Fractures of the humeral diaphysis Published: September 2013 Minos Tyllianakis, GR AOT Basic Principles Course

Learning outcomes Classify and identify appropriate treatment strategies for humeral diaphyseal fractures Establish the operative indications for humeral diaphyseal fractures Understand the benefits and limitations of the various treatment strategies Teaching points: This must be a general presentation and specific treatment strategy will be discussed in the Advanced Principles course. Avoid controversial evidence apart from the advice to use two distal interlocking screws in IM nailing to improve stability.

Two critical questions Can this fracture be treated nonoperatively? If no, what is the best surgical method for this particular fracture?

Can this fracture be treated nonoperatively? Before we decide: Ample blood supply to humerus Limb discrepancy not easily identified in the upper arm Slight angulation and malrotation likewise

Nonoperative treatment Good results in up to 95% Not only with a Sarmiento brace < 20o anterior and varus angulation < 15o of rotation < 3 cm shortening

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

15°varus 12°anterior angulation

Nonoperative treatment applicable in all cases? Failure of closed treatment Open fractures Vascular injury Radial nerve palsy after closed reduction Floating elbow Pathological fractures (bone metastases) Brachial plexus injury Absolute indications for operative treatment

Relative operative indications Polytrauma Bilateral humeral fractures

Morbid obesity Segmental fractures Need to use crutches

If we operate, what is the best method for this particular fracture? First consider: What type of reduction do we need—anatomical or functional? What type of stability? Absolute (direct callus formation) Relative (indirect callus formation)

More specifically? Fracture pattern indicates the stability required and the method chosen: Relative stability: External fixation IM nailing Plate Absolute stability: In the humeral diaphysis, the pattern of the fracture indicates the stability required and consequently the method chosen.

Surgical approaches Lateral approach

Surgical approaches Posterior approach

Antegrade nailing approach Surgical approaches Antegrade nailing approach

What is the criterion for choosing the approach? Surgical approaches What is the criterion for choosing the approach? “The nerve in the middle of the field”

Absolute anatomical reduction Plate

Relative functional reduction Absolute Relative functional reduction Plate Nail

Retrograde IM nailing

Absolute Plate

Absolute Relative Plate Plate Nail Recommended

Plate

Absolute Plate Not recommended

Absolute Relative Plate Plate Nail Ex-fix Not recommended Recommended

Plate MIPO

External fixation

Nail Plate

Acromion to the axillary nerve: 55.8 mm A mean distance of the locking screw to the axillary nerve was 1–2.7 mm Acromion to the axillary nerve: 55.8 mm References: Nijs S, Sermon A, Broos P. Intramedullary fixation of proximal humerus fractures: do locking bolts endanger the axillary nerve or the ascending branch of the anterior circumflex artery? A cadaveric study. Patient Safety in Surgery 2008, 2:33.

Nail versus plate There is no significant statistical or clinical difference in union rates or reoperation rates between DCP and IM nailing Apparent higher complication rate for IM nailing and a potentially greater risk of infection with DCP References: Vennettilli M, Petrisor B, Athwal GS. Operative treatment of diaphyseal humeral fractures. J Hand Surg Am. 2011 May;36(5):905-6.

Radial palsy

Fracture and nerve palsy Nerve palsy after closed reduction, surgical exploration, and ORIF Nerve palsy after fixation, surgical exploration, and ORIF?

Fracture and nerve palsy Postinjury radial nerve palsy 11.8% (532 palsies in 4,517 fractures) No significant difference between those initially managed expectantly with those explored early Spontaneous recovery up to 6 months References: Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec;87(12):1647-52.

Take-home messages Nonoperative treatment is a successful method for the majority of humeral diaphyseal fractures Principles of relative stability should be applied in the majority of fractures treated operatively Posttraumatic radial nerve palsy is not an indication for operative treatment of humeral fractures