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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?
Non-operative management of the humerus and plating of the femur
Plating of the humerus and intramedullary nailing of the femur
Non-operative management of the humerus and intramedullary nailing of the femur
Plating of both the humerus and femur
Intramedullary nailing of the humerus and plating of the femur
Select Answer to see Preferred Response
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.
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.
Bell MJ, Beauchamp CG, Kellam JK, McMurtry RY.
J Bone Joint Surg Br. 1985 Mar;67(2):293-6. PMID: 3980544 (Link to Abstract)
Heineman DJ, Bhandari M, Poolman RW.
Acta Orthop. 2012 Jun;83(3):317-8. Epub 2012 May 29. PMID: 22640178 (Link to Abstract)
Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD.
J Trauma. 2000 Aug;49(2):278-80. PMID: 10963539 (Link to Abstract)
Please rate question.
Average 4.0 of 15 Ratings
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?
Higher rates of radial nerve injury
Higher total complication rate
Lower rates of nonunion
Lower rates of shoulder impingement
Lower rates of malunion
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
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
Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M
Acta Orthop. 2010 Apr;81(2):216-23. PMID: 20170424 (Link to Abstract)
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?
Vitamin D deficiency
Parathyroid hormone disorder
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.
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.
Brinker MR, O'Connor DP, Monla YT, Earthman TP
J Orthop Trauma. 2007 Sep;21(8):557-70. PMID: 17805023 (Link to Abstract)
Kuo I, Ong C, Simmons L, Bliuc D, Eisman J, Center J.
Osteoporos Int. 2007 Dec;18(12):1633-9. Epub 2007 Jun 30. PMID: 17603741 (Link to Abstract)
Average 3.0 of 12 Ratings
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?
Neurapraxia of the median nerve
Axonotmesis of the radial nerve
Neurotmesis of the ulnar nerve
Neurotmesis of the radial nerve
Axonotmesis of the ulnar nerve
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.
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.
Ring D, Chin K, Jupiter JB
J Hand Surg Am. 2004 Jan;29(1):144-7. PMID: 14751118 (Link to Abstract)
Foster RJ, Swiontkowski MF, Bach AW, Sack JT.
J Hand Surg Am. 1993 Jan;18(1):121-4. PMID: 8423295 (Link to Abstract)
Average 3.0 of 16 Ratings
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?
Closed management with a coaptation splint
Closed management with a coaptation splint followed by transition to a functional brace after 7-10 days
External fixation of humeral shaft fracture until brachial plexus injury resolves
Open reduction, surgical fixation with plating
Closed management with a sling until brachial plexus injury resolves
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.
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.
Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA
J Bone Joint Surg Am. 2000 Apr;82(4):478-86. PMID: 10761938 (Link to Abstract)
Rutgers M, Ring D.
J Orthop Trauma. 2006 Oct;20(9):597-601. PMID: 17088660 (Link to Abstract)
Average 4.0 of 20 Ratings
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?
Decreased risk of post-operative elbow pain
Decreased risk of radial nerve injury
Decreased risk of reoperation
Decreased risk of infection
Decreased risk of blood loss
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.
Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH.
Acta Orthop. 2006 Apr;77(2):279-84. PMID: 16752291 (Link to Abstract)
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH
J Bone Joint Surg Br. 2000 Apr;82(3):336-9. PMID: 10813165 (Link to Abstract)
Average 3.0 of 22 Ratings
On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites?
Spiral groove of the humerus
At the arcuate ligament of Osborne
10 cm distal to the lateral acromion
10 cm proximal to radiocapitellar joint
At the origin of the deep head of the triceps
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.
Average 4.0 of 27 Ratings
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?
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
Gerwin M, Hotchkiss RN, Weiland AJ.
J Bone Joint Surg Am. 1996 Nov;78(11):1690-5. PMID: 8934483 (Link to Abstract)
Zlotolow DA, Catalano LW, Barron OA, Glickel SZ
J Am Acad Orthop Surg. 2006 Dec;14(13):754-65. PMID: 17148623 (Link to Abstract)
Average 3.0 of 21 Ratings
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?
Wrist extension in radial deviation
Middle finger MCP extension
Index finger MCP hyperextension
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.
Abrams RA, Ziets RJ, Lieber RL, Botte MJ.
J Hand Surg Am. 1997 Mar;22(2):232-7. PMID: 9195420 (Link to Abstract)
Branovacki G, Hanson M, Cash R, Gonzalez M.
J Hand Surg Br. 1998 Apr;23(2):167-9. PMID: 9607651 (Link to Abstract)
Average 3.0 of 49 Ratings
Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing?
worse functional results
higher need for subsequent surgeries
higher incidence of radial nerve injury
lower complication rates
decreased nonunion rates
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)
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
J Trauma. 1998 May;44(5):859-64. PMID: 9603089 (Link to Abstract)
Meekers FS, Broos PL.
Acta Orthop Belg. 2002 Dec;68(5):462-70. PMID: 12584975 (Link to Abstract)
Average 3.0 of 27 Ratings
All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:
Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
Mid-diaphyseal fracture with radial nerve palsy from nonballistic penetrating injury
Proximal one-third oblique fracture
Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation
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."
DeFranco MJ, Lawton JN.
J Hand Surg Am. 2006 Apr;31(4):655-63. PMID: 16632062 (Link to Abstract)
Average 2.0 of 44 Ratings
Which of the following is an indication for surgical treatment of an acute humeral shaft fracture?
radial nerve palsy
long oblique fracture type
Holstein-Lewis fracture type
ipsilateral both bone forearm fracture
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.
Average 3.0 of 20 Ratings
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?
Non-weight bearing bilateral lower extremities and right upper extremity
Weight bearing as tolerated bilateral lower extremities and right upper extremity
Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity
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.
Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP, Belkoff SM.
J Bone Joint Surg Am. 1999 Nov;81(11):1538-44. PMID: 10565645 (Link to Abstract)
Average 3.0 of 24 Ratings
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?
Manipulation under anesthesia
Nail removal and plate fixation
Percutaneous locked plating
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.
Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB.
Clin Orthop Relat Res. 2004 Aug;(425):50-4. PMID: 15292787 (Link to Abstract)
Rubel IF, Kloen P, Campbell D, Schwartz M, Liew A, Myers E, Helfet DL.
J Bone Joint Surg Am. 2002 Aug;84-A(8):1315-22. PMID: 12177259 (Link to Abstract)
Brinker MR, O'Connor DP.
J Bone Joint Surg Am. 2007 Jan;89(1):177-88. PMID: 17200326 (Link to Abstract)
HPI - fall from body-height.no other injuries except the humeral fracture.an I.M nail was used in another institution 7 days ago and the patient came for consulting.
how would you treat this fracture
Average 3.0 of 18 Ratings
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?
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.
Rupp RE, Chrissos MG, Ebraheim NA.
Orthopedics. 1996 Jul;19(7):593-5. PMID: 8823817 (Link to Abstract)
Average 3.0 of 39 Ratings
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?
Increased shoulder impingement
Increased risk of iatrogenic comminution
Increased shoulder range of motion
Increased rate of hardware failure
Increased risk of revision surgery
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.
Chapman JR, Henley MB, Agel J, Benca PJ
J Orthop Trauma. 2000 Mar-Apr;14(3):162-6. PMID: 10791665 (Link to Abstract)
Ma J, Xing D, Ma X, Gao F, Wei Q, Jia H, Feng R, Yu J, Wang J.
PLoS One. 2013;8(12):e82075. Epub 2013 Dec 16. PMID: 24358141 (Link to Abstract)
Average 2.0 of 28 Ratings
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?
Reassurance and appropriate followup
Use of a bone stimulator
Exchange humeral nailing
IM nail removal, open reduction internal fixation with bone grafting
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.
McKee MD, Miranda MA, Riemer BL, Blasier RB, Redmond BJ, Sims SH, Waddell JP, Jupiter JB.
J Orthop Trauma. 1996;10(7):492-9. PMID: 8892150 (Link to Abstract)
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?
EMG and nerve conduction tests followed by possible surgical exploration
Immediate surgical exploration
CT scan of the humerus
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.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG.
J Bone Joint Surg Am. 1981 Feb;63(2):239-43. PMID: 7462281 (Link to Abstract)
Böstman O, Bakalim G, Vainionpää S, Wilppula E, Pätiälä H, Rokkanen P.
Injury. 1985 Jul;16(7):499-502. PMID: 4030084 (Link to Abstract)
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?
ultrasound therapy to nonunion site
open reduction internal fixation with autologous bone graft
antegrade intramedullary nail
retrograde intramedullary nail
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.
Jupiter JB, von Deck M.
J Shoulder Elbow Surg. 1998 Nov-Dec;7(6):644-53. PMID: 9883429 (Link to Abstract)
Average 4.0 of 30 Ratings
HPI - Patient fractured his left humeral shaft and saw an outside surgeon, undergoing IM fixation. Fracture site initially looked promising, but soon went on to nonunion. One of the distal screws never seated properly and began to back out soon after his initial surgery.
At 3 months post-op, the patient returned to the outside facility and was pronounced healed by the PA.
3 years later, he presented to my clinic with significant pain and dysfunction.
Would you recommend surgery in this patient?
HPI - Fall from height (ladder) with immediate onset of pain and deformity
Would you obtain any advanced studies to help determine treatment in this case?
HPI - Fall at work site.injury to the left arm.inablity to move left arm
How would you treat this patient?
HPI - fixed since 6 months with IMN humerus
How would you have treated this fracture initially?
HPI - Undergone surgery for #shaft of humerus ,4weeks ago
Post op X-ray 4 weeks show dislocation shoulder
When to go for dislocation reduction?
HPI - On September 2013 right humerus fracture during seizure. Initial consrvative treatment with sarmiento splint. On March 2014 ORIF DCP 3.5 with 6 screws and iliac autografts. On September 2014 fixation failure. On November 2014 ORIF DCP 4.5 with 8 screws and iliac autografts. On May 2015 hardware failure.
Which is the best treatment plan for this patient?
HPI - A 56-year-old male suffered a closed fracture of the left humeral shaft which was treated by antegrade interlocking intramedullary nail 1.5 years ago. The patient now presents with persistent pain and inability to work.
How would you treat this humeral shaft nonunion?
HPI - MVA, sitting in rear seat without seatbelt. Crashed into a stationary lorry at 90km/hr.
How would you treat this fracture?
HPI - 32 yo male in head-on MVC. +ETOH. Polytrauma with all extremity injuries other than a head laceration. Also with L midshaft femur s/p IMN, R distal radius s/p ORIF, L pilon s/p exfix (pending ORIF).
Main concern: L grade 3A open segmental humerus shaft with 4 inches of distal bone loss including 75% of the articular surface. The medial half of the trochlea is all that remains. He also has a segmental olecranon fracture. There is no injury to the radius. He has undergone I&D, antibiotic bead placement, and ex-fix from the proximal humerus to the ulna shaft.
He is a firefighter. He needs to pass yearly physicals to keep his job.
What is the definitive solution for this patient, considering his current career as a firefighter?
HPI - History: 63 years old female non smoker right arm dominant who underwent ex-fix 9 years ago for closed left humeral fracture, 3 weeks after ex-fix: draining from the proximal fiche, therefore: removal fixator, antibiotic therapy, thoracobrachial cast for 45 days. One month after the infection was healed, with ESR, CRP within normal limits. The first cast was remade in the same way for another 45 days. At this point the patient underwent locked nail for delayed union. We don't have any control rx in the period 2007-2014
How would you treat this injury at this time?
HPI - 2008 rev TSR, full function, after fall from height periprosthetic fx
how would You proceed
HPI - Sustained injury 2 yrs. ago. Treated conservatively
How would you classify this nonunion?
HPI - History of fall at home. Immediate pain and swelling left arm.
HPI - Fall at home, landing on left elbow.
Is routinely used as temporary treatment the transolecranic skeletal traction in you Centre?
HPI - accidental trauma at home
How would you treat this injury?
HPI - 52 year old female smoker (1/2 pack per day) who fell onto her right arm in October 2011, underwent ORIF in August of 2012. 4 weeks after initial ORIF, patient presented with draining wound and failure of fixation. Patient then underwent hardware removal, addition of antibiotic beads, and flexible rod placement. A PICC line was placed and patient received 6 weeks of IV antibiotics for Staph Epi. Current ESR and CRP are within normal limits.
How would you treat this infected humeral nonunion
HPI - pain and inabilty to move the left humerus after a fall from height. no other injuries
operative open reduction internal fiaxtion or MIPO technique or conservative.
HPI - motor vehicle accident,neuro-nascular status ok,pain-deformity right humeral ,no other injuries.
how would you treat this
HPI - 40 y o smoker, overweight, fell down stairs
how would you treat
HPI - 28 y/o male, victim of car accident. Patient was seen in another hospital and transferred to your unit 2 days after injury.
How would you treat this fracture pattern?
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