Posted: Apr 14 2020 #(C101428)

Humeral Shaft Fracture in 72F

HPI

72-year-old female, right-hand dominant, presents to clinic after a ground-level fall 1 week prior. She was initially treated with a Sarmiento brace which she was unable to tolerate. She admits to some chronic pain in the right shoulder prior to this injury, but denies any current distal weakness, numbness, or tingling.

PMH

Her PMH is significant for anxiety, GERD, and previous right shoulder surgery (~40 years prior) of unclear indication.

BMI 29. Her skin is intact with no impending compromise but does have mild ecchymosis and tenderness about mid-brachium with obvious fracture motion. She is neurovascularly intact distally.

Poll

1 of 11

1. In addition to plain film radiographs, would you obtain additional imaging studies to guide management?

No - Current radiographs are sufficient

59%

1227/2061

Yes - Additional radiographs without Sarmiento brace in place

117/2061

Yes - Additional radiographs with Sarmiento brace in place

21%

450/2061

Yes - CT scan (CT)

167/2061

Yes - CT + Additional xrays

67/2061

Outside my area of expertise - best if I don't vote

33/2061

2. How would you manage this injury?

Nonoperative management

33%

689/2027

Operative management

64%

1313/2027

Outside my area of expertise - best if I don't vote

25/2027

3. If you choose Nonoperative management as definitive treatment, what technique would you choose?

I would not choose Nonoperative management

42%

836/1950

Sling now - leave until healing

47/1950

Coaptation splint now - leave until healing

96/1950

Sarmiento (functional) brace now - leave until healing

20%

398/1950

Coaptation splint now - in 1-2 weeks transition to Sarmiento brace and leave until healing

27%

533/1950

Outside my area of expertise - best if I don't vote

40/1950

4. If you choose Nonoperative management (either Sling, Coaptation, Sarmiento), how long would you leave it on for?

I would not choose Nonoperative management

39%

727/1859

Until pain free at fracture site

176/1859

Until Radiographic Union

13%

256/1859

2-3 weeks then remove regardless

51/1859

4-6 weeks then remove regardless

20%

388/1859

7-10 weeks then remove regardless

11%

223/1859

11-12 weeks then remove regardless

36/1859

Outside my area of expertise - best if I don't vote

2/1859

5. If you choose Nonoperative management, how often would you perform followups on the patient?

I would not choose Nonoperative management

38%

696/1795

Weekly until fracture union

77/1795

Weekly for 3 weeks, then monthly until fracture union

28%

506/1795

Every other week until fracture union

91/1795

Scheduled at 2 weeks, 6 weeks, and 12 weeks

22%

407/1795

Outside my area of expertise - best if I don't vote

18/1795

6. If you choose Operative management, what surgical technique would you choose?

I would not choose Operative management

155/1891

Open reduction and internal fixation (ORIF) only (includes plate, screws, wires, minimally invasive plate)

50%

958/1891

Intramedullary nailing (IMN) only

28%

539/1891

ORIF + IMN

11%

214/1891

Outside my area of expertise - best if I don't vote

23/1891

External Fixation

2/1891

7. If you choose ORIF, what approach would you use?

I would not choose ORIF

15%

286/1802

Anterolateral

68%

1227/1802

Posterior

13%

241/1802

Outside my area of expertise - best if I don't vote

48/1802

8. If you choose ORIF + IMN, what provisional fixation would you choose?

I would not choose Open reduction provisional fixation at fracture site+ IMN

38%

652/1690

Mini-frag plates

158/1690

Cerclage cables

24%

422/1690

Lag screws

16%

275/1690

Combination of screws and cables

129/1690

Outside my area of expertise - best if I don't vote

54/1690

9. If you choose IMN, what approach would you use?

I would not choose IMN

34%

570/1633

Antegrade IMN

59%

971/1633

Retrograde IMN

50/1633

Outside my area of expertise - best if I don't vote

42/1633

10. If you choose ORIF only (includes plate, screws, wires, minimally invasive plate), what construct would you choose?

I would not choose ORIF at fracture site only (includes plate, screws, wires, minimally invasive plate)

18%

296/1597

Screw fixation only

30/1597

Cerclage cable fixation only

16/1597

Single long proximal humerus locking plate - open

47%

765/1597

Single large-frag straight plate - open

19%

317/1597

Dual plating - open

28/1597

Outside my area of expertise - best if I don't vote

39/1597

Minimal-invasive plating with a long proximal locking humeral plate via deltoid-split approach proximally

106/1597

11. If you choose Operative management and obtained the construct below, what would your post-operative weight-bearing status be?

I would not choose IMN

24%

380/1532

Weight bearing as tolerated (WBAT)

23%

358/1532

Partial weight bearing (PWB) less than 5-10 lbs

29%

457/1532

Non-weight bearing (NWB)

19%

303/1532

Outside my area of expertise - best if I don't vote

34/1532

Post-procedure P1

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