Humeral shaft fractures

Includes diaphyseal fractures of distal third of humerus. For periarticular fractures of distal humerus see elbow.

Nonoperative management is the treatment of choice for the vast majority of humeral shaft fractures. Good or excellent outcomes are reported in 85% to 95% of patients.

Humeral fracture and radial nerve

A radial nerve palsy sustained concomitantly with a humeral fracture is not an indication for exploration of the nerve or for internal fixation of the fracture.

The presence of a radial nerve palsy in association with a closed fracture is not a contraindication to the use of functional bracing if the palsy appeared concomitantly with the injury.Conversely, when a radial nerve palsy develops while the fracture is being reduced, the radial nerve should be explored.

Whenever the nerve is explored and the humerus is not healed, internal fixation of the humerus is recommended.

In addition, patients with associated brachial plexus injury should have internal fixation. Stabilization of the humerus in this case permits earlier rehabilitation of the injured extremity and shortens the hospital stay.

Treatment options

Long arm cast
Functional brace
Compression plate
Intramedullary nail
External fixation

Indications for Surgery

The role of open treatment of fractures of the humerus remains controversial. Routine surgical management of humeral shaft fractures is probably not appropriate since the results of nonoperative treatment are generally satisfactory; acceptable alignment and healing occur in at least 90% of patients managed non-operatively.
Indications for surgical treatment

Type-III open fracture
Polytrauma with substantial chest and/or head injury
Floating elbow (Ipsilateral fracture of both bones of the forearm and humerus)
Extensive local injury involving the joint, brachial plexus, muscle, or tendon.
Impending or established pathological fracture due to metastasis.
Failure of closed treatment - no union by twelve to sixteen weeks

Functional Bracing

Gravity results in adequate alignment.

Varus angulation is common. However, the angulation is, in almost all instances, cosmetically and functionally acceptable.

The fact that functional bracing does not immobilize the joints adjacent to the fracture makes early restoration of motion possible.
The level of the fracture does not influence the ultimate result. The fact that the brace does not fully cover every proximal or distal fragment is irrelevant. As long as the soft tissues of the extremity are compressed by the adjustable brace and the arm hangs freely at the side of the body, the desirable environment for healing is present. Obesity in itself is not a contraindication. Angular deformities are more severe in obese patients. However, the larger amount of adipose tissue usually camouflages the deformities effectively.

Functional bracing is contraindicated in:

Fractures with axial distraction between the fragments, higher risk of delayed or nonunion.
Open fractures with major soft-tissue damage
Bilateral humeral fracture are usually better managed with surgical stabilization
Polytrauma who are unable to walk are best treated by surgical stabilization.
Fractures associated with vascular injuries that require surgical repair usually should be internally stabilized.

Method of bracing

Initially stabilize in a hanging cast or coaptation splint.

As soon as possible begin pendulum exercises of shoulder.

Use and adjust a collar and cuff to correct anteroposterior deformity.
The initial cast is removed when symptoms allow ( few days to 2 weeks).

The brace must be adjustable to ensure that the soft tissues can be compressed as swelling decreases and atrophy ensues.

The patient should remove the arm from the sling several times a day to passively flex and extend the elbow, emphasizing extension of the joint.

Active elbow exercises are started as soon as symptoms allow.

Active abduction and elevation of the shoulder must be avoided till fracture stable to limit angular deformities.

Leaning on the elbow should be avoided as it is likely to cause varus angulation.

Most patients fully extend their elbow 1 week after the application of the brace. At this time, the pendulum exercises are continued without the collar and cuff. Use of the collar and cuff may be discontinued if the patient wishes. However, use of the collar and cuff during recumbency is recommended until clinical union of the fracture has taken place.
The rate of nonunion reported in the literature in recent years has ranged from 1% to 5.8%. In one review, the rate of nonunion was 1.5% for closed fractures, with the brace removed between 10 and 13 weeks, and 5.8% for open fractures.

Plate Fixation

Randomized, controlled trials comparing plate fixation with intramedullary nailing have produced contradictory results. Both techniques, if performed properly, provide satisfactory outcomes for the majority of patients.
A minimum of 6 and preferably 8 cortices on both sides of the fracture should be engaged by the screws. The radial nerve must be protected throughout the entire surgical procedure.

Intramedullary Nailing

Antegrade - Incision over the greater tuberosity of the humerus with splitting of the proximal portion of the deltoid muscle.
Retrograde - Used to avoid problems around the shoulder that occur as a result of antegrade insertion.
Problems with retrograde nail insertion include difficult access to the narrow medullary canal in the distal part of the humerus, irritation of the triceps by pin prominence, a decreased range of motion of the elbow, and fracture at the level of the nail insertion site. (4- 10 % complication of fracture on nail insertion retrograde).

Intramedullary nailing does not ensure union. Reported union rates from the primary procedure range from 77 -100% (most likely mid 90% appropriate figure) The increase in complications after intramedullary nailing appears to be related primarily to the rates of union, which are somewhat lower than those after plate fixation, and to a substantial increase in functional symptoms, such as shoulder pain and stiffness. Complications such as radial nerve palsy, infection, delayed union, and failure of fixation appear to occur at a similar rate after both types of fixation.
Intramedullary nailing has a place in the management of pathological fractures of the humerus, particularly if there is more than one metastatic deposit within the bone. It is also useful in the management of comminuted and segmental humeral shaft fractures that require operative treatment.

Distal third humeral shaft fractures (extra articular)

Distal third diaphyseal fractures have their own particular considerations regarding treatment)

Treatment

Two treatment options exist, functional treatment with Humeral brace or Open reduction and internal fixation. Each method has its own advantages and disadvantages. Final treatment choice depends on the patient and treating surgeons preference.

Operative treatment advantages:

Predictable alignment (which may not be functionally important)
Immediate stability (which may lead to more rapid restoration of function)

Operative treatment disadvantages:

15% Risk of further surgery
15% Iatrogenic radial nerve palsy (more common than shaft 3%)
5 % Loss of fixation (harder to hold distal third compared with shaft)
2-5% infection
0-6% non union

Functional bracing advantages:

95-100% rate of union
Nearly full shoulder and elbow motion (Elbow 20% FFD 5-25º, 20% lost 5-25º flexion)

Functional bracing disadvantages:

Cumbersome, initially difficult (brace worn 8-12 weeks), no shoulder abduction or forward elevation till evidence of union
Skin problems
Increased angular and translational malalignment in most patients (40% more than 10º varus), does not necessarily impair function .

Summary

Functional bracing renders a high rate of union and seems to be a safe method of treatment for the majority of closed fractures.

Type-II and type-III open fractures seem to respond best to plate fixation or external fixation, particularly if there are associated neural or vascular pathological findings.

Patients with polytrauma who are unable to walk are best treated some form of fixation.
None of the treatments described are a panacea, and complications may occur with each one of them.

References

Scheerlinck, Thierry MD. Handelberg, Frank MD. Functional Outcome after Intramedullary Nailing of Humeral Shaft Fractures: Comparison between Retrograde Marchetti-Vicenzi and Unreamed AO Antegrade Nailing. Journal of Trauma-Injury Infection & Critical Care. 52(1):60-71, January 2002

Selected Instructional Course Lecture
Diaphyseal Humeral Fractures: Treatment Options
Augusto Sarmiento, MD, James P. Waddell, MD, FRCS(C) and Loren L. Latta, PE, PhD
The Journal of Bone and Joint Surgery (American) 83:1566-1579 (2001)

Cox, M. A.. Dolan, M.. Synnott, K.. McElwain, J. P.. Closed Interlocking Nailing of Humeral Shaft Fractures With the Russell-Taylor Nail. Journal of Orthopaedic Trauma. 14(5):349-353, June/July 2000.

DYKES, DARYLL C.; KYLE, RICHARD F.; SCHMIDT, ANDREW H.; Operative Treatment of Humeral Shaft Fractures: Plates Versus Nails. Techniques in Shoulder & Elbow Surgery. 2(3):194-209, September 2001.

5. Rommens, P. M. MD, PhD. Blum, J. MD. Runkel, M. MD, PhD. Retrograde Nailing of Humeral Shaft Fractures. Clinical Orthopaedics & Related Research. (350):26-39, May 1998.

Andrew Jawa, Pearce McCarty, Job Doornberg, Mitch Harris, and David Ring; Extra-Articular Distal-Third Diaphyseal Fractures of the Humerus. A Comparison of Functional Bracing and Plate Fixation; JBJS Am., Nov 2006; 88: 2343 - 2347.