1) Fractures of the humerus shaft account for 3-5% of all fractures and usually heal well with conservative treatment. 2) Non-operative treatment is indicated for undisplaced or minimally displaced fractures, while operative treatment involving plating or nailing is used for more displaced fractures or those with complications. 3) Surgical treatment options include plating through various approaches like anterior or posterior, as well as intramedullary nailing. Plating remains the gold standard due to high union rates and limited complications.

1. HUMERUS SHAFT
FRACTURES
• Dr. Pawan K. Yadav
• D.ORTHO.,DNB(ORTHO)
• BIRRD HOSPITAL, TIRUPATHI

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 scanningmay 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)
• Brachial Artery Injury

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
• SUPINE ON 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 motion.

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
• Reliable, 96% union
• Good
shoulder/elbow
function
• Soft tissue – scars,
radial nerve,
bleeding
• Nail
• Less incision required
• Higher incidence of
complications?
• Lower union rate?

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