The Management of Humeral Shaft Fractures Shaft... · Imaging •Plain AP and 900 lateral –move whole patient not limb –include joints •associated dislocations, #’s into joints

The Management of Humeral

Shaft Fractures

David Chapple MSc FRCS

SHAFT

• NOT

–Proximal

–Distal

Anything New?

• Anatomy

• Classifications

• MOI and Clinical aspects

• Management options

• Management indications

• Management Complications

Anatomy

• three borders

– Anterior

– Medial

– lateral

• three surfaces

– anterolateral

– anteromedial

– posterior

The Humerus

• Anterior aspect

– Head

– necks

– tuberosities• < > & Deltoid

• sulcus, bicipital groove

– supracondylar ridges

– epicondyles

– Coronoid fossa

– trochlea/Capitulum

– Supracondylar process

• Anterior Muscle attachments– supraspinatus

– subscapularis

– Pectoralis major

– latissimus dorsi

– Teres Major

– triceps medial head

– deltoid

– coracobrachialis

– Brachialis

– Brachioradialis

– Extensor Carpi radialis

longus

– Pronator Teres

– Common Origins

The Humerus

• Posterior aspect

– Head

– Necks

– greater tuberosity

– Sulcus for radial

nerve

– supracondylar ridges

– epicondyles

– Olecranon fossa

– Trochlear

The Humerus

• Posterior Muscle

attachments

– infraspinatus

– teres minor

– Triceps lateral head

– Deltoid

– Brachialis

– triceps Medial Head

– Anconeus

Biceps Coracobrachialis

Deltoid

Lateral head of

Triceps

Long head of Triceps

Pectoralis major

Muculocutaneous

Median nerve

Brachial artery

Basilic vein

Ulnar nerve

Profunda artery

Radial nerve

Median nerve

Brachial artery

Basilic vein

Ulnar nerve Profunda artery

Radial nerve

Muculocutaneous

Biceps

Brachialis

Median nerve

Brachial artery

Basilic vein

Ulnar nerve

Radial nerveMuculocutaneous

Biceps

Brachialis

Cross-section

• Upper section

– cylindrical

• Lower section

– comma shaped

– flattened AP

• IM device diameter

and length

• posterior flat surface

– plates

• Ossification

– 8 ossification centres

• shaft appears at middle of bone and grows towards ends

• at 8th week of intrauterine life

• Radial Nerve

– between long and

medial heads of

triceps

• Whitson

– JBJS 1954

– “..the radial nerve

transversed the

triceps at such a

depth that it was

nowhere in contact

with the humerus.”

– “..as the

supracondylar ridge

was approached, the

radial nerve was

found to be in

WhitsonJBJS 1954

• “.. It was apparent that the separation of the

triceps into three heads was artificial and

that the medial and lateral heads were in

reality a single muscle group traversed by a

nerve and an artery.”

• similar to posterior interosseous passes through

the supinator.

• “The Spiral Groove in every specimen gave origin

to the uppermost fibres of the brachialis,”

WhitsonJBJS 1954

• Admit clinical importance of these

observations is not great.

• Explain that the muscle fibres of triceps and

brachialis offer some protection from sharp

bone edges.

Peripheral Nerve Injury Unit

• Mr Birch on Whitson’s findings

– “.. Not his experience, felt that the nerve

had a close relationship to the bone for a

considerable distance.”

– possible explanation could be that the

cadavers had been lying supine and so

compression deformation occurred which

distorted the true in vivo anatomical

position of the nerve

MainNutrient

artery to

humerus

Profunda brachii

Gives

nutrient

deltoid

posterior

descending

radial

collateral

Blood Supply

Blood supply

• Laing 1956 JBJS 38-A

• main nutrient artery enters the humerus at

the junction of the middle and distal third,

or in the lower part of the middle third.

• Middle third fractures damage this vessel

• higher rate of delayed union

– Klenerman JBJS 48-B

Humeral Shaft fractures

• Humeral shaft fractures 3% all all fractures

• Christensen Acta Chir Scand 1967

• Humeral Shaft fractures 1% of all fractures

• Emmett and Breck 11,000 #

Shaft Fractures

• Classifications

– anatomical

– management based

– comparison

– useless

Classification

• No universally accepted system for humeral

shaft fractures

• anatomical

– proximal shaft, middle shaft, or distal shaft

– relative to muscle attachments

• pectoralis major, deltoid

– Character

• description

Classification

• Fracture comminution

• A-simple

• B-butterfly fragments

• C-comminuted

Classification

• Associated

– soft tissue injury

– periarticular involvement

– nerve injury

– vascular injury

– intrinsic condition of the bone

Mechanism of Injury

• Klenerman experimental #’s

– Compression proximal or distal #‟s

– bending produce transverse #‟s

– Torsional forces give spiral #‟s

– Bending combined with torsion produces

an oblique # with a butterfly fragment

Mechanism of Injury

• Direct and Indirect

trauma

– Falls(FOOSH)

– RTA‟s

– Direct blow to arm

– Extreme muscle

contraction

• ball and javelin

throwing

• arm wrestling

Arm Wrestling

• Ogawa and Ui 1997 J Trauma 42-2, Tokyo

• 30 cases

• all spiral #’s

• 23% radial nerve palsy

• occurred when trying to change from a

static to dynamic phase

• shoulder rotators:- intense rotational force

Andy

Signs and Symptoms

• Pain, swelling and deformity

• motion and crepitus

• associated injuries

– vascular

– neural

• secondary injury due to swelling

– particularly the multiple trauma or

unconscious pt.

Imaging

• Plain AP and 900 lateral

– move whole patient not limb

– include joints

• associated dislocations, #’s into joints

– traction radiographs for comminuted #‟s

– Comparison films for planning

• Bone scan for pathological #’s

Goals of treatment

Establish union with an

acceptable humeral

alignment and restore

patients to their

previous level of

function

Mal-Union

• Klenerman JBJS 1966 48-B

Concluded:

– “The degree of radiological deformity that

can be accepted is far greater than in other

long bones”

– anterior bowing of 200

– varus of 300

– before clinically obvious

Methods of Treatment

• NUMEROUS OPTIONS

– Closed

– Open

• Good to excellent results have been

reported with all methods

• Patient characteristics

• Fracture characteristics

Management

CONSERVATIVE

“Most humeral shaft

fractures can be

managed

nonoperatively”

Closed Management Methods

• Greater than 90% expected union rate

– Hanging arm cast

– U-shaped brachial splint

– Velpeau dressing

– Abduction humeral splint/shoulder spica

cast

– skeletal traction

– functional brace

Hanging arm cast

• Gravity traction for reduction

• arm and cast must be dependant at all times

– Problems

• RoM of shoulder and elbow impaired

• fracture distraction and hinging

• avoid transverse fractures

• Indications

– midshaft spiral or oblique with shortening

Hanging arm cast

• Lightweight

• elbow at 900, forearm in neutral

• at least 2cm proximal to fracture

• distal forearm loops

• dorsal, volar and neutral

• must hang free

• regular Follow-up

Hanging arm cast

• Apex anterior

angulation

– shortening of the

sling

• Apex posterior

angulation

– lengthening the sling

Hanging arm cast

• Valgus(Apex medial)

angulation

– using the volar loop

• Varus(Apex lateral)

angulation

– using the dorsal loop

U-shaped splint

with C/C• Indicated for

– acute management of #‟s with minimal shortening

• slipping of the cast is common

• poor patient tolerance

• often exchanged for a functional brace at 2/52

Thoracobrachial

immmobilization• Velpeau shoulder

dressing– inexpensive, comfortable

and easily applied and

adjusted

• minimally displaced

#’s

– axillary pad

• early pendulum exercises

• Traction• rarely indicated, as operative management has same

indications

Functional

bracing• Sarmiento 1977JBJS 59-A

• “effects fracture

reduction through soft

tissue compression”

– allows good shoulder

and elbow

movement

• after one week until

eight weeks

Functional bracing

• Sarmiento et al 1990, 72-B

• suggests well proven method for mid shaft

#’s

• presents a series of distal shaft #’s which

had good results from functional bracing

after a period of hanging cast treatment

Functional bracing

• Sarmiento et al 1990, 72-B

• control of angulation

– showed average of 9o varus in 81% of patients

(n65)

• high incidence of radial nerve damage

– (18%) all were resolved or improving

• residual stiffness of shoulder and elbow

– minimal loss of RoM and good functional results

• 96% went onto union

Functional bracing

• Balfour et al 1982 JBJS 64-A, LA California

• adapted Sarmiento’s brace

– proper fit

– swelling of the forearm

– discomfort

• shoulder flare with sling support

Functional bracing

• Balfour et al 1982 JBJS 64-A

• “Stress that the brace requires the influence

of gravity on the dependent arm of an

ambulatory patient”

– all except in one patient the fracture united

– average of 90 varus and 60 AP bowing

– RoM elbow and shoulder excellent

Functional bracing

• Camden et al 1992 Injury 23-4

• comparison of U-slab with functional brace

– no difference for healing time and

alignment

– better RoM at elbow

• Zagorski 1988 JBJS 70-A

– can be used to treat proximal shaft

fractures

• have less angulation

Operative treatment

INDICATIONS

INTERVENTION

• INDICATIONS

– “It‟s Begging for a nail”

– “It will be Good fun to plate it?”

– “I need the experience.”

– “Why don‟t we try that new nail from……?”

– “That rep had a delightful, intelligent and

generous personality so why don‟t we

use….?”

Indications for operative

management• Open fracture

• associated vascular injury

• floating elbow

• segmental fracture

• pathological fracture

• Bilateral humeral fractures

• polytrauma patients

• radial nerve palsy

• neurological deficiency after penetrating injury

• fractures with unacceptable alignment


management

• Open fracture

– require debridement

– fracture stabilisation afterwards

• to reduce infection

• Not absolute

– Sarmiento shown cases where no

debridement of low velocity gun shot

fractures

– and non operative management of fracture


management

• Associated vascular injury

– internal or external fixation

– prior or post repair

• If repaired then non-operative management

is contra-indicated

– fracture motion jeopardise the repair

Associated vascular injury

• Arteriography

– controversial

– clinical assessment

can detect 50%

– time delay

• Urgent exploration

and repair

– intraluminal shunts

– end to end or grafts


management

• Floating Elbow

• Rogers et al 1984 JBJS 66-A, Houston

• retrospective study

– higher incidence of non-union of the

humerus in injuries without ORIF

– ORIF of both forearm and humerus

indicated

Floating Elbow


• 19 patients

– traffic elbow, sideswipe injury

• severe injury with poor outcome

• amputation, arthrodesis, non-union and poor elbow

function

• Two groups

– elbow involvement

Floating Elbow


• Group I

– no elbow involvement

– all mid-shaft humerus

– 5 open, 6 closed

– closed did better than open

– conservatively managed had more non-

unions

– all forearm fractures healed


management

• Segmental fractures

• Foster et al 1985 JBJS 67-A

– multi centre trial

– segmental humeral fractures have a high

rate of non-unions if treated nonoperatively

– at one or both the fracture sites


management

• Pathological fractures

– internal fixation

• Enders nails, locked nails, no reaming

• cement augmentation

– patient comfort

• pain relief,

– regain function

• daily activities, independence


management

• Bilateral humeral shaft

fractures

– improves patients

ability to perform

daily tasks and

personal toilet


management

• Multiple trauma patient

• advantages

– pain relief

– protect adjacent soft tissues

– „fracture disease‟

– help nursing and rehab

• Brumback et al 1986 JBJS 68-A, Baltimore

Multiple trauma patient


• 58 patients with multiple trauma

• Shock Trauma Center

– 2000 patients annually

– most scooped and run by helicopter

• retrospective

• ISS, average 23.5

Multiple trauma patient


• stabilise long bone fractures

• 95% were stabilised within 1st 24 hrs.

• Used Rush rods and Enders nails

– “semi-rigid fixation”

– “minimal violation of fracture haematoma”

– no reaming

Multiple trauma

patient• Brumback et al 1986

JBJS 68-A

• Results

– 5 deaths

– alignment 98% <150

varus

– RoM dependant on

insertion point

– epicondylar approach

had poor results

– 55% had devices

removed

Multiple fractures

• Jensen and Rasmussen 1995 Injury 26(4), Denmark

• showed poor results for multiple injured

patients with bracing

– Neer score

– small study


management

• Radial nerve palsy

– mandatory if occurs after closed

manipulation and reduction

• Packer et al 1972 CORR 88

• Shergill and Birch 1997

– open wounds

– arterial injury

Radial nerve palsy

• Commonly middle

third #’s

• higher rate in distal

third #’s

• Holstein-Lewis

fracture

– oblique, distal third

Radial Nerve

palsy

• Triceps sparing

• Supination lost in the

extended elbow

– flexed allows biceps

• wrist drop

• unable to extend

MCPj

• DIP/PIPj’s extend via

intrinsics

Treatment of Radial

Neuropathy Associated with

Fractures of the Humerus• Pollock et al, San Francisco, 1981, JBJS 63-A

• Retrospective

• 15 yrs, 23 patients,

• all with CLOSED treatment of # humerus

with a Radial Nerve Palsy

• 6% of all humeral shaft #’s (11% lit)

• 13 male, 10 female, (1mth-63yrs)

Treatment of Radial



• mainly severe trauma

• 3 segmental,

• 5 oblique

• 4 comminuted

• 5 transverse

• 7 spiral

Treatment of Radial



• 3 open, 21 closed

• 2 prox. 1/3

• 5 middle 1/3

• 14 distal 1/3

• 3 segmental

# and Radial

palsy• Conservative methods

of treatment

– sugar-tong 8

– shoulder spica 5

– hanging cast 5

– palm to axilla cast 3

– olecranon traction 2

– posterior splint 1

# and Radial

palsy• Extent of palsy

– complete M & S (n9)

– partial M (n6)

– partial M & S (n3)

– complete M, intact S

(n3)

– isolated S (n1)

• partial lesions distributed through out length of humerus

Treatment of Radial


Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A

All patients in this series

had a complete return

of radial nerve

function.

Treatment of Radial



• Distal 1/3 fractures have a high incidence of

palsies

• vast majority have a lesion in continuity

• clinical or EMG improvement should be

apparent by 14 to 16 weeks

• if not then explore and repair

Treatment of Radial



• Time course of recovery

– complete loss

• first signs of recovery between 6 days and seven

months

• average seven weeks

• Full recovery

– one day to one year, average fifteen weeks

Early Exploration

• Literature review

• n95

• 12% found nerve lacerated

• Nerve recoveries 70%

• non-recovery 20%

• lost to follow-up 10%

Delayed exploration

• Literature review

• n53

• 3 to 6 months delay

• divided nerves found 19%

• entrapped in callus 6%

• reasonable recovery

Delayed exploration

• Advantages over early

– time for recovery

• neurapraxia, axonotmesis

– evaluation of nerve lesion

• degree, tinel sign, neurophysiology

– fracture united

– results of late repair reported similar to

early


management

• Neurological loss after penetrating injury

– almost an absolute indication

– similar to other areas of the body

– primary repair of nerve, requires

stabilisation

– tag and refer after stabilisation


management

• Failure of conservative management

– failure to maintain acceptable alignment

• obese, pendulous breasts

– 200 AP

– 300 varus

• thin individuals, less tolerant

– 3cm of shortening

– malrotation well tolerated

Failure of conservative

management• Obese

– Jensen et al 1995

Injury 26-4, Denmark

– Sarmiento brace

– compared with non-

obese

– Neer scores lower

– 45% non-unions

• pendulous breasts

What Operation?

• Screws

• screws and plates

• cerclage wires

• External fixation

• Intra medullary fixation

Approaches

• Anterolateral– supine, incision lateral border of biceps,

– proximal fractures

• Anterior– coracoid to deltoid insertion then lateral border of

biceps

– limited distally

• Posterior– excellent exposure, limited proximally, 8cm from

acromium

– lateral and long heads of triceps, medial head incised

Open reduction and internal

fixation• Disadvantages

– infection

– non-union

• requiring re-operation

– injury to the radial

nerve

• initially or on removal

of metal work

– prolonged disability


fixation• Advantages

– early mobilization of

limb

• good joint function

– good pain relief

– exploration of radial

nerve

• repair

• prognosis for recovery

– bone grafting


fixation• Bell et al 1985 JBJS 67-B, Sunnybrook

• Griend et al 1986 JBJS 68-A, Mississipi

• 36 patients had AO plating

• indications

– multiple injuries

– open fractures

• retrospective

AO plating

• Griend et al 1986 JBJS 68-A, Mississipi

• “..comparisons may not be entirely valid..”

– multiple methods of fixation

– “uncomplicated fractures” cf. “Problem fractures”

• anterolateral approach

• 4.5mm DCP

• bone grafted if bone loss or comminution

AO platingGriend et al 1986 JBJS 68-A, Mississipi

• One non-union

• no deep infection, two superficial infections

• one (transient)post operative radial nerve palsy

• radial nerve palsy– 9 explored, 1 lacerated, 4 contused, 4 normal

– 6 resolved

• good RoM, except in severe vascular or neural

defect

AO platingGriend et al 1986 JBJS 68-A, Mississipi

• Conclude

– safe if nerve exposed and protected

– high rates of union

– good function

• only where non-operative management not

indicated

External fixation

• Indications

– open fractures

– extensive soft tissue injury

– fractures over burns

– infected non-unions

– neurovascular injury

External

fixation• Complications

– pin tract infections

– impalement

• muscle, tendon

• neurovascular

– non-union

• advise direct visual

placement of pins

advise direct visual placement

of pins

Humerus

Musculocutaneous

Ulnar nerve

Brachial artery

Median nerve

Brachial veins

Radial nerve

Intramedullary fixation

• General advantages– mechanical axis

• less likely to fail by

fatigue

– load-sharing

– axial gliding

– osseus alignment

– less stress shielding

– less refracture after nail

removal

– biological benefits


• Flexible intramedullary nails

– Enders nails, Hackenthal, Rush rods

• not rigid, # can shorten and rotate

• entrance point

• Interlocked nails

– numerous on the market

– to ream or not,

– antegrade insertion can cause

impingement


• Antegrade

– high rates of shoulder

stiffness

– subacromial

impingement

• Retrograde

– no shoulder problems

– can get elbow

restriction of extension

• Epicondylar portal p

– poor results

Locking nails

• Habernek and Orthner 1991 JBJS 73-B, Austria

• 19 Seidel nails

– good results

• no non-unions, infections, radial nerve palsies

• only fractures in the middle 60% of the humerus• secondary radial palsies

• lower 5th of shaft #’s should not be nailed• mal-alignment

Locking nails

• Court-Brown et al 1992 JBJS 74-B, Edinburgh

• 30 Seidel nails

– poor results (87% complication rate)

– technical difficulties

• failed distal (30%)locking

– nail protrusion (40%)

– poor shoulder function

• did not advocate its use

Rehabilitation

• RoM of hand and wrist started immediately

• RoM of elbow and shoulder as pain allows

– shoulder to avoid postfracture stiffness

– elbow ACTIVE exercises only

• myositis ossificans

• post # healing

– strengthening exercises

• isometric to isotonic

Management of humeral shaft

fractures Summary

• Vast majority can be managed closed

• There are absolute indications for open

management

• You can find supporting evidence for each

type of open method

• Patient and fracture characteristics dictate

management

Thank you

The Management of Humeral Shaft Fractures Shaft... · Imaging •Plain AP and 900 lateral –move whole patient not limb –include joints •associated dislocations, #’s into joints

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