1. Fractures of the Humeral Shaft
Gregory L. DeSilva, MD
Associate Professor,
University of Arizona

2. Introduction Shaft fractures traditionally treated nonsurgically
high rate of complications?
Infection
Nonunion
Radial nerve palsy.

3. AO/OTA Classification

4. AO/OTA Classification

5. Physical Examination Cardinal signs: Look for associated injuries
pain
swelling
deformity
Look for associated injuries
Document neurovascular exam!
Radial Nerve Function

6. Imaging Standard X-raysAP
lateral view
Joints above and below
CT/MRI if pathologic fx suspected, x-rays not clear

7. Nonsurgical Treatment
Most humeral fractures are amenable to closed, nonsurgical treatment
rigid immobilization is not necessary for healing
perfect alignment is not essential for an acceptable result

8. What is Acceptable Alignment?
Great tolerances of alignment
We don’t walk on arms
Shoulder/elbow have large ROM
20 degrees of anterior or posterior angulation
30 degrees of varus (less in thin patients)
3 cm of shortening

9. Closed Treatment For you, the Jr. Resident!!!
Coaptation splint or a hanging arm cast in ED
Coaptation splint is preferred due to the support it offers proximal to the fracture site
Conversion to a functional brace in 7 to 10 days

10. Functional Bracing Sarmientio, 1977
Soft-tissue compression/hydrostatic pressure
Anterior and posterior shell w/ Velcro straps
Applied acutely or following coaptation splint
Active shoulder and elbow ROM

11. Contraindications to Functional Bracing
Massive soft-tissue or bone loss
Unreliable or uncooperative patient
Inability to obtain and maintain acceptable fracture alignment
Fracture gap present - increases risk of nonunion

12. Surgical Treatment
Surgical intervention is preferable in specific cases
Injury Related Factors
Patient Related Factors

13. Indications for ORIF - Injury Factors
Failed closed treatment
Loss of reduction
Poor patient tolerance/compliance
(Open fractures)
Vascular injury/
Change in neuro exam (radial n.)
Floating elbow

14. Indications for ORIF - Injury Factors
Associated intra-articular fractures
Associated injuries to the brachial plexus
Chronic problems
Delayed union
Nonunion/malunion
Infection

15. Indications for ORIF - Patient Factors
Polytrauma-requiring arm for mobilization
Head injuries
Burns
Chest trauma
Multiple fractures
Patient unable to be upright

16. Surgical Treatment Plate osteosynthesis IM fixation External fixation
Lag screws alone are not strong enough
IM fixation
External fixation

17. Plate Osteosynthesis
The best functional results: use of plates and screws
Direct fracture reduction
Stable fixation of the humeral shaft
No violation of the rotator cuff
Visualization of radial nerve

18. Plate Osteosynthesis Results:
Union rates averaged 96% with significant complications ranging from 3% to 13%
motion restrictions at the elbow

19. Anterolateral Approach
Benefits
Supine positioning
Proximal extension possible via deltopectoral interval
Drawbacks
less direct exposure of radial nerve (posterior to intermuscular septum)
Difficulty in applying plate to lateral aspect of humerus for distal fractures

20. Anterolateral Approach
For proximal and middle third fxs

21. Posterior Approach Benefits of posterior approach:
Allows more direct exposure of the radial nerve
Allows application of a broad plate to flat surface of distal humerus for distal third fractures
Drawbacks to posterior approach:
Requires lateral or prone positioning which may be problematic for polytrauma patient
Requires nerve mobilization for plate application, theoretically increasing risk of iatrogenic palsy

22. Mills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996.
Lateral Approach
Benefits of posterior approach:
Allows direct exposure of the radial nerve
Extensile
Supine position
Drawbacks to posterior approach:
Less familiar to surgeons
Posterior antebrachial cutaneous nerve at risk
Mills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996.

23. Medial Approach True internervous interval Not extensile proximally
Used in open fxs when wound medial?

24. Complications of Humeral Shaft Fractures
Radial nerve injury
Vascular injury
Nonunion

25. Radial Nerve Injury
Incidence varies from 1.8% to 24% of shaft fractures
Primary - injury
Secondary - occurs later during closed or open management
Management controversial

26. Radial Nerve Injury Spontaneous recovery: ~90%
Even secondary palsies, have a high rate of spontaneous recovery
EMG and nerve conduction studies can help, (but not acutely!)
If no recovery, tendon transfers very reliable

27. Preferred Management of Fractures with Associated Radial Nerve Palsy
Indications for surgery:
Open fractures
Secondary palsies developing after a closed reduction

28. Vascular Injury Uncommon Key is clinical diagnosis Debate:
Shunt, ORIF, then bypass/repair
ORIF then bypass/repair

29. Nonunion
Rate: 0% to 15%

30. Nonunion: Predisposing Factors
transverse fracture pattern
older age
poor nutritional status
osteoporosis
endocrine abnormality affecting calcium balance
use of steroids
anticoagulation
previous RT

31. Nonunion: Surgical Treatment
Compression plate fixation for hypertrophic nonunions
Biologic stimulation + plate for atrophic nonunions

32. Nonunion: Surgical Treatment
Compression plate fixation for hypertrophic nonunions
Biologic stimulation + plate for atrophic nonunions

33. Summary Humeral Shaft Fractures
Results very good for functional bracing
Need to carefully document radial nerve exam
Most radial nerves injuries recover
Most prefer plates over nails
Look for prospective study of immediate fixation vs. functional bracing

34. SWOTA : 2010 Resident Course - Fundamentals of Fracture Care
PROXIMAL HUMERUS AND DIAPHYSEAL FRACTURES
Helpfulness of Material
A) B) C) D) E)
Worst Bad OK Good Best
COMMENTS Please

35. Quality of Presentation
SWOTA : 2010 Resident Course - Fundamentals of Fracture Care
PROXIMAL HUMERUS AND DIAPHYSEAL FRACTURES
Quality of Presentation
A) B) C) D) E)
Worst Bad OK Good Best
COMMENTS Please