Executive Editor: Chris Colton

Authors: Pol Rommens, Peter Trafton

Humeral shaft 12-C3

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Glossary

General considerations

12-C3

C type fractures are multifragmentary, and even after reduction it is not possible to have direct contact between the main distal and proximal fragments.

They are generally high energy injuries and tend to be very unstable.

C 3 fractures are complex fractures with irregular fragments.

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
  • Inexpensive
  • Delayed surgery always possible
  • Typically, most of the comminuted fragments will heal, so that later surgery may be easier

Disadvantages

  • Possibility of nerve entrapment in healing fracture
  • Requires patient compliance
  • Close observation required
  • Early discomfort
  • Fracture deformity may exceed tolerable limits
  • Possible skin irritation
  • Limited ability to stabilize the segmental fracture
External fixation
Indication summary Skill Equipment
Unstable fracture, unstable patient, open fracture, usually temporary treatment Highly experienced and skilled surgeon 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 inadequate stability
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
Closed reduction; bridge plating (MIO)
Indication summary Skill Equipment
Closed fractures, associated injuries same arm, surgeon's preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Bridging requires fixation at both ends of the plate, but there is no attempt at compression.

It may be possible to perform this procedure without disturbing the fracture site, i.e. through a minimally invasive approach.

Classically, absolute stability is recommended for two-fragment fractures, but experience with IM nail fixation and bridge plating applied biologically, with soft-tissue protection demonstrates excellent healing with relative stability. The chosen plate could be a DCP, LC-DCP, or LCP.

Indications

  • Ability to reduce fracture closed
  • 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
  • Pathological fractures

Contraindications

  • 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 open plating
  • Can be used for proximal and distal shaft fractures
  • Early callus formation
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Early restoration of function

Disadvantages

  • Possibility of poor stability leading to delayed healing
  • May not reduce and stabilize displaced wedge fragment
  • Risk of radial nerve injury
  • Requires image intensification
  • Risk of malreduction
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
Open reduction; bridge 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

Bridging requires fixation at both ends of the plate, but there is no attempt at compression.

If the fracture is open or the surgeon is not comfortable with performing a minimally invasive approach, the fracture should be opened.

Classically, absolute stability is recommended for two-fragment fractures, but experience with IM nail fixation and bridge plating applied biologically, with soft-tissue protection demonstrates excellent healing with relative stability. The chosen plate could be a DCP, LC-DCP, or LCP.

Indications

  • Open fractures
  • 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
  • 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

Contraindications

  • Articular involvement
  • Irreducible fracture
  • Patient not fit for surgery
  • Extreme osteoporosis
  • Active infection

Advantages

  • Can be used for proximal and distal shaft fractures
  • More accurate reduction than closed methods
  • Immediate stability leading to pain reduction
  • Improved care for soft tissue injuries
  • Improved mobilization of polytrauma patient
  • Earlier restoration of function

Disadvantages

  • Possibility of poor stability leading to delayed healing
  • Risk of soft tissue stripping and interference with fracture healing
  • May not reduce and stabilize displaced wedge fragment
  • Risk of radial nerve injury
  • Risk of malreduction
  • Risk of infection
  • Risk of fixation failure
  • Requirement for anesthesia
*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