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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
    • distally humerus becomes triangular
    • intramedullary canal terminates 2 to 3 cm proximal to the olecranon fossa
  • 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
      • will often present with shortening and in varus
    • 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 
        • rotating the patient prevents rotation of the distal fragment avoiding further nerve or soft tissue injury
      • 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
      • weekly radiographs for first 3 weeks to ensure maintenance of reduction
        • every 3-4 weeks after that
  • 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%) 
        • functional shoulder outcome scores (ASES scores) not shown to be different between IMN and ORIF 
      • 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
  • Humeral shaft fx nonunion 
  • Malunion
    • varus angulation is common but rarely has functional or cosmetic sequelae
    • risk factors
      • transverse fracture patterns
  • 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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