|
https://upload.orthobullets.com/topic/1016/images/humerus-fracture-midshaft.jpg
https://upload.orthobullets.com/topic/1016/images/radial nerve.jpg
https://upload.orthobullets.com/topic/1016/images/distal third humerus.jpg
https://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
 

Please rate topic.

Average 4.4 of 108 Ratings

Technique Guides (2)
Questions (36)

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

QID: 996
FIGURES:
1

Increased shoulder impingement

7%

(38/544)

2

No difference in rate of union

4%

(20/544)

3

Increased shoulder range of motion

69%

(376/544)

4

No difference in rate of radial nerve injury

14%

(76/544)

5

Increased risk of revision surgery

6%

(30/544)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

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

QID: 4649
FIGURES:
1

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

0%

(10/2728)

2

Plating of the humerus and intramedullary nailing of the femur

86%

(2345/2728)

3

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

10%

(283/2728)

4

Plating of both the humerus and femur

1%

(23/2728)

5

Intramedullary nailing of the humerus and plating of the femur

2%

(54/2728)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

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

QID: 926
1

radial nerve palsy

4%

(76/1719)

2

long oblique fracture type

1%

(10/1719)

3

comminuted fracture

1%

(20/1719)

4

Holstein-Lewis fracture type

3%

(55/1719)

5

ipsilateral both bone forearm fracture

90%

(1550/1719)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SBQ12TR.13) A 23-year-old man presents with the injury seen in Figure A after a motor vehicle collision. He undergoes the treatment seen in Figure B. Which of the following statements is most accurate when comparing his treatment with open reduction and internal fixation? Review Topic

QID: 3928
FIGURES:
1

Higher rates of radial nerve injury

11%

(354/3114)

2

Higher total complication rate

74%

(2306/3114)

3

Lower rates of nonunion

7%

(203/3114)

4

Lower rates of shoulder impingement

2%

(77/3114)

5

Lower rates of malunion

5%

(162/3114)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SBQ12TR.27) Figure A is a radiograph of an 80-year-old woman who sustained a closed injury to her left arm 10 months ago. She presents to office today complaining of persistent pain in her arm. What is the most likely metabolic or endocrine abnormality contributing to this patients presentation? Review Topic

QID: 3942
FIGURES:
1

Vitamin D deficiency

67%

(1746/2620)

2

Central hypogonadism

3%

(71/2620)

3

Thyroid disorder

2%

(45/2620)

4

Parathyroid hormone disorder

7%

(192/2620)

5

Calcium deficiency

21%

(549/2620)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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

QID: 960
1

Non-weight bearing bilateral lower extremities and right upper extremity

5%

(22/461)

2

Weight bearing as tolerated bilateral lower extremities and right upper extremity

2%

(10/461)

3

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

2%

(8/461)

4

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

87%

(402/461)

5

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

3%

(12/461)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 563
1

Mid-diaphyseal segmental fracture with ipsilateral pilon fracture

8%

(32/425)

2

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

10%

(44/425)

3

Proximal one-third oblique fracture

16%

(66/425)

4

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

58%

(245/425)

5

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

7%

(31/425)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 4526
FIGURES:
1

Closed management with a coaptation splint

5%

(222/4114)

2

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

18%

(730/4114)

3

External fixation of humeral shaft fracture until brachial plexus injury resolves

2%

(93/4114)

4

Open reduction, surgical fixation with plating

71%

(2930/4114)

5

Closed management with a sling until brachial plexus injury resolves

2%

(101/4114)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 3001
1

Ulnar

2%

(9/574)

2

Musculocutaneous

10%

(55/574)

3

Radial

81%

(465/574)

4

Median

1%

(4/574)

5

Axillary

5%

(31/574)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 4426
FIGURES:
1

Neurapraxia of the median nerve

1%

(41/4735)

2

Axonotmesis of the radial nerve

27%

(1270/4735)

3

Neurotmesis of the ulnar nerve

1%

(45/4735)

4

Neurotmesis of the radial nerve

70%

(3332/4735)

5

Axonotmesis of the ulnar nerve

0%

(6/4735)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 2996
1

Spiral groove of the humerus

14%

(81/592)

2

At the arcuate ligament of Osborne

5%

(31/592)

3

10 cm distal to the lateral acromion

4%

(23/592)

4

10 cm proximal to radiocapitellar joint

73%

(434/592)

5

At the origin of the deep head of the triceps

3%

(19/592)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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

QID: 3023
1

Elbow extension

1%

(8/894)

2

Forearm supination

1%

(12/894)

3

Wrist extension in radial deviation

6%

(51/894)

4

Middle finger MCP extension

10%

(90/894)

5

Index finger MCP hyperextension

82%

(731/894)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 992
FIGURES:
1

Radial

30%

(267/898)

2

Ulnar

3%

(25/898)

3

Anterior interosseous

21%

(189/898)

4

Axillary

0%

(2/898)

5

Musculocutaneous

46%

(409/898)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 1216
FIGURES:
1

EMG and nerve conduction tests followed by possible surgical exploration

87%

(1536/1775)

2

Continued observation

11%

(200/1775)

3

Immediate surgical exploration

2%

(29/1775)

4

Shoulder MRI

0%

(1/1775)

5

CT scan of the humerus

0%

(3/1775)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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

QID: 3219
FIGURES:
1

Decreased risk of post-operative elbow pain

8%

(57/733)

2

Decreased risk of radial nerve injury

17%

(122/733)

3

Decreased risk of reoperation

72%

(528/733)

4

Decreased risk of infection

2%

(15/733)

5

Decreased risk of blood loss

1%

(8/733)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 508
1

worse functional results

2%

(6/390)

2

higher need for subsequent surgeries

5%

(19/390)

3

higher incidence of radial nerve injury

25%

(96/390)

4

lower complication rates

48%

(187/390)

5

decreased nonunion rates

20%

(79/390)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
ARTICLES (97)
POSTS (1)
VIDEOS (9)
CASES (23)
GROUPS (1)
Topic COMMENTS (49)
Private Note