FRACTURES OF HUMERAL

DIAPHYSIS
ANATOMY
 INCIDENCE
 Humerus shaft fractures make up 5% of all
fractures. 
 Sixty percent of the fractures are non-
displaced or minimally displaced, and
therefore, can be managed non-operatively.
 Associated injuries are common in patients
with osteoporosis.
 Sometimes nerve and rarely vascular
injuries are associated with humeral shaft
fractures.
 
 HISTORY
 History of a benign fall in
which the elbow is either
struck directly or axially
loaded in a fall onto an
outstretched hand.
 Motor vehicle and sport
injuries account for most
humeral injuries for
younger males.
 Pathologic fractures of the
humerus may occur with
minimal trauma.
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
 CLASSIFICATION
 Morphological classification:
Traditionally, humeral shaft fractures are
described
according to their level(proximal, middle
and distal
thirds) and pattern.
 – Transverse
 – Oblique
 – Spiral
 – Segmental
 – Comminuted
AO CLASSIFICATION
(Muller)
 Bone = humerus = 1 Segment =
diaphysis = 2
 Groups = A/B/C where
 A: Simple fracture
 B: Wedge fracture
 C: Complex fracture
Subgroups:
A1: Simple fracture, spiral
A2: Simple fracture, oblique (≥30o)
A3: Simple fracture, transverse (<30o)
B1: Wedge fracture, spiral wedge
B2: Wedge fracture, bending wedge
B3: Wedge fracture, fragmented wedge
C1: Complex fracture, spiral
C2: Complex fracture, segmental
C3: Complex fracture, irregular
 AO coding

A simple transverse fracture of lower

shaft is coded as:
 1.2. A 3.3
1= Humerus
2= Diaphysis
A= Simple fracture
3= transverse
3= midshaft
 Clinical evaluation
Thorough history and
physical
Patients typically
present with pain,
swelling, and deformity
of the upper arm
Careful NV exam
important as the radial
nerve is in close
proximity to the
humerus and can be
injured
 CLINICAL EVALUATION
 Diaphyseal fracture patients present with a
painful deformed arm. (The direction of
displacement of the fractured fragment depends
on the level of the fracture. An injury distal to the
deltoid insertion causes abduction of the
proximal, and adduction of the distal fragment. It
is reverse in fractures proximal to deltoid
insertion).
 Associated with a radial nerve palsy. Usually,
the radial nerve palsy is reversible.
 Crepitus may be observed.
 Shortening of the arm suggests displacement.
 With all humerus fractures, ensure strong radial
 Holstein-Lewis
Fractures
Distal 1/3 fractures
May entrap or lacerate radial nerve as the
fracture passes through the intermuscular
septum
 RADIOLOGICAL
EVALUATION
 Radiographic evaluation
 AP and lateral views of the humerus
 Traction radiographs may be indicated
for hard to classify secondary to severe
displacement or a lot of comminution.
FRACTURE PATTERNS
FRACTURE PATTERNS
 TREATMENT

 ATLS

 FIRST AID
 Rest
 Reassurance
 Analgesia

 DEFINITIVE TRATMENT
DEFINITIVE TREATMENT
 Depends on:

 Age of patient
 Fracture pattern
 Associated co-morbidities
 Polytrauma
 Associated complications
DEFINITIVE TREATMENT

TYPES:
 Conservative
 Interventional
 O.R.I.F
 EXTERNAL FIXATION
 RECONSTRUCTION
Vascularized fibula
Bone grafting
Ilizrov / distraction osteosynthesis / distraction
osteogenesis.
 Conservative
Treatment
Goal of treatment is to
establish union with
acceptable alignment
>90% of humeral shaft
fractures heal with nonsurgical
management
20 degrees 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 splint
or a hanging arm cast followed by
 Sling Method

This method utilizes the GRAVITY for

treatment
 A long arm cast is applied and the supporting
sling is kept as far towards the wrist as possible.
 Gravity pulls the arm down because of the weight
of the plaster and aligns the fragments which
then tend to unite in good alignment
 Periodic X-rays are necessary to check fracture
alignment.
 Operative Treatment
Indications for operative treatment
include:
inadequate reduction,
nonunion,
associated injuries,
open fractures,
segmental fractures,
associated vascular or nerve injuries

 Careful prospective planning is essential. The

risks of a neurovascular injury, delayed or non-
union and other associated problems should be
discussed with the patient
 Methods of operative
interventions
 Open reduction and internal
fixation
The fracture site is exposed, fragments reduced
and fixed with a dynamic compression plate (DCP)
and screws.
 Interlocking Intramedullary nail
An ‘ante grade’ or a ‘retrograde’ nail is
introduced into the medullary cavity of the
humerus after closed reduction of the fracture.
The nail is then locked proximally and distally to
achieve rotational stability. This requires image
intensification.
 External fixation
This method of treatment may be used in open
or multiple fractures. Percutaneous pins are
 Open Reduction Internal
Fixation
 Open reduction with internal fixation may be indicated
when:

 (1) satisfactory position and alignment cannot be achieved by

conservative measures,
 (2) associated injuries in the extremity require early
mobilization,
 (3) a fracture is segmental,
 (4) a fracture is pathological,
 (5) fractures are associated with major vascular injuries
 (6) a spiral fracture of the distal humerus is of the type
described by Holstein and Lewis, in which radial nerve palsy
develops after manipulation or application of a cast or splint ,
(7) when treatment of associated injuries makes bed rest
necessary, and
 (8) Severe neurological disorders, such as uncontrolled
parkinsonism, that
Open Reduction Internal
Fixation
Open Reduction Internal
Fixation
INTERLOCKING NAILING
INTERLOCKING NAILING
 EX Fix

 Used in Gustillo II and onwards

 Fracture reduction should be as best
as possible
 Min 2 SS in each fragment
 Avoid radial nerve
 Uni-planar
 Ilizrov
 Cleanliness
 Complications

 Malunion
 Nonunion
 Radial nerve palsy
 Infection / iatrogenic osteomyelitis
 Painful scar
 Restricted elbow function
QUESTIONS

ARSALAN