1) Proximal humerus fractures are common in elderly patients and can be classified using the AO or Neer systems. 2) Nondisplaced fractures are usually treated non-operatively while displaced fractures may require surgical intervention such as open reduction internal fixation, hemiarthroplasty, or reverse total shoulder arthroplasty. 3) Surgical treatment aims to restore anatomy and stability but can increase risks of complications compared to nonoperative treatment. The optimal management of displaced proximal humerus fractures remains controversial.

1. Humerus Fractures
Dr. Anshu Sharma
Assistant Prof.
Dept. of Orthopaedics, GMC&H.

2. Proximal Humerus Fractures
• Defined as Fx occurring at or proximal to surgical neck.
• 80 % of all humeral #.
• 07% of all #.
• Pt > 65 yrs – 2nd most common Fx of the upper extremity.
• 65% of # occur in Pt’s > 60 yrs
• F:M – 3:1.
• Incidence increases with age.

3. Mechanism of Injury
• Old Pts - Low energy trauma [FOOSH].
• Most # are nondisplaced, good prognosis –>nonsurgical Mx.
• Risk factors:
Poor quality bone,
Impaired vision & balance,
Medical comorbidities,
Decreased muscle tone.
• Young Pts – High energy trauma.
• Severe soft tissue damage always require Sx intervention.
• Seizures & electric shock – indirect causes.

4. Common mechanism for low energy proximal
humerus Fx in elderly patients.

5. Anatomy • Proximal humerus comprises of four
major segments
• The Articular head
• The greater tuberosity
• Lesser tuberosity and
• The shaft
• Articular segment is almost
spherical, with a diameter of
curvature averaging 46 mm
(ranging from 37 to 57 mm)
• Inclination of the humeral head
relative to the shaft averages 130
degrees.
• Retroversion of the head varies
from 18 to 40 degrees.

6. Anatomy
• Greater tuberosity has three regions
into which the supraspinatus,
infraspinatus, and teres minor insert.
• Subscapularis tendon  lesser
tuberosity, which is separated from
the greater tuberosity by the bicipital
groove.

7. Deforming forces of PHF
• The greater tuberosity is
pulled posteromedially by
the effect of the supra- and
infraspinatus tendons.
• The lesser tuberosity is
pulled anteriorly by the
subscapularis tendon.
• The shaft segment is pulled
anteromedially by the
pectoralis major tendon.

8. Clinical Evaluation
• A complete history and physical examination must be
obtained about the mechanism of injury and energy of trauma.
• Complaints of Shoulder pain and limitation of movement.
• Ecchymosis appears 24-48 hrs.
• Look for rib, scapular, cervical # in high energy trauma.
• Concurrent brachial plexus injury 5%.
• Axillary nerve is susceptible in anterior # Dislocation.
• Association of arterial injury is rare.
• The patient will hold the arm in internal rotation.
• Radial pulse and capillary refill of fingers should be
assessed

9. Imaging and Diagnostic studies
• Radiographs :- Consist of three views
• AP- Perpendicular to the plane of scapula (Grashey view)
• Neer View (Scapula Y view)
• Axillary view

10. AP Grashey view of the shoulder
The patient’s torso is rotated 30–45 degrees bringing the side opposite to the
injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the
plane of the scapula.

11. Neer view (lateral Y) of shoulder
Affected shoulder located against the cassette the patient’s torso is rotated
60 degrees bringing the side opposite to the injured shoulder toward the source.

12. Axillary view
The arm is abducted as much as possible, with the patient supine and the x-ray
beam projected from the axilla onto the cassette located on top of the
shoulder.

13. Velpeau axillary view of the shoulder
The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked
to lean back, to place the shoulder between the x-ray source and the cassette

14. • CT Scan- Allows more detailed understanding of fracture
configuration, degree of osteopenia, presence and location of
bone impaction and extent of fracture comminution.
• MRI
• Is rarely indicated in trauma setting.
• May be helpful in confirming a non-displaced Fx in a pt
with shoulder trauma, normal radiographic findings and
clinical symptoms.
• Pathological Fx.
• Angiography
• Vascular imaging is required when there is suspicion
of vascular injury.
• CT Angiography- Diagnostic modality of choice. It allows
rapid evaluation of vascular system, while simultaneously
allowing assessment of bone and soft tissues

16. Proximal Humeral Fracture Classfication
AO classification
• Is based on fracture location and presence of impaction,
angulation, translation, or comminution of the fracture, as
well as whether a dislocation is present.
• Type A- Extra-articular unifocal fractures associated with
single fracture line.
• Type B- Extra-articular bifocal fractures accociated with
two fracture lines
• Type C- Articular fractures which involve the humeral
head or anatomic neck.
• Each type is further sub classified into groups and
subgroups.
• Each subgroup fracture is assigned a level of severity.

18. Proximal Humeral Fracture Classfication
Neer Classification (1970)
• Fractures are classified by evaluating the displacement
of the Parts (head, shaft, greater tuberosity, lesser
tuberosity) from each other.
• Criteria to consider as a part, fragment must be rotated
45 degree or displaced 1 cm from the another fragment.
• Classifies as One part, Two part, Three Part and Four
part Fractures

19. One-Part Fractures
• No fragments meet the criteria for displacement; a fracture
with no fragments considered displaced is defined as a one-
part fracture regardless of the actual number of fracture lines
or their location.
Two-Part Fractures
• One segment is displaced.
Three-Part Fractures
• With a three-part fracture, one tuberosity is displaced and
the surgical neck fracture is displaced. The remaining
tuberosity is attached, which produces a rotational
deformity.
Four-Part Fractures
• All four segments (both tuberosities, the articular surface,
and the shaft) meet criteria for displacement. This is a
severe injury and carries a high risk of avascular necrosis.

21. Valgus-Impacted Four-Part Fractures
• Neer added this pattern as a separate category in 2002 .
In this situation, the head is rotated into a valgus posture
and driven down between the tuberosities, which splay out
to accommodate the head. Unlike in the classic four-part
fracture, the articular surface maintains contact with the
glenoid.
Fracture Dislocations and Articular Surface Injuries
• Fractures combined with glenohumeral dislocation are
classified as fracture dislocation.
• Fractures involving articular surface can be of two
varieties- head-splitting fractures and impaction fractures.
They are included in group of fracture dislocations

22. Fracture Frequency
• In 2001 Court-Brown et al published study on distribution of
PHF types.
• Non-displaced or minimally displaced one-part fractures
comprised half (49%) of all fractures.
• Two part- 37%. Surgical neck fractures comprised 3/4th of
these. Two part anatomic neck fractures were rare (0.2 %)
• Three part fractures- 9 %
• Four part- 3 %, of which one third were true fracture
dislocations. Fractures involving articular surface
occurred in 0.7 % cases.

23. Risk of Avascular Necrosis
• Four-part fractures and fracture dislocations are
considered to have the highest risk for humeral head
necrosis.
• Hertel criteria –
• Metaphyseal extension of the humeral head < 8 mm
• Medial hinge disruption of >2 mm, and
• Fracture through anatomical neck
• The combination above above factors had 97% positive
predictive value for humeral head ischemia.

24. Metaphyseal extension of the humeral
head of >9 mm
Metaphyseal extension of the humeral
head of <8 mm.

25. Undisplaced medial hinge Medial hinge with >2 mm of
displacement

26. Non-operative Mx of Proximal Humerus Fx
• The majority of proximal humeral fractures are
nondisplaced or minimally displaced and nonoperative
treatment is indicated.
• Fracture stability can be assessed both radiographically
and clinically.
• Radiographically, stable fractures exhibit impaction or
interdigitation between bone fragments
• Clinically, fracture stability may be assessed by palpating the
proximal humerus just distal to the acromion with one hand,
while rotating the arm at the elbow with the other. If the
proximal humerus is felt to move as a unit with the distal
segment, the fracture is considered stable.

27. Non-Operative Treatment
• Indications
• Stable non-displaced or minimally displaced fractures,
• Patients not fit for surgery,
• Elderly patients with low functional demands.
• Relative Contraindications
• Displaced fractures with loss of bony contact.
• Close follow-up is required to confirm acceptable alignment
and fracture stability. Weekly radiographs should be
performed during the first month of treatment, followed by
biweekly radiographs until 6 weeks after injury or initial
callus formation is visible.

28. Complications
• Major complications following nonoperative treatment of
proximal humerus fractures include-
• Avascular necrosis
• Nonunion
• Malunion
• Stiffness
• Rotator cuff dysfunction
• Posttraumatic arthritis

29. Surgical vs nonsurgical treatment of adults with displaced fractures of
the proximal humerus involving surgical neck
Studied 231 pt(114 in surgical group and 117 in nonsurgical group) aged 16
yrs or older (mean age 66 yrs)
Patients were followed up for 2 years
Results
• There was no significant difference between surgical treatment
compared with nonsurgical treatment in patient-reported clinical
outcomes over 2 years following fracture occurrence.

30. • Total 518 patients (average age 70.93) met inclusion
criteria.
• Patients were followed up for at least 1 year in all the
studies.
Conclusion
• Operative treatments did not significantly improve the
functional outcome and healthy-related quality of life in
elderly patients. Instead, Operative treatment for CPHFs
led to higher incidence of postoperative complications.

31. CONTROVERSIAL
What is optimal management for
displaced Proximal Humerus
Fractures?

32. Operative Treatment of Proximal
Humeral Fractures
• Many surgical techniques have been described, but no single
approach is considered to be the standard of care.
• Appropriate treatment is individualized and selected on the basis
of the fracture pattern and the underlying quality of the bone.
• Surgical Options-
• Open Reduction and Internal Fixation
• Tension Band Fixation
• Closed Reduction and Percutaneous Fixation
• Hemiarthroplasty
• Reverse Total Shoulder Arthroplasty

33. Open Reduction and Internal Fixation (ORIF)
• ORIF is the most frequently used method of surgical
treatment of proximal humeral fractures.
• Surgical Approaches
• Deltopectoral Approach
• Deltoid-Splitting Approach

34. Deltopectoral Approach

35. Fixation using Conventional Plate
• Prior to the use of locking-plate technology, conventional
plate fixation was used for the majority of patients.
• Several studies have reported satisfactory healing rates
and functional outcomes after conventional plate and
screw fixation of proximal humeral fractures, especially
in younger patient populations.
• Many studies have however reported high rates of
infection, humeral head necrosis, and subacromial
impingement.
• Traditional plate constructs are usually reserved for
• Young patients with an intact medial hinge,
• Adequate diaphyseal cortex(>4 mm), and
• No metaphyseal comminution.

36. Fixation using Locking Plate
• The inability of conventional plates and screws to resist varus
deforming forces in the proximal humerus, particularly if the
bone is osteoporotic,has led to locking plate fixation being
used for these fractures.
• Several clinical studies have shown high rates of healing and
excellent functional recovery with proximal humerus locking
plates.
• Plate designs vary in terms of the number of proximal screws
and their arrangement, as well as the ability to place screws
at different angles with regard to the plate.
• A plate is selected to allow at least three screws to be placed
into the distal shaft segment. The plate position is also
selected to avoid subacromial impingement and to allow two
screws to be placed into inferomedial aspect of the humeral
head.

37. • A minimum of five or six screws are routinely placed into the
proximal segment. Screw placement should be performed by
drilling through the near cortex only. This avoids perforation of
the articular surface, and reduces the possibility of secondary
screw penetration.
• Once the plate and screws have been placed transtendinous
sutures are tied onto the plate to provide additional fixation.

38. • The use of IM fibular strut grafting has been described to
improve stability of varus-impacted fractures in which the
medial calcar may not be reliably reconstructed.
• Goal being to create a buttress at the inferior aspect of
the anatomic neck to prevent delayed varus collapse

39. Postoperative Care
• Patients are followed at 2 weeks, 6 weeks, and 3 months
after surgery.
• Patients are immobilized for 6 weeks in a sling while
active range-of-motion exercises of the elbow, wrist, and
hand are encouraged.
• Depending on the fracture pattern and stability that was
achieved, passive range of motion is started between 2
and 4 weeks after surgery with forward elevation,
external rotation, and pendulum exercises.
• If healing has adequately progressed both clinically and
radiographically at 6 weeks active-assisted range of
motion is started.

40. Tension Band Fixation
• It is most frequently used as an adjunct to plates and screw
fixation, IM nailing, and arthroplasty.
• The main goal of tension band fixation is the neutralization of
tension forces generated by the rotator cuff at the level of the
tuberosities, and bending at the level of the surgical neck.
• The main advantage of tension band fixation is the minimal amount
of hardware that is required. Thus avoiding the risks associated
with hardware, which include pain, neurovascular compromise,
migration, failure, and the need for removal.
• Contraindications
• Previous attempt(s) at internal fixation or
• Fractures older than six weeks.
• Highly comminuted four part fractures.

41. Tension-band construct with transosseous
suture fixation

42. Closed Reduction and Percutaneous Fixation
• It has theoretical advantage of minimizing soft tissue trauma,
thereby promoting healing and reducing the risk of AVN of the
humeral head.
• It also has the advantage of decreased scarring in the
scapulohumeral interface and subsequent easier rehabilitation.
• Indications-
• Fracture without significant communition in pt with good
quality bone.
• Pt should be willing to comply with postop care plan.
• Contra indications
• Severe comminution and osteopenia are absolute
contraindications
• Inability to reduce Fracture Fragments
• Fracture Dislocation
• Non Compliant patients

43. To avoid injury to the axillary nerve, lateral pins
should enter the humeral cortex at a point at least
twice the distance from the upper aspect of the
head to the inferior head margin with the wire
angulated approximately 45 degrees to the cortical
surface. The end point for the greater tuberosity pin
should be >2 cm from the inferior most margin of
the humeral head.

44. Intramedullary Nailing
• Biomechanical advantages in osteoporotic bone
• It allows stabilization with minimum surgical invasion
• Indications-
• Displaced two part surgical neck fractures
• Pathological fractures
• Contraindications-
• Varus four-part fractures with lateral displacement of
the humeral head
• Head-splitting fractures

46. Hemiarthroplasty
• Also known as humeral head replacement
• Indications-
• Four-part fractures,
• Three-part fractures in older patients with
osteoporotic bone,
• Fracture-dislocations
• Comminuted head-splitting fractures
• Head depression fractures involving more than 40%
of the articular surface
• Contraindications-
• Active infection of the shoulder joint and/or the
surrounding soft tissue

47. Postoperative Care
• Passive range-of-motion exercises are started on the
first postoperative day. They are limited to neutral
rotation and 90 degrees of forward elevation.
• Patients are followed up clinically and radiographically at
2 weeks, 6 weeks, and 3 months.
• Active-assisted range-of-motion exercises are started at
6 weeks and strengthening exercises at 3 months

49. Reverse Total Shoulder Arthroplasty
• By placing a hemisphere onto the glenoid surface and a
concave tray onto the humeral stem, reverse shoulder
arthroplasty allows for rotation to occur at the
glenohumeral joint through activation of the deltoid,
without the need for a functional rotator cuff/tuberosity
unit.
• Indications
• Complex acute proximal humeral fractures
• Proximal humerus malunion or nonunion where the normal
anatomy of the tuberosities cannot be reliably restored
• Glenohumeral joint arthritis with advanced rotator cuff
pathology
• Massive irreparable rotator cuff tears with painful
pseudoparesis

50. The ideal candidate for reverse total shoulder arthroplasty in a patient with a
complex proximal humerus fracture is a low demand elderly patient with pre-
existing rotator cuff pathology and glenoid pathology.

51. Comparison of outcomes of reverse shoulder arthroplasty (RSA) and
hemiarthroplasty (HA) in elderly pt.
Sixty-two patients older than 70 years were randomized to RSA (31 patients) and HA
(31 patients)
The mean functional scores and active range of motion were significantly better in the
RSA group. Revision rate was lower in RSA.

52. Complications
• Avascular necrosis of humeral head and/or tuberosity
• Non-union- The normal time for clinical union of a proximal
humeral fracture is typically 4 to 8 weeks. Nonunion is said to
be present if a fracture site is still mobile 16 weeks post injury.
• Malunion
• Post-traumatic Shoulder stiffness
• Post traumatic arthritis
• Infection
• Iatrogenic-such as inadequate reduction, incorrectly
positioned implants, screw penetration into the joint, loss
of fixation, tuberosity disruption, and nerve injury.
• Heterotopic bone formation

53. General Treatment Philosophy of
Proximal Humerus Fractures
• All nondisplaced fractures, minimally displaced fx as well
as most valgus-impacted fractures are treated non
operatively especially in patients with lower functional
expectations.
• In patients with higher baseline shoulder function and
higher expectations, surgical treatment may be
recommended for most displaced fractures.
• For patients undergoing surgical treatment fracture
reduction and fixation is performed in majority of cases
and effort should be made to reconstruct the proximal
humerus with emphasis being placed on achieving
anatomic reduction and stable fixation of the tuberosities.

54. • Shoulder arthroplasty is considered in fractures in which
a high suspicion of head nonviability is suspected
because of severe displacement of the fracture through
the anatomical neck without metaphyseal extension,
disruption of the medial hinge and frank dislocation from
the glenoid.
• In younger patients, hemiarthroplasty is the chosen
treatment method, in elderly patients, reverse shoulder
arthroplasty is preferred.

55. Treatment of Individual Injury Patterns
of Proximal Humerus Fracture
• Nondisplaced or Minimally Displaced One-Part
Fractures
• These are treated nonoperatively with initial
immobilization in a sling.
• Weekly radiographs and clinical assessment are
performed for the first 3 weeks. Elbow, wrist, and hand
mobilization begins immediately.
• Passive range-of-motion exercises are begun at 3
weeks if no change in fracture position has been
confirmed. Active-assisted range of- motion exercises
are begun at 6 weeks and strengthening is started at 3
months when bony healing has been confirmed
radiologically.

56. • Greater Tuberosity Fractures
• Displacement of the greater tuberosity is poorly tolerated
because of its key role in shoulder function
• Currently threshold of displacement for surgical
treatment of greater tuberosity fractures in active
patients is accepted as 5 mm (instead of 1 cm as per
Neers’s criteria)
• Flatow et al. reported the results of 12 displaced two-part
greater tuberosity fractures that were treated by heavy
suture fixation and rotator cuff repair. They reported
100% excellent or good results with all fractures healing
without displacement .

57. • Two-Part Greater Tuberosity Fractures and Fracture
Dislocations
• In elderly, frail patients (usually older than 80 years) with
limited functional expectations, a substantial degree of
displacement and these are treated non operatively.
• Operative treatment is advised for physiologically
younger patients with fractures, which are either
primarily displaced by more than 5 mm or become
displaced by this amount within the first 2 weeks after
injury.
• Fixation is obtained either with suture anchors in a
double row pattern or by the use of transosseous
sutures, or alternatively, a small T-plate may be fixed
laterally

58. • Two-Part Lesser Tuberosity Fractures and Fracture
Dislocations
• Isolated lesser tuberosity fractures typically occur in
younger or middle-aged patients and are displaced.
• ORIF- Preferred
• Single large fragment -definitive internal fixation is
performed using partially threaded 3.5-mm cancellous
screws, inserted through the lesser tuberosity.
• If communited- transosseous sutures is used for
fixation.

59. • Two-Part Surgical Neck Fractures
• All fractures in which the shaft is impacted into the
surgical neck are treated nonoperatively. A substantial
degree of translation of these two fragments is usually
tolerated, as long as there is residual cortical contact and
impaction.
• Displaced and comminuted surgical neck fractures in
physiologically younger patients are managed with ORIF
using a locking plate.

60. • Three- and Four-Part Fractures
• In physiologically older patients these are usually treated
nonoperatively if there is residual cortical continuity of
the humeral head fragment on the shaft, the tuberosities
are not too widely displaced, and the humeral head
appears viable.
• Operative treatment is offered to physiologically younger
patients, where the risk of nonunion, cuff dysfunction, or
osteonecrosis is high.
• ORIF is performed whenever possible, and preoperative
CT scan provide an indication of its feasibility. The
patient is always preoperatively counseled that if the
fracture is deemed to be unreconstructable, an
arthroplasty will be performed.
• Young patients - Cemented humeral head replacement
• Older patients – Reverse total shoulder arthroplasty

61. FRACTURE SHAFT
HUMERUS

62. 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.

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

64. AGE & GENDER SPECIFIC INCIDENCE
OF SHAFT HUMERUS FRACTURE

65. 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

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

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

68. 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.

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

71. 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.
 MRI for pathological #

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

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

75. 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)
○ Brachial Artery Injury.

76. TREATMENT OPTIONS
Non operative operative

77. 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

78. HUMERAL SHAFT
FRACTURES
 Conservative Treatment
 >90% of humeral shaft fractures
heal with nonsurgical
management
20degrees of anterior angulation,
30 degrees of varus angulation &
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.

79. 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.

80. 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.

82. 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.

83. TIME TO APPLY
 Not at the time of injury.
 Regular casts, time to correct any angular or
rotational deformity.
 Compound #, 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.

86. OPERATIVE MANAGEMENT
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.

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

88. 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.

89. ANTERIO LATERAL
APPROACH
 SUPINE ON THE ARM TABLE WITH 600
ABDUCTIONAT SHOULDER

90. 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.

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

92. PLATING - POSTERIOR APPROACH

93. 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).

94. 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).

95. 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)

96. 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.

97. EXTERNAL FIXATION

98. EXTERNAL FIXATION