Executive Editor: Chris Colton

Authors: Pol Rommens, Peter Trafton

Humeral shaft 12-A2

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Glossary

General considerations

12-A2

In an A 2 fracture there are only two fragments, and the fracture plane is short and with > 30° obliquity.

Nonoperative treatment; brace
Indication summary Skill Equipment
Closed isolated injury, minimally displaced, cooperative patient Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Isolated injury 
  • Closed fracture
  • Cooperative patient
  • Acceptable alignment

Contraindications

  • Polytrauma patient
  • Open fracture
  • Additional ipsilateral fracture
  • Patient unable to sit or stand
  • Irreducible displacement
  • Obesity
  • Nerve injury developing during closed treatment
  • Nerve interposed in fracture

Advantages

  • Non-invasive
  • > 90% healing rate reported
  • Inexpensive
  • Delayed surgery always possible

Disadvantages

  • Requires patient compliance
  • Close observation required
  • Early discomfort
  • Fracture deformity may exceed tolerable limits
  • Possible skin irritation
External fixation
Indication summary Skill Equipment
Unstable fracture, unstable patient, open fracture, usually temporary treatment Some specialized surgical experience Simple surgical and imaging resources

External fixation is used in the treatment of humeral shaft fractures with extensive soft-tissue damage, severe contamination, infection, and/or major bone loss. It may also be used as an element of a salvage procedure in cases with major complications after nailing or plate osteosynthesis.

External fixation can be used as primary treatment in polytrauma patients.

Further indications

  • Need for rapid application, eg patient with multiple injuries or vascular injury
  • Surgeon’s preference for external fixation in patients requiring surgical stabilization

Contraindication

  • Osteoporosis

Advantages

  • Rapid provisional treatment
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Earlier restoration of function

Disadvantages

  • Risk of nerve injury
  • Possible loss of fixation
  • Pin-track infection
  • Cumbersome fixation interferes with arm use
Closed reduction; antegrade nailing
Indication summary Skill Equipment
Adequate medullary canal, diaphyseal fracture not too proximal, pathological fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

An intramedullary nail is usually used for internal fixation with closed reduction.

If it is difficult to obtain closed reduction, it may be necessary to open the fracture site.

Indications

  • Adequate medullary canal in length and shape
  • Diaphyseal fracture not too proximal
  • Pathological fracture
  • Ability to reduce fracture closed
  • Open fractures
  • Multiple injuries
  • Unacceptable reduction
  • Loss of reduction
  • Failure to heal
  • Vascular injury
  • Other injuries of the arm (eg floating elbow, associated hand or wrist injury)
  • Bilateral humeral fractures
  • Delayed onset of radial nerve palsy
  • Ipsilateral brachial plexus injury
  • Obesity or large breast
  • Requirement for early load bearing

Contraindications

  • Medullary canal obstructed, too narrow, or too short
  • Infected pin tracks
  • Gross contamination
  • Shoulder abnormality
  • Radial nerve palsy (nerve possibly interposed between fracture fragments)
  • Articular involvement
  • Irreducible fracture
  • Patient not fit for surgery
  • Extreme osteoporosis
  • Active infection

Advantages

  • Less soft-tissue stripping than plate application
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Early restoration of function

Disadvantages

  • Shoulder pain and stiffness
  • Needs image intensification
  • Risk of radial nerve injury
  • Risk of malreduction
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
Closed reduction; retrograde nailing
Indication summary Skill Equipment
Adequate medullary canal, diaphyseal fracture not too distal, pathological fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

An intramedullary nail is usually used for internal fixation with closed reduction.

If it is difficult to obtain closed reduction, it may be necessary to open the fracture site.

Indications

  • Adequate medullary canal in length and shape
  • Diaphyseal fracture not too distal
  • Pathological fracture
  • Ability to reduce fracture closed
  • Open fractures
  • Multiple injuries
  • Unacceptable reduction
  • Loss of reduction
  • Failure to heal
  • Vascular injury
  • Other injuries of the arm (eg floating elbow, associated hand or wrist injury)
  • Bilateral humeral fractures
  • Delayed onset of radial nerve palsy
  • Ipsilateral brachial plexus injury
  • Obesity or large breast
  • Requirement for early load bearing

Contraindications

  • Medullary canal obstructed, too narrow, or too short
  • Infected pin tracks
  • Gross contamination
  • Radial nerve palsy (nerve possibly interposed between fracture fragments)
  • Articular involvement
  • Irreducible fracture
  • Patient not fit for surgery
  • Extreme osteoporosis
  • Active infection

Advantages

  • Less soft-tissue stripping than plate application
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Early restoration of function

Disadvantages

  • Iatrogenic fracture at entry point
  • Needs image intensification
  • Risk of radial nerve injury
  • Risk of malreduction
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
Open reduction; lag screw(s) with neutralization plate
Indication summary Skill Equipment
Closed displaced fractures, associated injuries same arm, associated radial nerve injury, surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources

Lag screws can fix oblique fractures with absolute stability, but this fixation alone is weak, and must be protected with a neutralization plate. The chosen plate could be a DCP, LC-DCP, or LCP.

Indications

  • Oblique fracture that is well suited to lag screw fixation, with the screw(s) through or outside the plate
  • Open fractures
  • Unacceptable reduction
  • Failure of fracture healing
  • Vascular injury
  • Radial nerve palsy (if exploration of nerve relative to fracture is indicated)
  • Ipsilateral brachial plexus injury
  • Obesity or large breast
  • Requirement for early load bearing
  • Pathological fractures
  • Multiple injuries
  • Loss of reduction
  • Other injuries of the arm (eg floating elbow, associated hand or wrist injury)
  • Bilateral humeral fractures

Contraindications

  • Patient not fit for surgery
  • Extreme osteoporosis
  • Active infection
  • Noncompliant patient

Advantages

  • Accurate reduction
  • Potentially stongest fixation
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Early restoration of function

Disadvantages

  • Larger incision
  • Risk of nerve injury
  • Risk of fixation failure
  • Requirement for anesthesia
  • Risk of infection
Open reduction; compression plating
Indication summary Skill Equipment
Displaced fractures, associated injuries same arm, associated radial nerve injury, surgeon's preference Highly experienced and skilled surgeon Simple surgical and imaging resources

Compression requires lag screws or plate tensioning.

The chosen plate could be a DCP, LC-DCP, or LCP. The sequence of plate application and screw insertion is important, as described in “Reduction & Fixation.”

Indications

  • Oblique fracture that is well suited to lag screw fixation, with the screw(s) through or outside the plate
  • Open fractures
  • Unacceptable reduction
  • Failure of fracture healing
  • Vascular injury
  • Radial nerve palsy (if exploration of nerve relative to fracture is indicated)
  • Ipsilateral brachial plexus injury
  • Obesity or large breast
  • Requirement for early load bearing
  • Pathological fractures
  • Multiple injuries
  • Loss of reduction
  • Other injuries of the arm (eg floating elbow, associated hand or wrist injury)
  • Bilateral humeral fractures

Contraindications

  • Patient not fit for surgery
  • Extreme osteoporosis
  • Active infection
  • Noncompliant patient

Advantages

  • Accurate reduction
  • Potentially stongest fixation
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Early restoration of function

Disadvantages

  • Larger incision
  • Risk of nerve injury
  • Risk of fixation failure
  • Requirement for anesthesia
  • Risk of infection
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2006-09-14