This document provides an overview of fractures of the humeral shaft, including:
1) It discusses the relevant anatomy of the humeral shaft and the deforming forces that can result from fractures in different locations.
2) It describes classification systems for humeral fractures and indications for both nonsurgical and surgical treatment. Nonsurgical treatment typically involves immobilization with a splint or brace while surgical options include plate osteosynthesis or intramedullary fixation.
3) For surgical treatment, it covers plate versus nail fixation and different surgical approaches for plate application, emphasizing the need to protect surrounding soft tissues and nerves.
This document provides an overview of fractures of the humeral shaft, including:
1) It discusses the relevant anatomy of the humeral shaft and the deforming forces that can result from fractures in different locations.
2) It describes classification systems for humeral fractures and indications for both nonsurgical and surgical treatment. Nonsurgical treatment typically involves immobilization with a splint or brace while surgical options include plate osteosynthesis or intramedullary fixation.
3) For surgical treatment, it covers plate versus nail fixation and different surgical approaches for plate application, emphasizing the need to protect surrounding soft tissues and nerves.
This document provides an overview of fractures of the humeral shaft, including:
1) It discusses the relevant anatomy of the humeral shaft and the deforming forces that can result from fractures in different locations.
2) It describes classification systems for humeral fractures and indications for both nonsurgical and surgical treatment. Nonsurgical treatment typically involves immobilization with a splint or brace while surgical options include plate osteosynthesis or intramedullary fixation.
3) For surgical treatment, it covers plate versus nail fixation and different surgical approaches for plate application, emphasizing the need to protect surrounding soft tissues and nerves.
Original Author: Patrick J. Brogle, MD; Created March 2004 Second Author: Andrew Sems, MD; Revised 2006 Current Author: Gregory J. Della Rocca, MD, PhD; Revised 2010
Introduction Humeral fractures traditionally treated nonsurgically, with predictably satisfactory outcomes. Strong bias formerly existed against surgical intervention due to high rate of complications. Both operative and nonoperative treatments have been refined. Relevant Anatomy Humeral diaphysis extends from the upper border of the insertion of the pectoralis major proximally to the supracondylar ridge distally
Fracture alignment determined by the location of the fracture relative to the major muscle attachments, most notably the pectoralis major and deltoid attachments Deforming Forces Example of a fracture distal to pectoralis major attachment and proximal to deltoid tuberosity Adduction of proximal fragment results Reproduced with permission from Epps H Jr., Grant RE: Fractures of the shaft of the humerus in Rockwood CA Jr., Green DP, Bucholz RW (Eds.) Rockwood and Greens Fractures in Adults Ed 3, Philadelphia, PA JB Lippincott, 1991, Vol. 1, pp: 843-869 Example of a fracture distal to deltoid tuberosity The proximal fragment is abducted and shortening occurs at fracture site due to pull of biceps and triceps Reproduced with permission from Epps H Jr., Grant RE: Fractures of the shaft of the humerus in Rockwood CA Jr., Green DP, Bucholz RW (Eds.) Rockwood and Greens Fractures in Adults Ed 3, Philadelphia, PA JB Lippincott, 1991, Vol.. 1, pp. 843-869 Classification Systems Classification based on fracture descriptors AO Classification Fracture Descriptors Location Pattern Low-energy vs. high-energy Open / Closed Injury Classifications AO/OTA Classification Mechanism of Injury Direct (fracture at site of impact) or indirect forces (compression or torsion between elbow and shoulder) Violent muscle contraction (e.g. arm wrestling)
Physical Examination Cardinal signs of long bone fracture include: pain swelling deformity Look for associated injuries Document neurovascular exam radial nerve function Imaging Standard radiographic examination AP lateral view Both joints CT/MRI if pathologic fx suspected, xrays not clear Nonsurgical Treatment Many humeral fractures are amenable to closed, nonsurgical treatment rigid immobilization is not necessary for healing perfect alignment is not essential for an acceptable result* *Klenerman JBJS 48B:105-111 (1966) An understanding by the treating physician of the postural and muscular forces that must be controlled A dedication to close patient supervision and follow-up A cooperative and preferably upright and mobile patient An acceptable reduction Nonsurgical Treatment - Requirements What is Acceptable Alignment? Because the shoulder and elbow are joints capable of wide ranges of motion, the arm is thought to be able to accommodate the following without a significant compromise of function or appearance: 20 degrees of anterior or posterior angulation 30 degrees of varus (less in thin patients) 3 cm of shortening Klenerman, JBJS-B, 48:105 (1966) This has not been proven Closed Treatment Initial immobilization with either a coaptation splint or a hanging arm cast with conversion to a functional brace in the subacute phase when swelling and pain have improved, usually at 7 to 10 days Coaptation splint is preferred due to the support it offers proximal to the fracture site Functional Bracing for the Humerus Principles were introduced by Sarmiento in 1977
98% union rate with good functional restoration and minimal angular deformity Nearly full ROM of the extremity were restored and complications were minimal Functional Bracing for the Humerus Effects fracture reduction through soft-tissue compression (hydraulic cylinder) Consists of an anterior and posterior shell held together with Velcro straps Can be applied acutely or following application of a coaptation splint Success depends on: Upright patient Tightening daily Cannot lean on elbow Contraindications to Functional Bracing Massive soft-tissue or bone loss An unreliable or uncooperative patient An inability to obtain or maintain acceptable fracture alignment Fracture gap present (e.g. distraction of fracture) - increases risk of nonunion Surgical Treatment Surgical intervention is preferable in specific cases Injury Related Factors Patient Related Factors Indications for ORIF - Injury Factors Failed closed treatment Loss of reduction Poor patient tolerance/compliance Failure of union Open fractures Vascular injury Floating elbow Indications for ORIF - Injury Factors Associated intra-articular fractures Associated injuries to the brachial plexus Chronic problems Delayed union Nonunion/malunion Infection Only open fractures and those with vascular injury present absolute indications for surgical intervention Indications for ORIF - Patient Factors Polytrauma-requiring arm for mobilization Head injuries Burns Chest trauma Multiple fractures (need for crutch use) Patient unable to be upright Bilateral fractures of the humerus Pathologic fractures Morbid obesity Surgical Treatment If surgical intervention is elected, the following options are available: Plate osteosynthesis Intramedullary fixation External fixation There likely is no role for stabilization of the humeral shaft by screw fixation alone due to the high bending and torsional forces imposed on the humerus during patient and extremity mobilization Surgical treatment plate vs nail Slightly increased rate of good-excellent results and slightly faster union speed after plating compared with nailing Singisetti and Ambedkar, Int Orthop 34:571-576 (2010) Slightly faster union speed after nailing but equal union rates and functional outcomes between plates and nails Changulani et al, Int Orthop 31:391-395 (2007) Plating results in fewer re-operations and complications as compared to nailing McCormack et al, JBJS 82B:336-339 (2000) Surgical treatment plate vs nail Both work in capable hands Neither has been proven to be better than the other Plate Osteosynthesis The best functional results after surgical management of humeral shaft fractures have been reported with the use of plates and screws These implants allow direct fracture reduction and stable fixation of the humeral shaft without violation of the rotator cuff Plate Osteosynthesis Results: Union rates average 96% with significant complications ranging from 3% to 13% motion restrictions at the elbow or shoulder usually due to other severe bony or soft-tissue injuries to the same extremity Plate Osteosynthesis-Approaches The surgical approach is dependent on the fracture level and the need to visualize the radial nerve Anterolateral , posterior, and lateral approaches are supported by the literature The anterolateral approach is preferred for proximal third fractures The anterolateral and posterior approach are both adequate for midshaft and distal third fractures Lateral approach gives good exposure of entire shaft, but is less familiar. Anterolateral Approach Benefits of anterolateral approach Supine positioning Proximal extension possible via deltopectoral interval
Drawbacks of anterolateral approach Allows for less direct exposure of radial nerve since it lies posterior to intermuscular septum Difficulty in applying plate to lateral aspect of humerus for distal fractures Posterior Approach triceps splitting 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 Delineation of interval between long and lateral heads often not distinct; medial head split may denervate part of triceps Posterior approach triceps- sparing Does not split triceps Triceps elevated and mobilized medially Identify lower lateral brachial cutaneous nerve Always reaches radial nerve trifurcation Incise lateral intermuscular septum to improve nerve mobility Can expose ~90% of posterior humerus Gerwin and Hotchkiss, JBJS 78A:1690-1695 (1996) Lateral Approach Benefits of lateral approach: Allows direct exposure of the radial nerve Extensile Supine position Drawbacks to lateral approach: Less familiar to surgeons Posterior antebrachial cutaneous nerve at risk Mills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996. Technique & Choice of Implant During fracture exposure, excessive soft-tissue stripping must be avoided Take care to preserve soft-tissue attachments, and vascularity to butterfly fragments Remember sound plating techniques Pre bend plate for transverse fracture to prevent gapping of far cortex
Humeral shaft is subject to large rotational forces Broad 4.5-mm compression plate with staggered holes was developed specifically for use in tubular bones subject to these forces Theoretically, the in-line nature of the holes in the narrow 4.5-mm plate increases the chance of a longitudinal stress fracture when a rotational force is applied Plate Osteosynthesis: Choice of Implant Plate Osteosynthesis: Choice of Implant The anterolateral application of a plate for proximal and middle 1/3 shaft fractures is relatively straightforward Placement of a broad plate anteriorly on the narrow lateral condyle for distal 1/3 shaft fractures is technically difficult When fracture is in the distal 1/2 of the humeral shaft, a posterior approach for placement of a plate on the flat surface of the posterior humerus is often accomplished more easily Plate Osteosynthesis: Choice of Implant Narrow 4.5-mm plates, limited contact plates, and even 3.5-mm compression plates may be acceptable implants with proper attention to the details of reduction and stabilization 4.5 mm plates, and perhaps 3.5 mm plates, will allow immediate weight bearing for crutch/walker use. Tingstad et al, J Trauma 49:278-280 (2000) Plate Osteosynthesis Injury film of patient with bilateral humeral shaft fractures and C5- C6 fracture-dislocation and associated spinal cord injury Surgical intervention is indicated Bilateral fractures Neurological deficit Plate Osteosynthesis ORIF performed through anterolateral approach Lag screw placed though plate 4 bicortical screws placed in each fracture fragment Uneventful union followed Plate osteosynthesis Osteoporosis Locking plates biomechanically acceptable for osteoporotic humeri Two bicortical screws per segment acceptable Hak et al, J Orthop Trauma 24:207-211 (2010)
Locking plates for humerus fractures without osteopenia Consider for fractures with distal or proximal extension Anatomically- contoured plates More fixation options (multiple screws, differing screw trajectories) Intramedullary Fixation IMN (Intramedullary Nails) offers biologic and mechanical advantages over plates and screws IMN can be inserted without direct fracture exposure, minimizing soft-tissue scarring Because the implant is closer to the mechanical axis than a plate, they are subject to smaller bending loads than plates and are less likely to fail by fatigue Intramedullary Nailing IMN can act as load-sharing devices in fractures that have cortical contact if the nail is not statically locked Stress shielding, with cortical osteopenia, commonly seen with plates and screws, is minimized with intramedullary implants Intramedullary Nailing- Relative Indications Segmental fractures for which plate placement would require considerable soft-tissue dissection Humerus fractures in osteopenic bone Pathologic humeral fractures Highly comminuted fractures, shaft fractures with extension to surgical neck Intramedullary Nails Two types of IMN are available for use in the humeral shaft: Flexible Nails Interlocked Nails Flexible Nails Many types: Hackenthal nails, Rush rods, Ender nails, titanium elastic nails Rationale: fill the canal with multiple nails and to achieve an interference fit, creating both rotational and bending stability Reality: relatively poor stability Use perhaps should be reserved for humeral shaft fractures with minimal comminution or for treatment of pediatric humeral shaft fractures Flexible Nailing Retrograde insertion of 3.0 mm elastic titanium nails allowed healing of this segmental humerus fracture with callus Flexible Nailing Retrograde Enders nailing of this displaced humeral shaft fracture in a polytrauma patient allowed healing to occur with exuberant callus Flexible Nails-Outcomes Early reports of using antegrade insertion method documented unacceptable rates of nonunion, delayed union, and postoperative shoulder pain Series in which retrograde insertion method was used have shown better outcomes Alignment was consistently good No association with loss of elbow ROM Interlocked Nails In the past, these nails required reaming of the canal to accommodate their larger size Concerns about damage to the radial nerve during reaming have led to the development of implants small enough to be inserted without prior reaming Beware of jamming nail into tight distal segment, causing fracture distraction. Medullary canal ends proximal to olecranon/coronoid fossae and narrows substantially proximal to its end Many of these nails are solid Interlocked Nails: Proximal Locking Typically done with outrigger attached to nail Screws inserted from lateral to medial, or obliquely Screws protruding beyond the medial cortex may potentially impinge upon the axillary nerve during internal rotation Anterior to posterior screws are avoided due to potential for injury to the main trunk of the axillary nerve Interlocked Nails: Distal Locking Usually consists of a single screw in the anteroposterior plane Distal locking screw can be inserted anterior to posterior or posterior to anterior via an open technique, minimizing the chance of neurovascular injury Lateral - medial screws risk injury to lateral antebrachial cutaneous nerve Interlocked Nails: Insertion Techniques Antegrade insertion involves opening the IM canal proximally in the vicinity of the rotator cuff The optimal location and the proximal method of entry remain controversial Nail must be seated beneath the cuff to prevent impingement High incidence of shoulder pain plagues technique of antegrade insertion of humeral nails Interlocked Nails: Insertion Techniques Retrograde insertion involves opening the IM canal at a point proximal to the olecranon fossa Supracondylar portal weakens humerus considerably in torsion Strothman, J Orthop Trauma 14:101 (2000) Care must be taken to prevent creation of an iatrogenic distal humerus fracture No significant problems with postoperative elbow ROM Interlocked Nails: Reaming Reaming increases the length along which the nail contacts the endosteal surface, thereby providing better fracture stability Reaming decreases the risk of nail incarceration Reaming decreases the risk of fracture diastasis Reaming permits placement of a larger diameter, and therefore stronger nail Reaming produces potentially osteogenic morselized bone chips, which may enhance fracture healing Interlocked Nails: Reaming Reaming obliterates the nutrient artery and endosteal blood supply Placing an unreamed nail does much of this as well Blood supply will reconstitute if the nail has channels along its length Since the cortical thickness of the humerus is much less than that of the femur and tibia, excessive endosteal reaming may thin the humeral cortex and result in increased fracture comminution Interlocked Nailing Closed locked nailing of this pathologic humeral shaft fracture secondary to multiple myeloma resulted in pain relief Interlocked Nailing Closed locked nailing was chosen for this difficult fracture pattern in a patient with multiple medical comorbidities Proximal fixation is achieved via a spiral blade Interlocked Nails: Outcomes Antegrade insertion resulted in loss of shoulder motion in 6% to 36% of cases Less shoulder pain with anterior acromial approach compared to lateral deltoid splitting approach Retrograde insertion seems to give a more predictable long-term function without elbow dysfunction provided no associated injuries in same extremity Nonunion has been noted in 0% to 8% of locked IMN of humeral shaft fractures
Interlocked Nails: Outcomes Rates of delayed union are as high as 20% Malunion, hardware failure, and iatrogenic nerve palsy are all uncommon in series of humeral shaft fractures treated with interlocking nails External Fixation: Indications Severe open fractures with extensive soft- tissue injury or bone loss Associated burns Infected nonunions Humeral shaft fracture with neurovascular injury External Fixation: Techniques Attention to safe zones for pin placement is recommended Open insertion techniques are utilized to minimize neurovascular injury Meticulous pin care, stable frame constructs, and liberal use of bone grafting can reduce the problems associated with external fixation External Fixation: Techniques Fixator can be used provisionally with conversion to internal fixation or functional bracing after any associated soft-tissue problems are resolved External Fixation A unilateral frame was used to align this comminuted fracture is a patient with extensive soft tissue injury Healing occurred with callus External Fixation: Outcomes Function reported as good or excellent in 70% of patients in one large series Average arc of elbow ROM was 90 degrees Worse results were encountered in patients with concomitant multiple nerve injuries and intra-articular fracture extension External Fixation: Outcomes Complications cited in one large series included: delayed union and malunion pin tract infection and formation of pin tract sequestra late fracture secondary to another major trauma Complications of Humeral Shaft Fractures Radial nerve injury Vascular injury Nonunion
Radial Nerve Injury Incidence varies from 1.8% to 24% of shaft fractures Primary - occurs @ injury Secondary - occurs later during closed or open management Mangement controversial
Radial Nerve Injury Transverse fractures of the middle 1/3 are most commonly associated with neuropraxia Spiral fractures of the distal 1/3, the Holstein-Lewis fracture, present a higher risk of laceration or entrapment of the radial nerve Radial Nerve Injury Spontaneous recovery of nerve function is found in >70% of reported cases Even secondary palsies, those associated with fracture manipulation, have a high rate of spontaneous recovery 90% will resolve in 3 to 4 months EMG and nerve conduction studies can help to determine the degree of nerve injury and monitor the rate of nerve regeneration
Preferred Management of Fractures with Associated Radial Nerve Palsy Three most frequently stated indications for immediate surgical management for fractures associated with radial nerve palsy are: open fractures Holstein-Lewis fractures Secondary palsies developing after a closed reduction Preferred Management of Fractures with Associated Radial Nerve Palsy Exploration for palsies associated with open fracture is the only indication that is not associated with conflicting data For secondary palsies, but it is not clearly established that surgery will improve the ultimate recovery rate compared to nonsurgical management Preferred Management for Fractures with Primary Palsy If open, exploration indicated In a review of 714 cases of primary and 130 secondary palsies all observed initially, there was no difference noted in recovery rates (88.6% and 93.1%, respectively) after closed management Hak D, Orthopedics 32:111 (2009) Early exploration may risk additional injury to nerve if it is only contused Conclusion: Nonsurgical fracture management is indicated initially Advantages of Late Versus Early Nerve Exploration Enough time will have passed for recovery from neuropraxia or neurotmesis Precise evaluation of a nerve lesion is possible The associated fracture will(may) have united The results of secondary repair are as good as those of primary repair Vascular Injury Although uncommon, injury to the brachial artery can occur Mechanisms include: Gunshot wound Stab wound Vessel entrapment by fracture fragments Occlusion after hematoma or swelling in a tight compartment Vascular Injury Brachial artery has the greatest risk for injury in the proximal and distal 1/3 of arm Role of arteriography in evaluation of long bone fractures with vascular compromise remains controversial Unnecessary delays for studies of equivocal value are imprudent in the management of an ischemic limb Vascular Injury Arterial inflow should be emergently established within 6 hours At surgery, the vessel should be explored and repaired and the fracture stabilized If limb viability is not in jeopardy, bone repair may precede vascular repair External fixation should be considered an option Vascular injury Possible algorithms of treatment (dependent upon condition of limb and resources available): Rapid external fixation, vascular repair, then definitive fixation Vascular repair, then definitive vs. external fixation Temporary vascular stenting to re-establish flow, external vs. definitive fixation, then vascular repair
Nonunion Rate for humeral shaft fractures ranges from 0% to 15% Proximal and distal aspects of the humerus are at greatest risk for nonunion Nonunion Caused by biological and mechanical factors including: significant bone gaps secondary to fracture distraction, soft-tissue interposition, or bone loss uncontrolled fracture motion impaired soft-tissue envelope and blood supply infection Nonunion: Predisposing Factors transverse fracture pattern older age poor nutritional status osteoporosis endocrine abnormality affecting calcium balance use of steroids anticoagulation previous RT open fracture Nonunion: Treatment Goals Obtain osseous stability Elimination of nonunion gap Maintain or restore osseous vascularity Eradication of infection
Nonunion: Surgical Treatment Stable internal fixation is the treatment of choice for most nonunions Compression plate fixation provides favorable results overall while IM fixation has been less successful Biologic stimulation with drilling, shingling and autografting is an important adjunct to internal fixation, especially for atrophic nonunions Infected Nonunions: Surgical Treatment Require additional attention to complete debridement of all pathologic tissue May benefit from antibiotic bead placement May require provisional external fixation When the infection has been defined and controlled, definitive management may then require additional bone grafting and internal fixation
Complex Nonunions Nonunions associated with significant bone loss, synovial cavities, or failed prior surgical procedures These may require more elaborate reconstructive efforts Vascularized fibular transfers, intramedullary fibular grafting, and even Ilizarov techniques may be applicable Infected Nonunion This infected nonunion was initially managed with radical debridement and insertion of antibiotic impregnated cement beads Infected Nonunion Following appropriate antibiotic therapy, ORIF with abundant autograft was performed Healing slowly occurred Selected References Brumback RJ, Bosse MJ, Poka A et al: Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma. J Bone Joint Surg 1986;68A:960-970 Dalton JE, Salkeld SL, Satterwhite YE et al: Biomechanical comparison of intramedullary nailing systems for the humerus. J Orthop Trauma 1993;7:367-374 Foster RJ, Swiontkowski MF, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg 1993;18A:121-124 Gregory PR, Sanders RW: Compression plating versus intramedullary fixation of humeral shaft fractures. JAAOS 1997;5(4):215-223 Holstein A, Lewis GB: Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg 1963;45A:1382-1388 Jupiter, JB: complex nonunion of the humeral diaphysis: Treatment with a medial approach, an anterior plate, and a vascularized fibular graft. J Bone Joint Surg 1990;72A:701-707 Selected References Mostafavi HR, Tornetta P: Open fractures of the humerus treated with external fixation. Clin Orthop 1997;337: 187-197 Riemer BL, DAmbrosia R: The risk of injury to the axillary nerve, artery, and vein from the proximal locking screws of humeral intramedullary nails. Orthopedics 1992;15:697-699. Rommens PM, Verbruggen J, Broos PL: Retrograde locked nailing of humeral shaft fractures: A review of 39 patients. J Bone Joint Surg 1995;77B:84-89 Rosen H: The treatment of nonunions and pseudarthroses of the humeral shaft. Orthop Clin North Am 1990;21:725-742 Sarmiento A, Horowitch A, Aboulafia A et al: Functional bracing for comminuted extra-articular fractures of the distal-third of the humerus. J Bone Joint Surg 1990:72B:283-287 Wright TW, Miller GJ, Vander Griend RA et al: Reconstruction of the humerus with an intramedullary fibular graft: A clinical and biomechanical study. J Bone Joint Surg 1993;75B:804-807
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