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

2. 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.

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

4. 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

6. 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

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

8. 15°varus
12°anterior angulation

9. 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

10. Relative operative indications
Polytrauma
Bilateral humeral fractures

11. Morbid obesity
Segmental fractures
Need to use crutches

12. 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)

13. 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.

14. Surgical approaches
Lateral approach

15. Surgical approaches
Posterior approach

16. Antegrade nailing approach
Surgical approaches
Antegrade nailing approach

17. 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”

18. Absolute anatomical reduction
Plate

19. Relative functional reduction
Absolute
Relative functional reduction
Plate
Nail

20. Retrograde IM nailing

21. Absolute
Plate

22. Absolute
Relative
Plate
Plate Nail
Recommended

23. Plate

24. Absolute
Plate
Not recommended

25. Absolute
Relative
Plate
Plate Nail Ex-fix
Not recommended
Recommended

26. Plate
MIPO

27. External fixation

28. Nail
Plate

29. 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.

30. 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 May;36(5):905-6.

31. Radial palsy

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

33. 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 Dec;87(12):

34. 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