Review Question - QID 214037

This patient's 8-week radiographs reveal significant gapping at the fracture site which predicts fracture mobility with continued conservative management. Open reduction and internal fixation with plate and screws is indicated.

Functional bracing remains the gold standard in the management of humeral shaft fractures. Despite appropriate initial management, fracture gap is evident on her recent radiographs and she likely has persistent mobility at the fracture site. With these findings, surgery should be considered. Fracture site gapping, smoking, and female sex are independent predictors for fracture mobility six weeks after injury. Moreover, each millimeter of gap increases the risk of fracture mobility by 40%.

Papasoulis et al. evaluated the use of functional bracing for treating humeral shaft fractures. In their literature review, they found that humeral shaft fractures treated with functional bracing heal in an average of 10.7 weeks with union rates of 94.5%. They concluded that varus angulation exceeding 10 degrees is rare and full shoulder and elbow motion will like be achieved in most patients.

Neuhus et al. retrospectively evaluated whether gapping between fracture fragments serves as a risk factor for fracture instability six weeks after functional bracing of humeral shaft fractures. They found that 20% of patients had motion at the fracture site when a persistent fracture line shown on radiographs six weeks or more after injury was evident. They noted that fracture gapping with the patient wearing the brace, smoking, and female sex increased the risk of fracture instability six weeks after injury. They concluded that the magnitude of the gap between the fracture fragments is an independent risk factor for fracture instability and the lack of a bridging callus six weeks after a diaphyseal humeral fracture.

Figure A is the AP radiograph of the left humerus demonstrating a fracture of the shaft without significant angulation.

Incorrect Answers:
Answer 1: This patient has fracture gapping 8-weeks following use of a functional brace and is at high risk for fracture mobility.
Answer 2: Percutaneous pinning of the humerus would be a poor construct for this patient and provide inadequate stability.
Answer 4: A bone stimulator is likely to be ineffective 8 weeks following injury with no evidence of union.
Answer 5: Transition to a coaptation splint would provide no benefit compared to a functional brace.