCP

69. LOCKING PLATE

70. LOCKING PLATE HOLE

71. LOCKING PLATE

72. LAG SCREWS

73. PEARLS AND PITFALLS—
COMPRESSION PLATING
 Use an anterolateral approach for midshaft or proximal
fractures, and a posterior approach for distal fractures.
 Use a 4.5-mm compression plate in most patients, with
a minimum of 3 (and preferably 4) screws proximal and
distal. A 4.5-mm narrow plate is acceptable for smaller
individuals.
 Insert a lag screw between major fracture fragments, if
possible.
 Check the distal corner of the plate for radial nerve
entrapment prior to closure following the anterolateral
approach.
 The intraoperative goal is to obtain sufficient stability to
allow immediate postoperative shoulder and elbow

74. INTRAMEDULLARY NAILING
 Rush pins or Enders nails, while effective
in many cases with simple fracture
patterns, had significant drawbacks such
as poor or nonexistent axial or rotational
stability
 With the newer generation of nails came a
number of locking mechanisms distally
including interference fits from expandable
bolts (Seidel nail) or ridged fins (Trueflex
nail), or interlocking screws (Russell-Taylor
nail, Synthes nail, Biomet nail)

75. INTRAMEDULLARY NAILING
 Problems such as insertion site morbidity,
iatrogenic fracture comminution (especially
in small diameter canals), and nonunion
(and significant difficulty in its salvage)
have been reported
 the use of locking nails is restricted to
widely separate segmental fractures,
pathologic fractures, fractures in patients
with morbid obesity, and fractures with poor
soft tissue over the fracture site (such as
burns).

76. INTRAMEDULLARY NAILING
 One point emphasized in most series of
large-diameter nails is that the humerus
does not tolerate distraction. This is a
risk factor for delayed and nonunion.
 Antegrade Technique
 Retrograde Technique-best suited for
fractures in the middle and distal thirds
of the humerus

77. PEARLS AND PITFALLS—
INTRAMEDULLARY NAILING
 Avoid antegrade nailing in patients with
pre-existing shoulder pathology or those
who will be permanent upper extremity
weight bearers (para- or quadriplegics).
 Use a nail locked proximally and distally
with screws: use a miniopen technique
for distal locking for all screws.

78. PEARLS AND PITFALLS—
INTRAMEDULLARY NAILING
 Avoid intramedullary nailing in narrow
diameter (<9 mm) canals: excessive
reaming is not desirable in the humerus.
 Choose nail length carefully, erring on the
side of a shorter nail: do not distract the
fracture site by trying to impact a nail that is
excessively long.
 Insertion site morbidity remains a concern:
choose your entry portal carefully and use
meticulous technique.

79. ANTEGRADE TECHNIQUE

80. ANTEGRADE TECHNIQUE

81. RETROGRADE
TECHNIQUE

82. EXTERNAL FIXATION
 Is a suboptimal form of fixation with a
significant complication rate and has
traditionally been used as a temporizing
method for fractures with contraindications
to plate or nail fixation.
 These include extensively contaminated or
frankly infected fractures , fractures with
poor soft tissues (such as burns), or where
rapid stabilization with minimal physiologic
perturbation or operative time is required
(―damage-control orthopaedics‖)

83. EXTERNAL FIXATION
 External fixation is cumbersome for the
humerus and the complication rate is high.
 This is especially true for the pin sites,
where a thick envelope of muscle and soft
tissue between the bone and the skin and
constant motion of the elbow and shoulder
accentuate the risk of delayed union and
malunion, resulting in significant rates of
pin tract irritation, infection, and pin
breakage.

84. EXTERNAL FIXATION

85. EXTERNAL FIXATION

86. PLATE OR NAIL?
 Plate  Nail
 Reliable, 96%  Less incision
union required
 Good  Higher incidence
shoulder/elbow of complications?
function  Lower union rate?
 Soft tissue –
scars, radial
nerve, bleeding

87. WHAT IS THE ROLE FOR
NAILING?
 Segmental fractures
 Particularly with a very proximal fracture line
 Pathologic fractures
 ? Cosmesis

88. COMPLICATIONS OF OPERATIVE
MANAGEMENT
 Injury to the radial nerve.
 Nonunion rates are higher when fractures
are treated with intramedullary nailing.
 Malunion.
 Shoulder pain -when fractures are treated
with nails and with plates .
 Elbow or shoulder stiffness.

89. REHABILITATION
 Allow early shoulder and elbow rom
 Weight bearing delayed till fracture is
united

90. CASE 1
IMPLANT FAILURE POST OP X RAY

91. CASE 2
IMPLANT FAILURE POST OP X RAY

92. THANK YOU