Humeral Shaft Fractures

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Humeral Shaft Fractures
AAOT

• Jeff Anglen, MD FACS
• Indiana University
• Orthopaedic Trauma Association

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www.ota.org
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Plate or Nail?

• Why are arms different than legs?

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Proconsul a miocene ape
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Brachiation
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Bipedal Brachiator
Lower Extremity
Upper Extremity
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Anatomy

• Axillary nerve
• Humeral circumflex artery
• Radial Nerve
• Profunda Brachii artery

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Fracture
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Treatment options

• Closed - Functional Brace
• Plate
• Nail
• External fixation

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Closed treatment

• Initially - splint or sling/swathe
• Hanging Arm Cast Historical treatment
• 2-3 weeks - functional brace
• active ROM of elbow

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Functional Fracture Bracing

• Sarmiento A. Zagorski JB. Zych GA. Latta LL.
  Capps CA.
• Functional bracing for the treatment of fractures
  of the humeral diaphysis.
• Journal of Bone Joint Surgery. 82(4)478-86,
  2000 Apr.

• 620 fractures followed -155 open
• 16 Nonunions 2.5
• 87 healed with lt160 angulation

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400
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Indications for Surgery

• Open fracture
• Segmental or floating elbow, ipsi shoulder fx
• Bilateral
• Multitrauma
• Penetrating trauma with neurologic deficit or
  vascular compromise
• Uncontrollable
• Pathological
• Not healing

Radial Nerve palsy is not an operative indication
in closed fractures
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Plate or Nail?

• Plate
• Reliable, 96 union
• Good shoulder/elbow function
• Soft tissue scars, radial nerve, bleeding

• Nail
• Less incision required
• Successful in LE
• Higher incidence of complications?
• Lower union rate?

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Plate or nail?

• Chapman et a. J. Ortho. Trauma 14(3)162-6, 2000
• McCormack et al. JBJS 82B336-9, 2000
• Chiu et al. J. Trauma 43(6)947-951, 1997
• Zatti et al. J. Trauma 45(6) 1046-50, 1998
• Lin, J. J. Trauma 44(5) 859-64,1998

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Plate or nail?

• Chapman et a. J. Ortho. Trauma 14(3)162-6, 2000
• McCormack et al. JBJS 82B336-9, 2000
• Chiu et al. J. Trauma 43(6)947-951, 1997

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Time to Union

• Chapman, Chiu, Zatti, Lin
• Nail 8.6 11.3 weeks
• Plate 9.2 10.4 weeks

Similar in all 3 studies No difference between
groups
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Incidence of Nonunion

• Low overall
• No statistically significant difference between
  groups

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Overall complications
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Reoperation
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Functional Outcome

• No study has good patient oriented outcome
  measures
• McCormack found no difference in pain or ASES
  functional score (small numbers)
• Both Chapman and McCormackmore problems with
  shoulder impingement, pain and restriction of
  motion after nailing

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What is the role for nailing?

• Segmental fractures
• Particularly with a very proximal fracture line
• Pathologic fractures
• ? Cosmesis

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Humeral plates - Technique

• Position
• supine
• lateral
• prone

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Supine - anterolateral
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Modified Posterior Approach

• Gerwin, Hotchkiss and Weiland
• JBJS Am, 76-A, 1996
• Identify nerve at lateral intermuscular septum
• Retract medial and lateral heads of the triceps
  medially

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Lag Screws
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Cases
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Segmental fracture Shaft Distal
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Segmental Fracture Shaft Proximal
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18 weeks
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• 35 yo RHD farmer falls from a hayloft suffering a
  midshaft humerus fracture
• Initial treatment is an IM Nail
• 9 months later - pain, instability, NU

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Initial Treatment

• Plate, Screws, Implantable stimulator
• Pain and instability recurs within a week

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Nonunion treatment

• Hardware Removal, replating with bone graft

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40 yo physicians wife
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3 months
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Thanks

• Jeff Anglen