http://upload.orthobullets.com/topic/1016/images/humerus-fracture-midshaft.jpg
http://upload.orthobullets.com/topic/1016/images/radial nerve.jpg
http://upload.orthobullets.com/topic/1016/images/distal third humerus.jpg
http://upload.orthobullets.com/topic/1016/images/proximal third spiral.jpg
Introduction
  • Incidence
    • 3-5% of all fractures
    • bimodal age distribution
      • young patients with high-energy trauma 
      • elderly, osteopenic patients with low-energy injuries
Relevant Anatomy
  • Osteology
    • humeral shaft is cylindrical
  • Muscles
    • insertion for
      • pectoralis major 
      • deltoid 
      • coracobrachialis 
    • origin for 
      • brachialis 
      • triceps 
      • brachioradialis 
  • Nerve
    • radial nerve 
      • courses along spiral groove 
      • 14cm proximal to the lateral epicondyle
      • 20cm proximal to the medial epicondyle
Classification
  • OTA
    • bone number: 1
    • fracture location: 2
    • fracture pattern: simple:A, wedge:B, complex:C
  • Descriptive
    • fracture location: proximal, middle or distal third
    • fracture pattern: spiral, transverse, comminuted
  • Holstein-Lewis fracture    
    • a spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (22% incidence)
Presentation
  • Symptoms
    • pain
    • extremity weakness
  • Physical exam
    • examine overall limb alignment
    • preoperative or pre-reduction neurovascular exam is critical
      • examine and document status of radial nerve pre and post-reduction
Imaging
  •  Radiographs
    • views
      • AP and lateral
        • be sure to include joint above and below the site of injury 
      • transthoracic lateral
        • may give better appreciation of sagittal plane deformity 
      • traction views
        • may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated
Treatment
  • Nonoperative 
    • coaptation splint followed by functional brace 
      • indications
        • indicated in vast majority of humeral shaft fractures
        • criteria for acceptable alignment include: 
        • < 20° anterior angulation
        • < 30° varus/valgus angulation
        • < 3 cm shortening
      • absolute contraindications
        • severe soft tissue injury or bone loss
        • vascular injury requiring repair
        • brachial plexus injury
      • relative contraindications 
        • see relative operative indications section
        • radial nerve palsy is NOT a contraindication to functional bracing 
      • outcomes
        • 90% union rate 
          • increased risk with proximal third oblique or spiral fracture 
        • varus angulation is common but rarely has functional or cosmetic sequelae
    • damage control orthopaedics (DCO)
      • closed humerus fractures, including low velocity GSW, should be initially managed with a splint or sling  
      • type of fixation after trauma should be directed by acceptable fracture alignment parameters, fracture pattern and associated injuries
  • Operative 
    • open reduction and internal fixation 
      • absolute indications 
        • open fracture 
        • vascular injury requiring repair
        • brachial plexus injury 
        • ipsilateral forearm fracture (floating elbow)  
        • compartment syndrome
      • relative indications
        • bilateral humerus fracture
        • polytrauma or associated lower extremity fracture 
          • allows early weight bearing through humerus 
        • pathologic fractures
        • burns or soft tissue injury that precludes bracing
        • fracture characteristics
          • distraction at fracture site
          • short oblique or transverse fracture pattern
          • intraarticular extension
    • intramedullary nailing (IMN) 
      • relative indications
        • pathologic fractures
        • segmental fractures
        • severe osteoporotic bone
        • overlying skin compromise limits open approach 
        • polytrauma
Techniques
  • Coaptation Splint & Functional Bracing
    • coaptation splint 
      • applied until swelling resolves
      • adequately applied splint will extend up to axilla and over shoulder
      • common deformities include varus and extension
        • valgus mold to counter varus displacement
    • functional bracing 
      • extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles
      • sling should not be used to allow for gravity-assisted fracture reduction
      • shoulder extension used for more proximal fractures
  • Open Reduction Internal Fixation with Plating
    • approaches
      • anterolateral approach to humerus 
        • used for proximal third to middle third shaft fractures 
        • distal extension of the deltopectoral approach
        • radial nerve identified between the brachialis and brachioradialis distally
      • posterior approach to humerus  
        • used for distal to middle third shaft fractures although can be extensile
        • triceps may either be split or elevated with a lateral paratricipital exposure
        • radial nerve is found medial to the long and lateral heads and 2cm proximal to the deep head of the triceps 
        • radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm proximal to radiocapitellar joint 
        • lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach  
    • techniques
      • plate osteosynthesis commonly with 4.5mm plate (narrow or broad)
        • 3.5mm plates may function adequately
      • absolute stability with lag screw or compression plating in simple patterns 
      • apply plate in bridging mode in the presence of significant comminution 
    • postoperative
      • full crutch weight bearing shown to have no effect on union 
  • Closed Intramedullary Nailing (IMN)
    • techniques
      • can be done antegrade or retrograde
    • complication  
      • nonunion
        • nonunion rates not shown to be different between IMN and plating in recent meta-analyses 
        • IM nailing associated with higher total complication rates   
      • shoulder pain
        • increased rate when compared to plating (16-37%) 
      • nerve injury 
        • radial nerve is at risk with a lateral to medial distal locking screw 
        • musculocutaneous nerve is at risk with an anterior-posterior locking screw 
    • postoperative
      • full weight bearing allowed and had no effect on union 
Complications
  • Malunion
    • varus angulation is common but rarely has functional or cosmetic sequelae
    • risk factors
      • transverse fracture patterns
  • Nonunion
    • incidence
      • 2 to 10% in nonoperative management
      • 5 to 10% with surgical management
    • risk factors
      • distraction at the fracture site on injury films 
      • open fracture
      • metabolic/endocrine abnormalities (Vitamin D deficiency most common) 
      • segmental fracture
      • infection
      • shoulder or elbow stiffness (motion directed to fracture site)
      • patient factors (smoking, obesity, malnutrition, noncompliance)
    • treatment
      • compression plating with bone grafting   
        • shown to be superior to both IM nailing with bone grafting and compression plating alone 
        • lateral, posterior or paratricipital (Gerwin) approach to allow exploration of the radial nerve 
  • Radial nerve palsy 
    • incidence
      • seen in 8-15% of closed fractures
      • increased incidence distal one-third fractures
      • neuropraxia most common injury in closed fractures and neurotomesis in open fractures
      • 85-90% of improve with observation over 3 months
      • spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months
    • treatment
      • observation
        • indicated as initial treatment  in closed humerus fractures
        • obtain EMG at 3-4 months
        • wrist extension in radial deviation is expected to be regained first 
        • brachioradialis first to recover, extensor indicis is the last 
      • surgical exploration
        • indications
          • open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve) 
          • closed fracture that fails to improve over ~ 3-6 months 
          • fibrillations (denervation) seen at 3-4 months on EMG
 

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Questions (19)

(OBQ13.14) A 30-year-old man is brought to your level 1 trauma center with a closed left diaphyseal humerus fracture, a closed left midshaft femur fracture, right sided rib fractures, and multiple facial fractures following a motorcycle accident. He is neurovascularly intact in his left arm and leg. Figure A shows a radiograph of his left humerus. What would be the most appropriate definitive treatment? Review Topic

QID:4649
FIGURES:
1

Non-operative management of the humerus and plating of the femur

0%

(7/2117)

2

Plating of the humerus and intramedullary nailing of the femur

86%

(1831/2117)

3

Non-operative management of the humerus and intramedullary nailing of the femur

10%

(210/2117)

4

Plating of both the humerus and femur

1%

(18/2117)

5

Intramedullary nailing of the humerus and plating of the femur

2%

(42/2117)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The clinical scenario involves a polytrauma patient with ipsilateral humerus and femur fractures. The humerus should be plated to facilitate early weight bearing, allowing for mobilization with crutches.

Humeral shaft fractures account for 3-5% of all fractures and follow a bimodal distribution. Most humerus fractures can be treated non-operatively with a coaptation splint, followed by functional bracing. However, a strong relative indication for surgical management is a polytrauma patient. Plating of humerus fractures has high union rates and facilitates early weight bearing, which is necessary for rehabilitation with a concomitant lower extremity injury.

Bell et al. retrospectively reviewed the outcomes of polytrauma patients treated with plate fixation for humeral shaft fractures. All but one of the fractures united, and patients had excellent function following surgery, allowing early weight-bearing through the injured extremity.

Heineman et al. recently updated their systematic review of randomized controlled trials comparing plating with intramedullary nailing for humeral shaft fractures. They conclude that current literature supports a reduction in complication rates when plating humeral shaft fractures compared to intramedullary nailing.

Tingstad et al. performed a retrospective study evaluating immediate weight-bearing with plated humeral shaft fractures. They demonstrated that ORIF of humeral shaft fractures followed by early weight-bearing was safe and efficacious.

Figure A is an AP x-ray of a left humeral shaft fracture. Illustration A shows the diaphyseal humerus fracture from Figure A following ORIF with a plate.

Incorrect Answers:
Answers 1 and 3: Non-operative management of the humerus would delay rehabilitation of this patient.
Answers 4 and 5: Midshaft femur fractures should be treated with intramedullary nailing to facilitate early weight-bearing.

ILLUSTRATIONS:

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(SBQ12.13) A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. He undergoes the treatment seen in Figure B. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? Review Topic

QID:3928
FIGURES:
1

Higher rates of radial nerve injury

11%

(202/1885)

2

Higher total complication rate

76%

(1437/1885)

3

Lower rates of nonunion

6%

(116/1885)

4

Lower rates of shoulder impingement

2%

(40/1885)

5

Lower rates of malunion

4%

(84/1885)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Antegrade intramedullary (IM) nailing of humeral shaft fractures has been found to be associated with increased complication rates when compared with open reduction and internal fixation (ORIF).

Operative treatment of humeral shaft fractures remains controversial, with prospective randomized studies demonstrating small differences between IM nailing and ORIF.

Heineman et al. (2010) conducted a meta-analysis of prospective randomized studies comparing IM nailing with ORIF for humeral shaft fractures. The authors found no significant difference between the two treatment modalities for either their primary outcome (complications) or any of the secondary outcomes (nonunion, infection, nerve palsy, re-operation)

Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of these newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF.

Figure A demonstrates a displaced, transverse humeral shaft fracture. Figure B demonstrates antegrade IM nailing of a humeral shaft fracture

Incorrect Answers:
Answer 1: Radial nerve injury has not been shown to be different between IM nailing and ORIF
Answer 3: No difference in union rates between the two modalities in prospective studies
Answer 4: Higher rates of shoulder impingement have been seen with IM nailing in some studies
Answer 5: No difference in rates of malunion between IM nailing and ORIF


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(SBQ12.27) Figure A is a radiograph of an 80-year-old woman who sustained a closed injury to her left arm 10 months ago. She presents to office today complaining of persistent pain in her arm. What is the most likely metabolic or endocrine abnormality contributing to this patients presentation? Review Topic

QID:3942
FIGURES:
1

Vitamin D deficiency

67%

(1301/1928)

2

Central hypogonadism

3%

(51/1928)

3

Thyroid disorder

2%

(29/1928)

4

Parathyroid hormone disorder

7%

(135/1928)

5

Calcium deficiency

21%

(401/1928)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Figure A is a radiograph showing oligotrophic nonunion of a proximal third humeral shaft fracture. The most likely underlying metabolic or endocrine abnormality with this presentation is vitamin D deficiency.

The etiology of fracture nonunion is multifactorial. Predisposing factors include: mechanical instability, poor bone-to-bone contact, infection and biological/biochemical factors. A variety of other contributing factors, such as cigarette smoking and malnutrition, have also been described. Correctable metabolic or endocrine abnormalities are common in elderly patients and are considered contributory in the etiology of fracture non-union. Correction of these abnormalities should be considered prior to surgical fixation.

Brinker et al. studied 37 patients with fracture nonunions with identifiable metabolic or endocrine abnormalities. The distribution of nonunion types at the 46 sites were: oligotrophic (23), atrophic (12), infected (7), and hypertrophic (4). They showed that 85% of patients had a previously undiagnosed metabolic or endocrine abnormality. The most common newly diagnosed abnormality was vitamin D deficiency in 25 of the 37 patients (68%).

Kuo et al. studied 155 consecutive minimal-trauma fracture subjects for metabolic abnormalities with bone mineral density and laboratory testing. At baseline, only 26% had had proper workup for metabolic abnormalities. After diagnostic work-up, 44% of patients were recommended for anti-resorptive therapy and 56% were recommended calcium/vitamin D medication.

Illustrations A and B show open reduction internal fixation of Figure A with a proximal humeral plate.

Incorrect Answers:
Answer 2: Studies show 15% of fracture nonunions can be attributed to undiagnosed central hypogonadism.
Answer 3: Studies show 24% of fracture nonunions can be attributed to previously established or undiagnosed thyroid disorders
Answer 4: Studies show 11% of fracture nonunions can be attributed to previously established or undiagnosed parathyroid disorders
Answer 5: Studies show 35% of fracture nonunions can be attributed to lack of calcium.

ILLUSTRATIONS:

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(OBQ12.66) A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. The brachial artery is disrupted and requires urgent attention in the operating room. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor digitorum, extensor indicis proprius, and extensor pollicis longus motor activity. What is the most likely etiology for this observed neurologic examination? Review Topic

QID:4426
FIGURES:
1

Neurapraxia of the median nerve

1%

(33/4038)

2

Axonotmesis of the radial nerve

27%

(1102/4038)

3

Neurotmesis of the ulnar nerve

1%

(36/4038)

4

Neurotmesis of the radial nerve

70%

(2828/4038)

5

Axonotmesis of the ulnar nerve

0%

(5/4038)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The most likely cause of the radial nerve palsy in a high energy open humerus fracture is laceration or complete disruption of the radial nerve (Neurotmesis).

Neurotmesis is complete disruption of nerve and is associated witn no spontaneous recovery without intervention. Axonotmesis constitutes axon disruption, but the surrounding neural connective tissue is intact and nerve regeneration can occur(Wallerian or antegrade degeneration). Neurapraxias occur often by compression and the axon maintains continuity but local demyelination and ischemia occur.

Ring et al. present a Level 4 study of 24 patients that had radial nerve palsy associated with a humerus fracture. All 6 patients with a transected radial nerve had an open humerus fracture also. The results of primary nerve repair in this circumstance found that there was no recovery in any of the patients.

Foster et al. authored a Level 4 review of 14 patients had a radial nerve palsy and an associated open humerus fracture. 64% of the 14 patients had a radial nerve that was either lacerated or interposed between the fracture fragments. They recommend exploration of the radial nerve in the setting of a radial nerve palsy and concomitant open humerus fracture in contrast to observation of a radial nerve palsy in closed humerus fractures.

Figure A demonstrates an open left humerus fracture.

Incorrect Answers:
Answer 1,3,5: The radial nerve provides distal motor activity to the ECRL, ECRB, EPB, EIP, and EPL.
Answer 2: Axonotmesis of the radial nerve is not the most common form of injury associated with closed or open humerus fractures.


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(OBQ12.166) A 42-year-old man sustains the injury shown in Figure A after a fall from 6 feet. Physical exam after the injury reveals a flaccid ipsilateral limb. An MRI is performed that reveals nerve root avulsions from C5-T1. Which of the following is the most appropriate management of his fracture at this time? Review Topic

QID:4526
FIGURES:
1

Closed management with a coaptation splint

5%

(184/3492)

2

Closed management with a coaptation splint followed by transition to a functional brace after 7-10 days

18%

(619/3492)

3

External fixation of humeral shaft fracture until brachial plexus injury resolves

2%

(73/3492)

4

Open reduction, surgical fixation with plating

72%

(2503/3492)

5

Closed management with a sling until brachial plexus injury resolves

2%

(83/3492)

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PREFERRED RESPONSE 4

A coexisting brachial plexus injury is an absolute indication for open reduction and internal fixation of humeral shaft fractures.

A majority of humeral shaft fractures may be treated non-operatively in a functional brace. Absolute indications of operative management include open fracture with severe soft tissue injury, vascular injury requiring repair, and a coexisting brachial plexus injury. Patients with a brachial plexus injury are more likely to go on to nonunion when treated non-operatively due to lack of muscular support controlling the fracture fragments.

Sarmiento et al. review 620 patients with humeral shaft fracture treated non-operatively in a coaptation splint followed by a functional brace. Only 16 patients developed a non-union, and any residual deformity was usually functionally and aesthetically acceptable.

Rutgers et al. present a retrospective case series of 49 patients who had humeral shaft fractures that were treated non-operatively in a functional brace. 44 of 49 patients went on to successful union. Fractures of the proximal third of the humeral shaft were most likely to go on to nonunion.

Figure A shows a midshaft humerus fracture.

Incorrect Answers:
Answer 1, 2, 5: operative management is indicated with a coexisting brachial plexus injury.
Answer 3: a coexisting brachial plexus injury is not an indication for external fixation of humeral shaft fractures.


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(OBQ10.125) A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. He undergoes the treatment shown in Figures A and B. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? Review Topic

QID:3219
FIGURES:
1

Decreased risk of post-operative elbow pain

11%

(52/490)

2

Decreased risk of radial nerve injury

13%

(62/490)

3

Decreased risk of reoperation

73%

(356/490)

4

Decreased risk of infection

2%

(12/490)

5

Decreased risk of blood loss

1%

(6/490)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Humeral shaft fractures treated with antegrade intramedullary nailing (IMN) have a higher risk of receiving an additional operation compared to those treated with plate fixation as seen in Figures A and B. Additionally, there is a higher incidence of shoulder impingement following IMN compared to plate fixation. There has been no difference found between the incidence of infection, elbow pain or radial nerve injury when comparing the two treatment options. Blood loss is not lower in an open case compared to nailing.

In a meta-analysis of 3 randomized studies comparing compression plate fixation to IMN fixation of humeral shaft fractures, Bhandari et al, found a significant relative risk reduction of 74% to reoperation with the use of plates and screws versus IMN. They also found a relative risk reduction of 90% in shoulder impingement with the use of plates and screws versus IMN. No significant difference was found between the two regarding rates of infection and/or radial nerve palsies.

In a prospective randomized study comparing IMN fixation to plate fixation in humeral shaft fractures, McCormack et al, also showed a significantly higher rate or reoperation in patients treated with IMN fixation. They also showed no difference in functional outcome or pain scores between the two groups. There were more nonunions in the IMN group in these studies, but the numbers were small and it did not reach statistical significance. Previous studies have shown higher nonunion rates in the IMN patients.


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(OBQ09.183) On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? Review Topic

QID:2996
1

Spiral groove of the humerus

13%

(51/379)

2

At the arcuate ligament of Osborne

6%

(22/379)

3

10 cm distal to the lateral acromion

4%

(17/379)

4

10 cm proximal to radiocapitellar joint

73%

(276/379)

5

At the origin of the deep head of the triceps

3%

(12/379)

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PREFERRED RESPONSE 4

The radial nerve enters the anterior compartment through the intercompartmental fascia on average 10 cm proximal to the radiocapitellar joint. It has never been found to remain in the posterior compartment within 7.5cm of this joint, leading to this area being named the "safe zone". During the posterior approach to the humerus, the radial nerve is found in the spiral groove in the middle third of the posterior humerus, medial to the lateral head and proximal to the deep head of the triceps. When performing an ORIF of a humerus fracture from a posterior approach it should be identified and protected.

Illustration A shows the radial nerve as seen during the posterior approach to the humerus. Illustration B shows the radial nerve along with a ruler showing the transition at 10cm proximal to the radiocapitellar joint.

ILLUSTRATIONS:

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(OBQ09.188) During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves? Review Topic

QID:3001
1

Ulnar

2%

(8/380)

2

Musculocutaneous

11%

(40/380)

3

Radial

80%

(305/380)

4

Median

1%

(2/380)

5

Axillary

5%

(18/380)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The posterior antebrachial cutaneous nerve (PABCN) branches from the radial nerve in the axilla.

The posterior antebrachial cutaneous nerve branches from the radial nerve just distal to the posterior brachial cutaneous nerve (PBCN) in the axilla and they course through the arm in closely to each other. In the proximal forearm, the posterior antebrachial cutaneous nerve is found on the lateral border of the brachioradialis muscle. The terminal branches innervate the posterior aspect of the forearm distally.

Gerwin et al recommended identifying the lower lateral brachial cutaneous nerve first when approaching the humerus posteriorly. It can be traced proximally to safely identify the radial nerve before any proximal exposure of the shaft is done. Gerwin et al in their review also found that the radial nerve crossed the posterior aspect of the humerus an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle.

In their review, Zlotolow et al. review the multiple surgical approaches to the humerus.

Illustration A depicts the course of the PABCN and its relation to the PBCN and the radial nerve

ILLUSTRATIONS:

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(OBQ09.210) A 32-year-old man presents to the emergency department with a humeral shaft fracture. He has wrist drop as well as impaired finger and thumb extension. Which motor function would be expected to recover last? Review Topic

QID:3023
1

Elbow extension

1%

(7/777)

2

Forearm supination

2%

(12/777)

3

Wrist extension in radial deviation

6%

(44/777)

4

Middle finger MCP extension

10%

(81/777)

5

Index finger MCP hyperextension

81%

(632/777)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The patient is presenting with radial nerve palsy secondary to his humerus fracture. Motor recovery proceeds in a proximal to distal direction.

Abrams et al detailed the order of innervation of the radial nerve and found the following order (proximal to distal): brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, abductor pollicis longus, extensor policis longus, extensor policis brevis, and extensor indicis proprius.

Branovacki et al found a slightly different pattern: brachioradialis, extensor carpi radialis longus, superficial sensory, extensor carpi radialis brevis, supinator, extensor digitorum/extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis proprius.

While both extensor digitorum and extensor indicis proprius extend the index finger MCP joint, only extensor indicis proprius hyperextends the index finger past neutral.


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(OBQ08.122) Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing? Review Topic

QID:508
1

worse functional results

1%

(2/215)

2

higher need for subsequent surgeries

5%

(10/215)

3

higher incidence of radial nerve injury

21%

(46/215)

4

lower complication rates

49%

(105/215)

5

decreased nonunion rates

24%

(51/215)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Controversy exists regarding nailing compared with plating of humeral shaft fractures, but the most recent and highest level evidence indicates decreased complication rates with open reduction and internal fixation of these injuries.

Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery, likely due to disruption of the rotator cuff tendon during insertion.

Meekers et al found a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation versus nailing. They concluded that plating was superior in most cases of humeral shaft fracture, however more recent studies have challenged these findings.

Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF. The authors found no significant difference between the two treatment modalities for the secondary outcomes (nonunion, infection, nerve palsy, re-operation)

Incorrect Answers:
Answer 1: Although prior level 4 studies indicated better functional outcomes with ORIF, more recent studies and pooled analyses have not shown superior functional outcomes with either treatment
Answer 2: A trend towards lower need for subsequent surgery is seen with ORIF, likely secondary to increased complications seen with IM nailing secondary to implant prominence and shoulder dysfunction
Answer 3: No difference in radial nerve injury is seen between the two treatments
Answer 5: Pooled analysis of the existing literature has demonstrated no difference in union rates between ORIF and IM nailing of humeral shaft fractures


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(OBQ08.177) All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT: Review Topic

QID:563
1

Mid-diaphyseal segmental fracture with ipsilateral pilon fracture

7%

(17/237)

2

Mid-diaphyseal fracture with radial nerve palsy from nonballistic penetrating injury

10%

(23/237)

3

Proximal one-third oblique fracture

15%

(36/237)

4

Mid-diaphyseal closed fracture with a radial nerve palsy on presentation

61%

(145/237)

5

Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

5%

(13/237)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management.

Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), segmental fractures, injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.

The article by Rutgers and Ring found that proximal one-third oblique humeral shaft fractures had an unacceptably high 29% rate of nonunion treated with a functional brace.

The article by Sarmiento et al found a 97% rate of union, a radial nerve palsy incidence of 11%, and no contraindication to the use of functional braces in humeral shaft fractures associated with radial nerve palsy.

The review article by Defranco and Lawton states that 70% of these radial nerve injuries recover spontaneously. They note that it "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course."


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(OBQ07.265) Which of the following is an indication for surgical treatment of an acute humeral shaft fracture? Review Topic

QID:926
1

radial nerve palsy

5%

(73/1585)

2

long oblique fracture type

1%

(10/1585)

3

comminuted fracture

1%

(17/1585)

4

Holstein-Lewis fracture type

3%

(50/1585)

5

ipsilateral both bone forearm fracture

90%

(1432/1585)

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PREFERRED RESPONSE 5

Humeral shaft fractures can be managed nonoperatively due to a high union rate with infrequent complications. Certain situations, however, favor operative osteosynthesis: failure of closed reduction, associated articular injury, vascular or brachial plexus injuries, associated ipsilateral forearm fractures, segmental fractures, and pathologic fractures. Open fractures should be irrigated and debrided if necessary with subsequent external or internal fixation. Polytrauma patients with multiple extremity or multi-system injuries may also be considered for operative stabilization. A relative indication also may be the transverse or short oblique fracture in an active patient since these fracture patterns are more prone to delayed union. An acute radial nerve palsy associated with a humeral shaft fracture is not an indication for surgery.


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(OBQ05.74) A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status? Review Topic

QID:960
1

Non-weight bearing bilateral lower extremities and right upper extremity

5%

(16/345)

2

Weight bearing as tolerated bilateral lower extremities and right upper extremity

1%

(5/345)

3

Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities

2%

(7/345)

4

Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities

89%

(307/345)

5

Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

2%

(8/345)

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PREFERRED RESPONSE 4

The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing.

Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates.

Brumback et al evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred.


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(OBQ05.85) A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure A. What is the next most appropriate step in treatment? Review Topic

QID:971
FIGURES:
1

Exchange nailing

10%

(158/1541)

2

Manipulation under anesthesia

0%

(4/1541)

3

Nail removal and plate fixation

84%

(1289/1541)

4

Percutaneous locked plating

1%

(12/1541)

5

Nail dynamization

5%

(76/1541)

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PREFERRED RESPONSE 3

Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.

Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.

Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. They
report 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.

Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.


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(OBQ05.106) A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk? Review Topic

QID:992
FIGURES:
1

Radial

26%

(187/706)

2

Ulnar

3%

(20/706)

3

Anterior interosseous

25%

(176/706)

4

Axillary

0%

(0/706)

5

Musculocutaneous

45%

(321/706)

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PREFERRED RESPONSE 5

With intramedullary (IM) nailing of the humerus, the distal anterior-to-posterior interlocking screws place the musculocutaneous nerve at high risk for injury as it goes through the coracobrachialis muscle and courses anteriorly along the brachialis (of which it innervates the medial half).

Rupp et al performed a cadaveric study with IM nails utilizing either lateral-to-medial or anterior-to-posterior distal interlocking screws. They showed that anterior-to-posterior screws placed the musculocutaneous nerve at high risk, while lateral-to-medial screws placed the radial nerve at high risk as it courses laterally distally along the humerus.


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(OBQ05.110) A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. Compared with open reduction and internal fixation with a plate and screw construct, the treatment shown in Figure A is associated with all of the following EXCEPT? Review Topic

QID:996
FIGURES:
1

Increased shoulder impingement

7%

(17/246)

2

Increased risk of iatrogenic comminution

3%

(8/246)

3

Increased shoulder range of motion

67%

(165/246)

4

Increased rate of hardware failure

18%

(44/246)

5

Increased risk of revision surgery

4%

(10/246)

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PREFERRED RESPONSE 3

The radiograph shows a humeral shaft fracture treated with an intramedullary nail (IMN).

It is important to note that this question continues to evolve as more data and studies are performed.

McCormack prosepectively randomized 44 humeral shaft fractures to treatment by intramedullary nailing vs. dynamic compression (DCP) plating and found the risk of shoulder impingement, iatrogenic comminution, and nonunion were higher in the nail treatment group resulting in a higher revision rate. They found no significant differences in shoulder/elbow function, VAS pain scores, ROM, or time to return to normal activity.

Chapman et al in their prospective randomized trial between IMN and plate fixation found that the IMN group had higher rates of post operative shoulder pain and a slower time to fracture union. The ORIF had faster time to union, but reduced elbow range of motion. Both studies show the effectiveness of IMN and ORIF in the treatment of humeral shaft fractures.

More recent meta-analysis such as by Ma et al show that both IMN and DCP can achieve similar fracture union with a similar incidence of radial nerve injury and infection. IMN was associated with an increased risk of shoulder impingement, more restriction of shoulder movement, an increased risk of intraoperative fracture comminution, a higher incidence of implant failure, and an increased risk of re-operation.


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(OBQ04.96) A 33-year-old male presents 7 months after a fall from 15 feet. He complains of continued pain over his left arm and you elicit pain and gross movement with palpation of his humerus. Infectious workup is negative and a radiograph is shown in Figure A. What is the most appropriate next step in his management? Review Topic

QID:1201
FIGURES:
1

Reassurance and appropriate followup

1%

(2/286)

2

Sarmiento bracing

1%

(2/286)

3

Use of a bone stimulator

3%

(10/286)

4

Exchange humeral nailing

14%

(40/286)

5

IM nail removal, open reduction internal fixation with bone grafting

80%

(228/286)

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PREFERRED RESPONSE 5

This patient has developed a hypertrophic non-union (greater than 6 months) of his left humerus following IM nailing. This will not go on to union without surgical intervention. McKee et al. reviewed 21 cases of humeral nonunion after failed intramedullary humeral nails. Although technically difficult, open reduction internal fixation with plating and bone grafting was more successful in union in 9/9 cases, vs exchanged humeral nailing which was only successful in 4/10 cases. Seven of the nonunions were atrophic, 2 were hypertrophic in the ORIF group. The authors conclude that the extent of humeral bone loss after failure of primary humeral nailing makes open reduction internal fixation with compression and bone grafting the most acceptable method of treating this problem.

It should be noted, however, that the use of bone grafting in the presence of a hypertrophic nonunion is controversial and has not been definitively proven in the literature to increase healing rates.


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(OBQ04.111) A 68-year-old male sustains the humeral shaft fracture shown in Figures A and B. Upon presentation, he is unable to extend his thumb, fingers, and wrist. After 4 months of non-operative management, the fracture has healed, but his physical exam is unchanged. What is the next most appropriate step in management? Review Topic

QID:1216
FIGURES:
1

EMG and nerve conduction tests followed by possible surgical exploration

87%

(1362/1570)

2

Continued observation

11%

(173/1570)

3

Immediate surgical exploration

2%

(28/1570)

4

Shoulder MRI

0%

(1/1570)

5

CT scan of the humerus

0%

(2/1570)

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PREFERRED RESPONSE 1

The clinical presentation is consistent for a residual radial nerve palsy 4 months after a humeral shaft fracture. An EMG is indicated at this time to evaluate the status of the nerve recovery.

A radial nerve injury which occurs during a humeral shaft fracture or after bracing is not an indication for immediate exploration. Most often, the nerve function returns without surgical intervention. An EMG should be performed at 3-5 months to evaluate the status of the nerve recovery. If fasciculations are present, then this represents recovery, and observation should be continued. If fibrillations are present, this represents denervation, and surgical exploration should be considered.

Pollock et al followed 24 humeral-shaft fractures with associated radial-nerve injuries, 2 of which required open exploration and all recovered. They recommend careful observation for return of nerve function and exploration at 3.5-4 months after injury if there is still no clinical or EMG evidence of recovery.

Bostman et al reviewed 59 immediate and 16 secondary radial nerve palsies and no support emerged for routine early exploration in either group.

Figures A and B show an oblique fracture at the junction of the middle and distal 1/3 of the humeral shaft.
Illustration A shows the relative close position of the radial nerve to the humerus at the midlevel of humerus, and why it is at risk with a humerus shaft fracture.

ILLUSTRATIONS:

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(OBQ04.229) A patient sustained a transverse humeral shaft fracture 6 months ago and presently complains of pain and instability at the area of injury. A plain radiograph is shown in Figure A and on exam there is gross motion at the fracture site. What is the most appropriate definitive treatment? Review Topic

QID:1334
FIGURES:
1

ultrasound therapy to nonunion site

0%

(4/877)

2

oral bisphosphonates

0%

(2/877)

3

open reduction internal fixation with autologous bone graft

96%

(838/877)

4

antegrade intramedullary nail

3%

(25/877)

5

retrograde intramedullary nail

0%

(2/877)

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PREFERRED RESPONSE 3

Figure A shows an atrophic nonunion of a humeral shaft fracture.

Humeral shaft nonunion is defined as failure of healing after 6 months. The nonunion can be hypertrophic, oligotrophic, or atrophic. The risk of atrophic nonunion increases with bone loss, open fractures, and infection among other factors.

As Jupiter has described, the application of a compression plate to stabilize the fracture fragments with autogenous cancellous bone graft has been successful as long as there is a well vascularized envelope of muscle.


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