Humeral Shaft Fractures

Author: Brian Weatherford

Topic updated on 03/19/13 10:25pm

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 for 7-10 days followed by functional brace
  - indications
    - gold standard and 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
Operative
- open reduction internal fixation with plating
  - absolute indications
    - open fracture with severe soft tissue injury
    - vascular injury requiring repair
    - brachial plexus injury
  - relative indications
    - ipsilateral forearm fracture (floating elbow)
    - 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
      - long oblique or spiral proximal fracture
      - 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 for 7-10 days until swelling resolves
  - adequately applied splint will extend into 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
    - triceps may either be split or elevated off the posterior humeral shaft
    - 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
    - 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)
  - absolute stability with lag screw or compression plating in simple patterns
  - apply plate in bridging mode if no axial stability (comminution)
- postoperative
  - full weight bearing shown to have no effect on union
Closed Intramedullary Nailing (IMN)
- techniques
  - can be done antegrade or retrograde
- complication
  - nonunion
    - nonunion rate may be increased with IMN compared to plating
    - IM nailing associated with higher need for secondary surgeries
  - 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
  - most common with 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
  - 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 modified posterior (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
  - 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
      - closed fracture that fails to improve over ~ 3-6 months
      - fibrillations (denervation) seen at 3-4 months on EMG

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Qbank (15 Questions)

TAG

(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? Topic

Review Topic

FIGURES: A

1. Decreased risk of post-operative elbow pain
2. Decreased risk of radial nerve injury
3. Decreased risk of reoperation
4. Decreased risk of infection
5. Decreased risk of blood loss

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Einhorn TA, O'Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 87-101.

2. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop. 2006 Apr;77(2):279-84. Review. PMID:16752291 (Link to Abstract)

3. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br. 2000 Apr;82(3):336-9. PMID:10813165 (Link to Abstract)

Question Authors:

Daniel Stahl MD, Patrick McCulloch MD, Jan Szatkowski MD,

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TAG

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

Review Topic

1. Spiral groove of the humerus
2. At the arcuate ligament of Osborne
3. 10 cm distal to the lateral acromion
4. 10 cm proximal to radiocapitellar joint
5. At the origin of the deep head of the triceps

PREFERRED RESPONSE ▶

DISCUSSION: 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 long and lateral heads 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: A

REFERENCES:

1. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 1984, pp 58-63

2. Martini FH, Timmons MJ, Tallitsch RB: Human Anatomy, ed 5. San Francisco, CA, Pearson/Benjamin Cummings, 2006, pp 300-302

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

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TAG

(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? Topic

Review Topic

1. Ulnar
2. Musculocutaneous
3. Radial
4. Median
5. Axillary

PREFERRED RESPONSE ▶

DISCUSSION: The posterior antebrachial cutaneous nerve branches from the radial nerve in the axilla. It extends distally to innervate the skin on the back of the arm. Gerwin et al recommended identifying the nerve first when approaching the humerus from the posterior shaft. 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.

REFERENCES:

1. Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposures of the posterior aspect of the humeral diaphysis, with reference to the radial nerve. J Bone Joint Surg Am 1996;78:1690-1695 PMID:8934483 (Link to Abstract)

2. Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754-765 PMID:17148623 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Ben Taylor MD,

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TAG

(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? Topic

Review Topic

1. Elbow extension
2. Forearm supination
3. Wrist extension in radial deviation
4. Middle finger MCP extension
5. Index finger MCP hyperextension

PREFERRED RESPONSE ▶

DISCUSSION: 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 policis 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.

REFERENCES:

1. Abrams RA, Ziets RJ, Lieber RL: Anatomy of the radial nerve motor branches in the forearm. J Hand Surg Am 1997;22:232-237 PMID:9195420 (Link to Abstract)

2. Branovacki G, Hanson M, Cash R: The innervation pattern of the radial nerve at the elbow and in the forearm. J Hand Surg Br 1998;23:167-169 PMID:9607651 (Link to Abstract)

Question Authors:

Mark Vitale MD, John Badylak MD, Michael Hughes MD,

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TAG

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

Review Topic

1. worse functional results
2. higher need for subsequent surgeries
3. less blood loss
4. higher union rates
5. increased postoperative shoulder stiffness

PREFERRED RESPONSE ▶

DISCUSSION: Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery 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, except for pathological fractures, very obese patients, and open fractures.

REFERENCES:

1. Lin J. Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation. J Trauma. 1998 May;44(5):859-64. PMID:9603089 (Link to Abstract)

2. Meekers FS, Broos PL. Operative treatment of humeral shaft fractures. The Leuven experience. Acta Orthop Belg. 2002 Dec;68(5):462-70. PMID:12584975 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Derek Moore,

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TAG

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

Review Topic

1. Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
2. Mid-diaphyseal fracture with radial nerve palsy from penetrating injury
3. Proximal one-third oblique fracture
4. Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
5. Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

PREFERRED RESPONSE ▶

DISCUSSION: 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."

REFERENCES:

1. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000 Apr;82(4):478-86 PMID:10761938 (Link to Abstract)

2. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace. J Orthop Trauma. 2006 Oct;20(9):597-601. PMID:17088660 (Link to Abstract)

3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006 Apr;31(4):655-63. Review. PMID:16632062 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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TAG

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

Review Topic

1. radial nerve palsy
2. long oblique fracture type
3. comminuted fracture
4. Holstein-Lewis fracture type
5. ipsilateral both bone forearm fracture

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1177-1199

Question Authors:

Greg Galano MD, Ben Taylor MD,

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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, internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status? Topic

Review Topic

1. non-weight bearing bilateral lower extremities and right upper extremity
2. weight bearing as tolerated bilateral lower extremities and right upper extremity
3. non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
4. non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
5. weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

PREFERRED RESPONSE ▶

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

REFERENCES:

1. Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000 Aug;49(2):278-80. PMID:10963539 (Link to Abstract)

2. Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP, Belkoff SM. Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg Am. 1999 Nov;81(11):1538-44. PMID:10565645 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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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? Topic

Review Topic

FIGURES: A

1. exchange nailing
2. manipulation under anesthesia
3. nail removal, autologous bone grafting and plate fixation
4. percutaneous locked plating
5. nail dynamization

PREFERRED RESPONSE ▶

DISCUSSION: Plate fixation with bone graft 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. Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.

REFERENCES:

1. Ring D, Kloen P, Kadzielski J, et al: Locking compression plates forosteoporotic nonunions of the diaphyseal humerus. Clin Orthop 2004;425:50-54. PMID:15292787 (Link to Abstract)

2. Rubel IF, Kloen P, Campbell D, et al: Open reduction and internal fixation of humeral nonunions: A biomechanical and clinical study. J Bone Joint Surg Am 2002;84:1315-1322. PMID:12177259 (Link to Abstract)

3. Brinker MR, O'Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg Am. 2007 Jan;89(1):177-88. PMID:17200326 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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Related Cases

http://upload.orthobullets.com/cases/1358/imag0021.jpg

humeral fracture (C1358)

Trauma - Treatment Consult - Humeral Shaft Fractures

HPI - fall from body-height.no other injuries except the humeral fracture.an I.M nail...

how would you treat this fracture

12/19/2012

1097 responses

TAG

(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? Topic

Review Topic

FIGURES: A

1. Radial
2. Ulnar
3. Median
4. Axillary
5. Musculocutaneous

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Rupp RE, Chrissos MG, Ebraheim NA. The risk of neurovascular injury with distal locking screws of humeral intramedullary nails. Orthopedics. 1996 Jul;19(7):593-5. PMID:8823817 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Guillem Lomas MD, Derek Moore,

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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? Topic

Review Topic

FIGURES: A

1. Increased shoulder impingement
2. Increased risk of iatrogenic comminution
3. Increased time to return to normal activity
4. Increased rate of nonunion
5. Increased risk of revision surgery

PREFERRED RESPONSE ▶

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

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.

REFERENCES:

1. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br. 2000 Apr;82(3):336-9. PMID:10813165 (Link to Abstract)

2. Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000 Mar-Apr;14(3):162-6. PMID:10791665 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Ben Taylor MD, John Badylak MD,

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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 next appropriate step in his management? Topic

Review Topic

FIGURES: A

1. Reassurance and appropriate followup
2. Sarmiento bracing
3. Use of a bone stimulator
4. Exchange humeral nailing
5. IM nail removal, open reduction internal fixation with bone grafting

PREFERRED RESPONSE ▶

DISCUSSION: 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. 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.

REFERENCES:

1. McKee MD, Miranda MA, Riemer BL, Blasier RB, Redmond BJ, Sims SH, Waddell JP, Jupiter JB. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma. 1996;10(7):492-9. PMID:8892150 (Link to Abstract)

Question Authors:

David Abbasi MD, Jan Szatkowski MD, Ben Taylor MD,

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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 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? Topic

Review Topic

FIGURES: A

1. EMG and nerve conduction tests followed by possible surgical exploration
2. Continued observation
3. Immediate surgical exploration
4. Shoulder MRI
5. CT scan of the humerus

PREFERRED RESPONSE ▶

DISCUSSION: 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 evaluated 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 fasiculations are present, then this represents recovery, and observation should be continued. If fibrillations are present, this is represents deneravation, 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: A

REFERENCES:

1. Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am. 1981 Feb;63(2):239-43. PMID:7462281 (Link to Abstract)

2. Böstman O, Bakalim G, Vainionpää S, Wilppula E, Pätiälä H, Rokkanen P. Radial palsy in shaft fracture of the humerus. Acta Orthop Scand. 1986 Aug;57(4):316-9. PMID:4030084 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, John Badylak MD, Jan Szatkowski MD,

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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? Topic

Review Topic

FIGURES: A

1. ultrasound therapy to nonunion site
2. oral bisphosphonates
3. open reduction internal fixation with autologous bone graft
4. antegrade intramedullary nail
5. retrograde intramedullary nail

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 177-190

2. Jupiter JB, von Deck M: Ununited humeral diaphyses. J Shoulder and Elbow Surg 1998;7:644-653 PMID:9883429 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, John Badylak MD,

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Cases

	Humeral shaft fracture (C1093) Trauma - - Humeral Shaft Fractures HPI - 28 y/o male, victim of car accident. Patient was seen in another hospital and tr... How would you treat this patient?	11/27/2011 96 responses
	humerus fracture (C1244) Trauma - Treatment Consult - Humeral Shaft Fractures HPI - 40 y o smoker, overweight, fell down stairs how would you treat	7/17/2012 321 responses
	humeral re-fracture (C1303) Trauma - Treatment Consult - Humeral Shaft Fractures HPI - motor vehicle accident,neuro-nascular status ok,pain-deformity right humeral ,n... how would you treat this	10/26/2012 175 responses
	mid third fracture humerus with a butterfly fragment (C1305) Trauma - Treatment Consult - Humeral Shaft Fractures HPI - pain and inabilty to move the left humerus after a fall from height. no other in... operative open reduction internal fiaxtion or MIPO technique or conservativ...	10/30/2012 66 responses
	humeral fracture (C1358) Trauma - Treatment Consult - Humeral Shaft Fractures HPI - fall from body-height.no other injuries except the humeral fracture.an I.M nail... how would you treat this fracture	12/19/2012 1097 responses 4
	Infected humeral nonunion (C1395) General - Treatment Consult - Humeral Shaft Fractures HPI - 52 year old female smoker (1/2 pack per day) who fell onto her right arm in Octo... How would you treat this infected humeral nonunion	1/25/2013 45 responses
	humeral fracture (C1441) Trauma - Surgical Techniques - Humeral Shaft Fractures HPI - accidental trauma at home How would you treat this injury?	3/9/2013 66 responses 5

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Videos

	Holstein-Lewis Fracture Trauma - Treatment Consult - Humeral Shaft Fractures This video describes the mechanism and potential treatment options for fractures...	10/17/2012 867 views 4
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	Posterior Approach to the Humeral Shaft Trauma - Surgical Approaches - Humeral Shaft Fractures This video demonstrates the posterior approach to the humeral shaft in a cadaver...	10/17/2012 555 views 3

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Groups

ABOS II: Humeral Shaft Fractures

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br. 2000 Apr;82(3):336-9. PMID:10813165 (Link to Abstract)
McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br. 2000 Apr;82(3):336-9. PMID:10813165 (Link to Abstract)
Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000 Mar-Apr;14(3):162-6. PMID:10791665 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop. 2006 Apr;77(2):279-84. Review. PMID:16752291 (Link to Abstract)

Level of Evidence 4 (Case Series)

Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000 Apr;82(4):478-86 PMID:10761938 (Link to Abstract)
Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace. J Orthop Trauma. 2006 Oct;20(9):597-601. PMID:17088660 (Link to Abstract)
DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006 Apr;31(4):655-63. Review. PMID:16632062 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Abrams RA, Ziets RJ, Lieber RL: Anatomy of the radial nerve motor branches in the forearm. J Hand Surg Am 1997;22:232-237 PMID:9195420 (Link to Abstract)
Branovacki G, Hanson M, Cash R: The innervation pattern of the radial nerve at the elbow and in the forearm. J Hand Surg Br 1998;23:167-169 PMID:9607651 (Link to Abstract)
Rupp RE, Chrissos MG, Ebraheim NA. The risk of neurovascular injury with distal locking screws of humeral intramedullary nails. Orthopedics. 1996 Jul;19(7):593-5. PMID:8823817 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Einhorn TA, O'Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 87-101.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 1984, pp 58-63
Martini FH, Timmons MJ, Tallitsch RB: Human Anatomy, ed 5. San Francisco, CA, Pearson/Benjamin Cummings, 2006, pp 300-302

Undefined

Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposures of the posterior aspect of the humeral diaphysis, with reference to the radial nerve. J Bone Joint Surg Am 1996;78:1690-1695 PMID:8934483 (Link to Abstract)
Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754-765 PMID:17148623 (Link to Abstract)
Lin J. Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation. J Trauma. 1998 May;44(5):859-64. PMID:9603089 (Link to Abstract)
Meekers FS, Broos PL. Operative treatment of humeral shaft fractures. The Leuven experience. Acta Orthop Belg. 2002 Dec;68(5):462-70. PMID:12584975 (Link to Abstract)
Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1177-1199
Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000 Aug;49(2):278-80. PMID:10963539 (Link to Abstract)
Brumback RJ, Toal TR Jr, Murphy-Zane MS, Novak VP, Belkoff SM. Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg Am. 1999 Nov;81(11):1538-44. PMID:10565645 (Link to Abstract)
Ring D, Kloen P, Kadzielski J, et al: Locking compression plates forosteoporotic nonunions of the diaphyseal humerus. Clin Orthop 2004;425:50-54. PMID:15292787 (Link to Abstract)
Rubel IF, Kloen P, Campbell D, et al: Open reduction and internal fixation of humeral nonunions: A biomechanical and clinical study. J Bone Joint Surg Am 2002;84:1315-1322. PMID:12177259 (Link to Abstract)
Brinker MR, O'Connor DP. Exchange nailing of ununited fractures. J Bone Joint Surg Am. 2007 Jan;89(1):177-88. PMID:17200326 (Link to Abstract)
McKee MD, Miranda MA, Riemer BL, Blasier RB, Redmond BJ, Sims SH, Waddell JP, Jupiter JB. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma. 1996;10(7):492-9. PMID:8892150 (Link to Abstract)
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humerus. 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. Radial palsy in shaft fracture of the humerus. Acta Orthop Scand. 1986 Aug;57(4):316-9. PMID:4030084 (Link to Abstract)
Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 177-190
Jupiter JB, von Deck M: Ununited humeral diaphyses. J Shoulder and Elbow Surg 1998;7:644-653 PMID:9883429 (Link to Abstract)

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Humeral Shaft Fractures

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