Humeral Shaft Fracture

Nonoperative Management

 

Indications

 

< 20o sagittal

< 30o coronal

< 3 cm of shortening

 

Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral

 

Options

 

1.  Vietnam Cast / hanging cast

 

2.  Functional bracing / Sarmiento

 

Functional Humerus Brace

 

Results

 

Union rates

 

Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative: 20% nonunion and 12% malunion

- operative group: 8% nonunion and 1% malunion

- no difference in time to union in two groups

 

Ali et al. J Shoulder and Elbow Surgery 2015

- retrospective review of 138 patients treated nonoperatively

- 17% nonunion (24/138)

- proximal fractures highest nonunion rate

 

Time to union and functional outcome

 

Papasoulis et al. Injury 2010

- literature review of functional bracing humerus shaft fractures

- average time to union 10.7 weeks

- full shoulder ROM in 80%

- full elbow ROM in 85%

https://pubmed.ncbi.nlm.nih.gov/19523625/

 

Humerus shaft 1Humerus shaft 2Humerus shaft 3Humerus shaft 4Humerus shaft 5

Progressive union in midshaft humerus fracture treated nonoperatively

 

Humerus shaft nonunionHumerus nonunion

Nonunion in a proximal humerus shaft fracture treated nonoperatively

 

Radial Nerve Injury

 

Incidence

 

Shao et al. JBJS Br 2005

- systematic review of humerus shaft fracture

- 11.8% (532/4517) radial nerve injuries

- most common with middle, and middle/distal fractures

- 70% spontaneously recovered without intervention

- recovery rate 88% in those undergoing delayed exporation (14 weeks)

- recovery rate 88% in those undergoing immediate exploration

 

Holstein Lewis fracture

 

Holstein LewisHolstein Lewis fracture

 

Holstein-Lewis JBJS Am 1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

- the radial nerve is closely assoicated with the fracture site and the fracture spike

 

Korompilias et al. Injury 2013

- 25 patients with complete nerve palsy and humerus shaft fractures

- 13 fully recovered by 12 weeks

- explored 12 patients with no recovery at 16 weeks

- nerve lacerated in two patients

- intact in remainder - these fully recovered by 20 - 24 weeks

 

Management

 

Absolute indications for exploration

- open fractures

- radial nerve palsy following closed reduction

 

Relative

- Holstein-Lewis fracture patterns

- patient undergoing ORIF

- no recovery at 10 - 12 weeks

 

Expectant management

- wait 10 - 12 weeks

- if no recovery EMG

- consider exploration +/- neurolysis +/- nerve graft at that time

- if that fails, tendon transfer for radial nerve palsy

 

Operative Management of Humeral Shaft Fractures

 

Indications

 

Absolute

 

Compound fracture

Failure to obtain / maintain acceptable reduction

Radial nerve palsy post reduction

Displaced Holstein Lewis with radial nerve palsy

Nonunion

 

Relative

 

Multi-trauma

Floating elbow

Segmental fracture

Proximal fracture

Pathological fracture - won't heal

Bilateral humeral fractures

Obese (very difficult to splint)

Brachial plexus injury - allows early rehab

 

Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral

 

Options

 

Open ORIF with plate

MIPO

Intra-medullary nail

 

Evidence

 

Nail v plate

 

Beeres et al. Eur J Trauma Emerg Surg 2021

- IM nail v open plate

- meta-analysis of 10 RCTs (500 pts)

- SR of 18 observational studies (4900 pts)

- 17% of IMN required reoperation for shoulder impingement

- IMN had faster union and lower infection rate

- no difference nonunion rates or shoulder function scores

 

van der Wall et al. Eur J Trauma Emerg Surg 2021

- IM nail v MIPO
- meta-analysis of 2 RCTs (87 pts)

- systematic review of 5 observational studies (600 patients)

- MIPO lower risk of nonunion and re-intervention

- MIPO better shoulder function

 

ORIF v MIPO
 

Beeres et al. Injury 2021

- MIPO v ORIF

- meta-analysis of 2 RCTS (98 pts)

- systematic review of 7 observational studies (263 patients)

- MIPO lower risk of nonunion

- no difference in infection or time to union

 

1.  Open ORIF with plate

 

Humeral Plate LateralHumeral Plate Long AP

 

Approaches

 

Anterolateral approach - proximal 2/3 of humerus

Posterior approach / triceps split - distal 1/3 of humerus

Posterior approach with triceps flip - Holstein lewis

 

A.  Anterolateral Approach Humerus for proximal / mishaft fractures

 

Prox humerus 1Prox humerus 2Prox humerus ORIFProximal humerus ORIF

 

AO foundation surgical approach

 

Vumedi video

 

Indication

- proximal fractures

- midshaft fractures

 

Set up

- lazy beachchair

- flat with arm on arm table

- ensure can get good images of humeral head

 

Incision

- deltopectoral proximally (to coracoid)

- lateral humerus distally

- distally between mobile wad and biceps

 

Proximally

- deltopectoral groove

- identify and protect cephalic vein

- take vein laterally to minimis bleeding

- can partially release deltoid insertion if needed

 

Distally

- follow cephalic

- open fascia laterally

- identify plane between biceps and brachialis

- biceps swept medially

- protect musculocutaneous nerve between the two

- will emerge as lateral cutaneous nerve of the forearm distally

- identify and split brachialis in midline

- can reflect brachialis medially, but will potentially damage radial innervation of medial brachialis

 

Distal extension

- between brachialis and brachioradialis in distal 1/4

- find and protect radial nerve as it emerges anteriorly through lateral intermuscular septum

- may be easiest to find radial nerve most distally between brachialis and bradioradialis

- avoid lateral hohman retractors in this area

 

Internervous plane

- radial nerve lateral brachialis

- musculocutaneous nerve medial brachialis

 

Plate

- narrow large fragment 4.5 mm DCP / long Philos proximal humeral plate

- minimum 6 cortices above and below

 

B.  Posterior Approach / triceps split for Distal 1/3 fractures

 

Humerus ORIF Posterior Approach

 

AO foundation surgical approach

 

Vumedi video

 

Indication

- distal 1/3 fractures

- holstein-lewis fractures

 

Position

- lateral approach with arm over bolster

 

Sterile tourniquet if needed

 

Midline incision

- split deep fascia

- develop interval between long and lateral heads of triceps (easiest in muscle bellies proximally)

- identify radial nerve and profunda brachii artery in proximally in spiral groove

- split triceps tendon distally

 

Proximally

- release lateral head of triceps from humerus

- limited by axially nerve / posterior circumflex humeral artery proximally

 

Distally

- reflect medial head of triceps from bone medially

- care of ulna nerve which emerges posteriorly through medial intermuscular septum

 

C. Posterior approach with triceps sparing for Holstein Lewis

 

AO foundation radial window distal humerus

 

Indication

 

Holstein Lewis / distal humerus fracture

 

Approach

 

Patient lateral with arm over bolster

 

A. Mobilise the lateral triceps from lateral intermuscular septum

- identify the radial nerve lateral to triceps 

- follow as it passes through the lateral intermuscular septum

- identify as passes across the humerus in the groove

- may have to elevate the radial nerve and pass the plate under

- can use a proximal triceps split window as needed to identify the radial nerve

 

Triceps flip Triceps flip 2

 

Plate

 

Precontoured long posterolateral distal humerus plates

 

Triceps flip plate 1Triceps flip 2

 

Humerus distal posterolateral plate 1Distal posterolateral plate 2

 

B. Can also mobilise medial triceps

- identify and release the ulna nerve medially

- additional medial plate if needed

 

Dis HumerusLateral humerusMedial humerus

 

Lateral and medial plates for an extra-articular distal humerus fracture

 

2. Minimally Invasive Plate Osteosynthesis (MIPO)

 

Concept

 

Bridge plating

Indirect fracture reduction

 

Indications

 

Surgical neck of humerus to 10 cm of elbow joint

 

Options

 

Anterior plating with narrow 4.5 mm LCP

Lateral plating with long proximal humerus plate

 

Jeong et al. BMC Musculoskeletal Disorders

- 18 patients treated with narrow LCP (anterior)

- 17 patients treated with long Philos plate (lateral)

- 2 metal failures in the Philos plate group requiring revision to LCP

 

Technique anterior MIPO plating

 

Tetsworth JAAOS 2018

 

Position

- patient supine

- arm on arm table

- ensure can image proximal humerus

- keep elbow flexed to aid reduction and reduce biceps tension

 

Narrow LCP plate

- place on arm to select appropriate size

 

MIPO humerus 1MIPO humerus 3MIPO humerus 2

 

Incisions

 

Proximal 4 - 5 cm

- deltopectoral approach

 

Distal 4 - 5 cm

- anterior approach to distal humerus

- mobilise biceps laterally

- identify and protect lateral cutaneous nerve of the forearm

- split bracialis

- keep arm supinated to protect radial nerve

- avoid deep retractors laterally to protect radial nerve

 

Create submuscular plane

- periosteal elevator along bone

 

Precontour narrow LCP plate

- subtle convex curve proximally

- subtle concave curve distally

- 10 - 15 degrees internally rotated

 

Pass plate

- indirect fracture reduction

- secure plate proximally to bone

- reduce fracture

- distal fixation

 

MIPO incisions 1MIPO incisions 2MIPO incisions 3MIPO plate insertion

 

3.  Antegrade Humeral Nail

 

Humeral Nail APHumeral Nail Lateral

 

Relative indications

 

Segmental fracture - need very long plate

Impending pathological fracture

Obesity

Skin compromise

 

Technique

 

Vumedi video

 

Set up

- lazy beach chair

- can do flat on bed, with bump under shoulder

- need to get fluoroscopy of shoulder and distal forearm

- have fluroscopy come from opposite side

- patient relatively supine to ensure ease of AP distal locking

 

Anterolateral approach shoulder

- longitudinal split supraspinatus

- can split at the anterior edge of supraspinatus, and retract posteriorly

- protect rotator cuff throughout

 

Entry with K wire or awl

- entry point at medial aspect greater tuberosity

- theorectically protects the cuff tendon

- check centred in humerus canal using fluoroscopy on AP and lateral

- increase diameter proximally with hand reamers

 

Pass guide wire

- can do closed

- can perform mini open incision over fracture site

- use finger to blunt dissect and protect radial nerve

 

Minimal reaming

 

Pass nail

- typically 7 mm

- ensure that nail is buried enough to protect cuff

- need to consider hardware removal

 

Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon

 

Distal AP locking screw/s

 

Careful repair of rotator cuff

 

Complications

 

Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

 

Humerus Prominent IM Nail

 

Non Union

 

Background

 

Definition

 

Mean time to union is 13 weeks

No evidence of callous on xrays taken 6 - 8 weeks apart

 

Fracture patterns

- highest risk is transverse fractures

- proximal humerus shaft fractures also at risk due to displacing force of pectoralis and deltoid, and LHB may interpose

 

Management

 

Peters et al. Injury 2015

- systematic review of union rate after operative intervention of humeral shaft non union

- plate only 95%

- plate and bone graft 98%

- IMN 66%

- IMN + bone graft 88%

- external fixation 98%

 

Technique

 

Vumedi video

 

Humerus nonunion plateHumerus nonunionHumerus nonuion plate 1Humerus nonunion plate 2

 

Approach

- fracture site dependant

- 4.5 mm plate with 6 cortices above and below

- if use 3.5 mm long proximal humeral plate, suggest 8 cortices below

- use iliac crest bone graft

- consider dual plating in proximal fractures with insufficient fixation, or in poor bone quality

 

Infection

 

Humerus infection 1Humerus infected 2