Humeral Shaft Fractures

Anatomy

Spiral Groove

• Radial nerve crosses humerus midpoint 14cm proximal to lateral epicondyle

Lateral Intermuscular Septum

• 7-10 cm above lateral epicondyle

Anterolateral Approach

• Best for proximal 2/3 fractures

Posterior Approach

• Best for distal 1/2 humerus

Non-Surgical Management

• Most common deformity is varus
• Acceptable deformity:
  • 30 degrees in coronal plane - varus is worse as it reduces shoulder abduction
  • 20 degrees in sagittal plane
  • cm shortening

Treatment

• Coaptation splinting in a U slab for comfort
• Or collar and cuff initially
• Application of functional brace at 1 week
• Serial brace tightening to prevent slipping

Results

• 2% (closed) and 6% (open) non-union rate - Sarmiento JBJSam 2000
• Mild deformity does not affect functional outcome
• Bracing worked as well for all types and location of fracture

Operative Treatment

Indications (All Relative)

• Even open fractures have been managed non-operatively

Indications for Surgery

• Inability to maintain closed reduction within acceptable parameters, especially varus
• Open fracture
• Simple fracture patterns, especially transverse and short oblique
• Polytrauma
• Floating elbow

Overall Results

• Surgery has a lower malunion and non-union rate

Method of Fixation

Ex Fix

• Indicated for polytrauma or gross contamination

Safe Zones

• Proximal 1/3:
  • Through the anterolateral fibers of deltoid – avoid axial nerve and LHB
• No safe zone in middle 1/3
• Distal 1/3:
  • Posterior, posteromedial, or posterolateral above olecranon fossa

Plate

• Large fragment plate
• 8 cortices either side of fracture traditionally
• 6 cortices if good lag screw
• If bridge plating, consider working length rather than the absolute number of screws

IM Nailing

• Problem: shoulder pain and cuff damage
• Risk of nerve and vascular injury during locking

Plate vs. Nail

• Meta-analysis Mo Bandhari Acta Orthopedica 2010:
  • Complication rate with IM nailing is higher:
    • Shoulder pain
    • Re-operation
    • Delayed but not non-union

Radial Nerve Palsy

• Systematic review of 4000 patients Gianoudis JBJSBr 2005:
  • 11% risk of radial nerve palsy
  • 24% for distal 1/3 fractures
  • Higher in spiral and transverse fractures
  • Spontaneous recovery in 70% at a mean of 7 weeks (longest 6 months)
  • EMG at 6 weeks if no recovery at all:
    • Look for fibrillations and sharp waves
    • Repeat at 3 months
    • If no activity at 3 months, refer to specialist unit
  • Exploration should not be delayed beyond 6 months in the presence of no activity

Indications for Exploration

• Open penetrating or high energy injury with palsy (higher incidence of laceration)
• Nerve deficit after reduction and a Holstein-Lewis fracture is a soft indication (not proven beneficial in the literature)

Non-Union

• Work up patient to identify cause:
  • Smoking
  • Infection
• Requires ORIF, bone grafting, and compression plating
• Compression plating alone suffices if it is a hypertrophic non-union