the management of humeral shaft fractures shaft... · imaging •plain ap and 900 lateral –move...
TRANSCRIPT
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The Management of Humeral
Shaft Fractures
David Chapple MSc FRCS
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SHAFT
• NOT
–Proximal
–Distal
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Anything New?
• Anatomy
• Classifications
• MOI and Clinical aspects
• Management options
• Management indications
• Management Complications
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Anatomy
• three borders
– Anterior
– Medial
– lateral
• three surfaces
– anterolateral
– anteromedial
– posterior
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The Humerus
• Anterior aspect
– Head
– necks
– tuberosities• < > & Deltoid
• sulcus, bicipital groove
– supracondylar ridges
– epicondyles
– Coronoid fossa
– trochlea/Capitulum
– Supracondylar process
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• 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
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The Humerus
• Posterior aspect
– Head
– Necks
– greater tuberosity
– Sulcus for radial
nerve
– supracondylar ridges
– epicondyles
– Olecranon fossa
– Trochlear
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The Humerus
• Posterior Muscle
attachments
– infraspinatus
– teres minor
– Triceps lateral head
– Deltoid
– Brachialis
– triceps Medial Head
– Anconeus
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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
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Median nerve
Brachial artery
Basilic vein
Ulnar nerve Profunda artery
Radial nerve
Muculocutaneous
Biceps
Brachialis
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Median nerve
Brachial artery
Basilic vein
Ulnar nerve
Radial nerveMuculocutaneous
Biceps
Brachialis
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Cross-section
• Upper section
– cylindrical
• Lower section
– comma shaped
– flattened AP
• IM device diameter
and length
• posterior flat surface
– plates
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• Ossification
– 8 ossification centres
• shaft appears at middle of bone and grows towards ends
• at 8th week of intrauterine life
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• 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
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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,”
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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.
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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
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MainNutrient
artery to
humerus
Profunda brachii
Gives
nutrient
deltoid
posterior
descending
radial
collateral
Blood Supply
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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
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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 #
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Shaft Fractures
• Classifications
– anatomical
– management based
– comparison
– useless
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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
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Classification
• Fracture comminution
• A-simple
• B-butterfly fragments
• C-comminuted
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Classification
• Associated
– soft tissue injury
– periarticular involvement
– nerve injury
– vascular injury
– intrinsic condition of the bone
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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
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Mechanism of Injury
• Direct and Indirect
trauma
– Falls(FOOSH)
– RTA‟s
– Direct blow to arm
– Extreme muscle
contraction
• ball and javelin
throwing
• arm wrestling
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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
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Andy
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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.
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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
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Goals of treatment
Establish union with an
acceptable humeral
alignment and restore
patients to their
previous level of
function
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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
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Methods of Treatment
• NUMEROUS OPTIONS
– Closed
– Open
• Good to excellent results have been
reported with all methods
• Patient characteristics
• Fracture characteristics
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Management
CONSERVATIVE
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“Most humeral shaft
fractures can be
managed
nonoperatively”
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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
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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
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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
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Hanging arm cast
• Apex anterior
angulation
– shortening of the
sling
• Apex posterior
angulation
– lengthening the sling
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Hanging arm cast
• Valgus(Apex medial)
angulation
– using the volar loop
• Varus(Apex lateral)
angulation
– using the dorsal loop
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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
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Thoracobrachial
immmobilization• Velpeau shoulder
dressing– inexpensive, comfortable
and easily applied and
adjusted
• minimally displaced
#’s
– axillary pad
• early pendulum exercises
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• Traction• rarely indicated, as operative management has same
indications
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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
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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
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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
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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
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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
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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
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Operative treatment
INDICATIONS
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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….?”
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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
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Indications for operative
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
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Indications for operative
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
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Associated vascular injury
• Arteriography
– controversial
– clinical assessment
can detect 50%
– time delay
• Urgent exploration
and repair
– intraluminal shunts
– end to end or grafts
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Indications for operative
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
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Floating Elbow
• Rogers et al 1984 JBJS 66-A, Houston
• 19 patients
– traffic elbow, sideswipe injury
• severe injury with poor outcome
• amputation, arthrodesis, non-union and poor elbow
function
• Two groups
– elbow involvement
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Floating Elbow
• Rogers et al 1984 JBJS 66-A, Houston
• 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
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Indications for operative
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
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Indications for operative
management
• Pathological fractures
– internal fixation
• Enders nails, locked nails, no reaming
• cement augmentation
– patient comfort
• pain relief,
– regain function
• daily activities, independence
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Indications for operative
management
• Bilateral humeral shaft
fractures
– improves patients
ability to perform
daily tasks and
personal toilet
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Indications for operative
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
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Multiple trauma patient
• Brumback et al 1986 JBJS 68-A, Baltimore
• 58 patients with multiple trauma
• Shock Trauma Center
– 2000 patients annually
– most scooped and run by helicopter
• retrospective
• ISS, average 23.5
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Multiple trauma patient
• Brumback et al 1986 JBJS 68-A, Baltimore
• 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
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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
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Multiple fractures
• Jensen and Rasmussen 1995 Injury 26(4), Denmark
• showed poor results for multiple injured
patients with bracing
– Neer score
– small study
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Indications for operative
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
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Radial nerve palsy
• Commonly middle
third #’s
• higher rate in distal
third #’s
• Holstein-Lewis
fracture
– oblique, distal third
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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
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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)
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Treatment of Radial
Neuropathy Associated with
Fractures of the Humerus• Pollock et al, San Francisco, 1981, JBJS 63-A
• mainly severe trauma
• 3 segmental,
• 5 oblique
• 4 comminuted
• 5 transverse
• 7 spiral
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Treatment of Radial
Neuropathy Associated with
Fractures of the Humerus• Pollock et al, San Francisco, 1981, JBJS 63-A
• 3 open, 21 closed
• 2 prox. 1/3
• 5 middle 1/3
• 14 distal 1/3
• 3 segmental
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# 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
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# 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
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Treatment of Radial
Neuropathy Associated with
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.
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Treatment of Radial
Neuropathy Associated with
Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A
• 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
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Treatment of Radial
Neuropathy Associated with
Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A
• 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
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Early Exploration
• Literature review
• n95
• 12% found nerve lacerated
• Nerve recoveries 70%
• non-recovery 20%
• lost to follow-up 10%
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Delayed exploration
• Literature review
• n53
• 3 to 6 months delay
• divided nerves found 19%
• entrapped in callus 6%
• reasonable recovery
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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
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Indications for operative
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
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Indications for operative
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
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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
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What Operation?
• Screws
• screws and plates
• cerclage wires
• External fixation
• Intra medullary fixation
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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
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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
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Open reduction and internal
fixation• Advantages
– early mobilization of
limb
• good joint function
– good pain relief
– exploration of radial
nerve
• repair
• prognosis for recovery
– bone grafting
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Open reduction and internal
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
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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
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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
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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
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External fixation
• Indications
– open fractures
– extensive soft tissue injury
– fractures over burns
– infected non-unions
– neurovascular injury
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External
fixation• Complications
– pin tract infections
– impalement
• muscle, tendon
• neurovascular
– non-union
• advise direct visual
placement of pins
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advise direct visual placement
of pins
Humerus
Musculocutaneous
Ulnar nerve
Brachial artery
Median nerve
Brachial veins
Radial nerve
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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
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Intramedullary fixation
• 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
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Intramedullary fixation
• Antegrade
– high rates of shoulder
stiffness
– subacromial
impingement
• Retrograde
– no shoulder problems
– can get elbow
restriction of extension
• Epicondylar portal p
– poor results
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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
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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
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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
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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
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Thank you