Review Question - QID 216783

In order to expedite this patient’s recovery and facilitate postoperative mobilization, this patient should undergo operative fixation of his humeral shaft fracture. Operative fixation with plate osteosynthesis allows immediate postoperative full-weightbearing, which would be necessary to help this patient mobilize with the use of crutches/front-wheeled walker (FWW).

Several options are possible for the management of humeral shaft fractures: conservative management, open reduction and internal fixation (ORIF) with plate osteosynthesis, or closed reduction and intramedullary nailing (IMN). An external fixator is also an option, however, rarely indicated. Isolated nondisplaced or minimally displaced humeral shaft fractures are routinely treated conservatively. Commonly cited parameters for non-operative management are anterior angulation < 20°, a varus or valgus angulation < 30°, malrotation < 15°, and < 3 cm of shortening. While this patient’s injury would be indicated for non-operative management in an isolated setting, he has sustained multiple lower extremity fractures. The patient will be weightbearing as tolerated on the right lower extremity and non-weightbearing to the left lower extremity (initially). To allow mobilization with crutches/FWW, he will need to be full-weightbearing to the right upper extremity. Full-weightbearing is allowed after fixation by either plate osteosynthesis (typically with a 4.5 mm plate, but a 3.5 mm plate may suffice) or intramedullary nailing (can be done either retrograde or antegrade).

Tingstad et al. evaluated the effect of immediate full-weightbearing of humeral shaft fractures treated with dynamic compression plates. Patients treated with ORIF plate osteosynthesis were grouped by either non-weightbearing or immediate full-weightbearing. The plates used included narrow 4.5mm dynamic compression plate (DCP), broad 4.5mm DCP, and 3.5mm DCP. They concluded that immediate full-weightbearing had no effect on the union or malunion rate (there was also no difference in outcomes between the plates used).

Bell et al. evaluated outcomes in 38 polytrauma patients with humeral shaft fractures that underwent ORIF with plate osteosynthesis. They reported complications were rare (one non-union and one surgical site infection) and that shoulder and elbow functional outcomes were excellent. They concluded plating of humeral shaft fractures in polytrauma patients produces reliable results.

Figure A demonstrates a transverse humeral shaft fracture. Figure B demonstrates a right tibia/fibula shaft fracture. Figure C demonstrates a left ankle fracture-dislocation.

Incorrect Answers:
Answer 1: Open reduction and internal fixation with plate osteosynthesis allows the patient to be full-weightbearing, not partial. Furthermore, partial-weightbearing would not allow this patient to use crutches.
Answers 2 and 4: If non-operative management is pursued with either a coaptation splint or acute placement of a Sarmiento brace, then this patient would be non-weightbearing to the right upper extremity. However, non-operative management is not appropriate in this patient as he would not be able to mobilize with the use of crutches/front-wheeled walker.
Answer 3: Fixation of humeral shaft fractures with intramedullary nailing also allows patients to be full-weightbearing, not partial. As stated above, a full-weightbearing designation would be necessary to allow the use of crutches/FWW for mobilization.