Humeral Shaft Fracture

 

Non operative Mangement

 

Indications

 

< 20o sagittal

< 30o coronal

< 3 cm of shortening

 

Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral

 

Options

 

1.  Vietnam Cast / hanging cast

2.  Functional bracing 3/52

 

Functional Humerus Brace

 

Results

 

United Humeral Fracture LateralUnited Humeral Fracture

 

Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative group nonunion 20% and 12% malunion

- operative group nonunion 8% v 1%

- no increased time to union or radial nerve palsy in operative group

 

Operative Managment

 

Indications

 

Absolute

- compound fracture

- radial nerve palsy post reduction

- failure to obtain / maintain acceptable reduction

- displaced Holstein Lewis with radial nerve palsy

 

Relative

- multi-trauma

- floating elbow

- obese (very difficult to splint)

- pathological fracture - won't heal

- segmental fracture

- bilateral humeral fractures

- brachial plexus injury - allows early rehab

 

Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral

 

Options

- antegrade IM Nail

- retrograde IM Nail

- ORIF with plate

 

Indications Plate vs Nail

 

Chapman et al J Orthop Trauma

- RCT antegrade nail v plate 84 patients

- union rates similar in each - 90%

- shoulder discomfort and decreased ROM with nail

- decreased elbow ROM with plate especially distal third

 

1.  Antegrade Humeral Nail

 

Humeral Nail APHumeral Nail Lateral

 

Relative indications

- segmental fracture - need very long plate

- impending pathological fracture

 

Technique

 

Set up

- lazy beach chair

- need to get II of shoulder and distal forearm

- patient relatively supine to ensure ease of AP distal locking

 

Anterolateral approach shoulder

- longitudinal split SS

- entry point at medial aspect GT

- entry with K wire or awl

- check down IM canal of humerus with II

- most nails have mild valgus proximal angulation

- increase diameter proximally with hand reamers

 

Pass guide wire

- can do closed

- can perform mini open to blunt dissect and protect radial nerve

 

Minimal reaming

 

Pass nail

- bury enough to protect cuff

- need to consider hardware removal

 

Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon

 

Distal AP locking screw

 

Careful repair of rotator cuff

 

Results

 

Cox et al J Orthop Trauma 2000

- 37 patients treated with antegrade nail

- 4 non unions and 4 delayed unions (>4 months)

- 6 patients had poor shoulder function (4 due to stiffness, 2 due to pain)

 

Complications

 

Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

- still incidence of shoulder pain

 

Humerus Prominent IM Nail

 

2.  Retrograde IM Nail

 

Relative indication

- distal 1/3 humeral fracture

- avoids shoulder pain

 

Technique

 

Set up

- Patient prone

- arm on table, need to flex elbow

 

Entry dorsal

- 3cm above Olecranon fossae

- gentle reaming to prevent blow-out

 

Distal locking with butterfly construct and screws

 

Proximal locking

- some have extendable hook

 

Complications

 

Distal blow out

- difficult problem

 

Nail removal

- not easy procedure

 

Results

 

Cheng et al J Trauma 2008

- RCT of antegrade v retrograde IMN

- similar union rates (>90%)

- longer time to perform retrograde IMN

- longer time to recover shoulder function in antegrade group

 

3.  Plate Osteosynthesis

 

Humeral Plate LateralHumeral Plate Long AP

 

Indications

- nerve injury requiring exploratation

 

Approaches

1.  Proximal 2/3

- anterior or anterolateral

2.  Distal 1/3

- posterior

 

Technique

 

A.  Anterior Approach Humerus

 

Sterile tourniquet

 

Incision lateral aspect of biceps

- incise deep fascia

 

Proximally

- retract deltoid laterally and biceps medially

 

Identify plane between biceps and brachialis

- protect MCN between the two

- identify and split brachialis in midline

 

Internervous plane

- radial nerve lateral brachialis

- MCN medial brachialis

 

Distal extension

- between brachialis and BR in distal 1/4

- find and protect radial nerve

 

4.5 mm DCP

- minimum 6 cortices above and below

 

B.  Anterolateral approach

 

Allows more distal plating

 

Utilise interval between triceps and brachialis

- identify and protect radial nerve distally between brachialis and BR

- extend proximally into deltopectoral groove

 

C.  Posterior Approach

 

Humerus ORIF Posterior Approach

 

Position

- lateral approach

- arm over bolster

 

Sterile tourniquet if needed

 

Midline incision

- interval between long and lateral heads

- Split medial head of triceps

- identify radial nerve proximally 

 

Radial Nerve Injury

 

Incidence

 

4% incidence of radial nerve injury

 

Associated with Holstein Lewis fracture

 

Holstein - Lewis JBJS Am  1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

 

Holstein Lewis

 

Incidence of laceration / entrapment

 

Noaman et al Microsurgery 2008

- operative exploration of 36 patients with radial nerve palsy

- entrapped in fracture site in 9 and lacerated in 8

- 9 epineural repairs and 5 nerve grafts

- neurolyis in remainder

 

Recovery

 

Average time to see recovery is 7 weeks

Average time to full recovery 15 weeks

Longest time to see recovery 7 months to 1 year

 

NHx

 

Sarmiento JBJS Am 2000

- 922 fractures managed in brace, 620 followed, no MUA

- radial nerve palsy in 11% / 101

- 1 radial nerve didn't recover

 

Pollock & Drake et al JBJS Am 1963

- 24 humeral shaft fractures with radial palsy (14/24 distal third)

- 9 of these were complete motor and sensory (8/9 distal third)

- treatment immobilisation or traction

- all had complete recovery

 

Options

 

1.  Explore + ORIF

- easy to make this decision if fracture requires operative management

 

2.  Manage non operative

- if no recovery tendon transfer