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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Humeral Shaft Fracture

 - See: Humeral Frx - Main Menu
           - Condylar Fractures
           - Non Union of Humeral Fractures
           - Pediatric Humeral Shaft Fracture
           - Synthes Humeral Shaft Products

- Discussion:
    - mechanism:
          - bending force produces transverse frx of the shaft;
          - torsion force will result in a spiral fracture; 
          - combination of bending and torsion produce oblique frx w/ or w/o a butterfly fragment;
          - compression forces will frx either proximal or distal ends of humerus;
    - types of humeral shaft frx:
          - transverse humeral fractures
          - distal third frx
          - short oblique fractures:
                 - displaced frx thru distal shaft are difficult to reduce & are difficult to maintain in reduced position;
                 - these fractures may be associated w/ delayed healing;
          - long spiral fractures:
                 - spiral, comminuted, and oblique fractures have the advantage of generous fracture surface areas and tend to heal rapidly;
                 - if displaced with a gap which does not close when rotational alignment is restored, there may be muscle interposition;
                 - if left with good alignment, but with a significant gap between the frx frag, these frx go on to atrophic nonunion
          - associated fractures:
                 - A review of outcomes in 18 patients with floating elbow.
                 - Functional outcomes of "floating elbow" injuries in adult patients.
                 - Management of concomitant ipsilateral fractures of the humerus and forearm
                 - Skeletal management of humeral shaft fractures associated with forearm fractures. 

- Exam:
      - need to rule out radial nerve palsy (see discussion), noting function of the ECRL/ECRB, EDC, ECU, EIP, and EPL; 
             - do not assume that every extension deficit reflects a radial nerve palsy (vs brachial plexus injury);
      - references:
             - Humeral shaft fracture with brachial artery injury.
             - Management of fractures of the humerus in patients who have an injury of the ipsilateral brachial plexus.

- Acceptable Reduction: (forces displacing the fracture)
      - axial malalignment:
            - upper arm will accommodate 10-20 deg of anterior angulation & 10-30 deg of varus;
            - this amount of angulation would be considered acceptable for patients w/ low to moderate functional demands;
      - overriding fracture:
            - bayonet position w/ upto 1 inch of  shortening is acceptable;
            - over-riding displacement is influenced to a considerable degree by muscle contraction, which may have led to hanging cast principle;
      - note displacing forces:
            - frx just distal to insertion of deltoid muscle are prone to abduction of proximal fragment & also require special attention;

- Non Operative Treatment of Humeral Shaft Frx:
     - note that these injuries are often very painful and that good initial immobilization is required;
            - long arm splint needs to be applied from shoulder to wrist to fully immobilize the extremity;
     - although rate of union is generally high with non operative treatment, incidence of mild malunion is high;
            - in the study by Sarmiento A, et al (2000), the researchers were able to follow 620 patients with humeral shaft fractures that were treated with cast bracing;
            - 465 (75 %) of the fractures were closed, and 155 (25 percent) were open;
            - non-union: 9 patients (6 %) who had an open fracture and seven (less than 2 %) who had a closed fracture had a nonunion after bracing;
            - 87 % of the 565 patients for whom AP radiographs were available, the fracture healed in less than 16 deg of varus angulation, and in
                   81 % of the 546 for whom lateral radiographs were available, it healed in less than 16 deg of anterior angulation;
            - at the time of brace removal, 98 % of the patients had limitation of shoulder motion of 25 degrees or less;
            - Functional bracing for the treatment of fractures of the humeral diaphysis.
     - cast bracing:
            - can be used for most closed humeral shaft frx;
            - in most cases, cast braces are applied at 10-12 days following injury;
            - forces displacing the fracture:
     - hanging casts:  may produce frx distraction & may increase risk of nonunion;
     - reference:
            - Tips of the trade #41. Modified coaptation splint for humeral shaft fractures.

- Indications for Operative Treatment:
    - unacceptable frx position following closed reduction;
    - new onset radial nerve palsy following closed reduction;
    - multi-trauma patients;
    - open humeral fractures;
    - segmental humeral fractures;
    - floating elbow or ipsilateral arm injuries;
    - pathologic fractures
    - ref: Outcome of Nonoperative vs Operative Treatment of Humeral Shaft Fractures: A Retrospective Study of 213 Patients 

- Operative Treatment:

     - internal fixation should be reserved for fractures w/ inadequate reduction or patients with multiple trauma;
     - IM Nailing of Humeral Shaft Fractures
     - External Fixation of Humeral Frx
     - Plate Fixation:
               - anterior approach to humerus;
               - posterior approach to humerus; 
     - ref: Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing


Fractures of the shaft of the humerus. A study of 401 fractures.

Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of corticocancellous bone.

Reconstruction of the humerus with an intramedullary fibular graft. A clinical and biomechanical study.

Open reduction and internal fixation of humeral shaft fractures. Results using AO plating techniques.

Surgical treatment of humeral shaft fractures--the Basel experience. 

 


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Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Saturday, June 23, 2012 2:31 pm