Executive Editor: Chris Colton, Steve Krikler

Authors: Pol Rommens, Peter Trafton, Martin Jaeger

Humeral shaft - Multifragmentary fracture, intact segment

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Glossary

General considerations

Indications for operative treatment include inability to obtain or maintain adequate reduction, multiple injuries, delayed union, and neurovascular injuries.

In the majority of patients with proximal and distal fractures, plating is the most reliable operative technique for achieving satisfactory union.

Intramedullary nails are the best option for pathological or impending pathological fractures of the humeral shaft.

Proximal humeral shaft fractures require a device which can provide a good hold in the small proximal fragment, which consists mainly of the humeral head. The PHILOS plate achieves this, as do some modern humeral nailing systems with proximal locking options. The choice is based on the surgeon’s preference.

Open fractures require different procedures depending on the severity of the soft-tissue injury. More severe types of open fractures (ie type III) should be fixed with an external fixator temporarily and a primary fixation with a nail or plate is contraindicated.

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

Further indications

  • Acceptable alignment

Contraindications

  • Polytrauma patient
  • Open fracture
  • Additional ipsilateral fracture
  • Irreducible displacement
  • Nerve injury developing during closed treatment
  • Nerve interposed in fracture
  • Obesity and/or large breasts which tend to cause varus angulation of fracture with “hinging” over the soft tissues

Advantages

  • Delayed surgery always possible

Disadvantages

  • Fracture deformity may exceed tolerable limits
  • 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

Further indications

  • Significant soft-tissue injury with contamination
  • Need for rapid application, eg patient with multiple injuries or vascular injury

Contraindications

  • Osteoporosis

Advantages

  • Rapid provisional treatment
  • Immediate stability leading to pain reduction

Disadvantages

  • Risk of nerve injury
  • Pin-track infection
  • Cumbersome fixation interferes with arm use
Antegrade nailing (proximal 1/3)
Indication summary Skill Equipment
Proximally extending fracture, adequate medullary canal, proximal fragment not too small, pathological fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Contraindications

  • Medullary canal obstructed, too narrow, or too short
  • Infected pin tracks
  • Infection or gross contamination
  • Radial nerve palsy (nerve possibly interposed between fracture fragments)

Advantages

  • Better stabilization than plates in extreme osteoporosis
  • Less soft-tissue stripping than plate application

Disadvantages

  • Shoulder pain and stiffness
  • Needs image intensification
  • Higher of radial nerve injury compared to ORIF
  • Risk of malreduction
  • Opening of glenohumeral joint
  • Violation of rotator cuff
  • Risk of injury to soft tissues or bone of central segment

Note: Closed reduction of segmental humeral fractures may be technically impossible. Attempting to ream and nail the central segment may also risk additional injury.

Antegrade nailing (middle 1/3)
Indication summary Skill Equipment
Adequate medullary canal, diaphyseal fracture not too distal or proximal, pathological fracture, proximal fragment not too small Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The choice of antegrade vs retrograde nailing is influenced by fracture configuration and surgeon’s preference.

Contraindications

  • Medullary canal obstructed, too narrow, or too short
  • Infected pin tracks
  • Infection or gross contamination
  • Radial nerve palsy (nerve possibly interposed between fracture fragments)

Advantages

  • Better stabilization than plates in extreme osteoporosis
  • Less soft-tissue stripping than plate application

Disadvantages

  • Shoulder pain and stiffness
  • Needs image intensification
  • Higher of radial nerve injury compared to ORIF
  • Risk of malreduction
  • Opening of glenohumeral joint
  • Violation of rotator cuff 
  • Risk of injury to soft tissues or bone of central segment

Note: Closed reduction of segmental humeral fractures may be technically impossible. Attempting to pass a nail through the central segment may also risk additional injury.

Retrograde nailing
Indication summary Skill Equipment
Adequate medullary canal, diaphyseal fracture not too distal or proximal, pathological fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

The choice of antegrade vs retrograde nailing is influenced by fracture configuration and surgeon’s preference.

Contraindications

  • Medullary canal obstructed, too narrow, or too short
  • Infected pin tracks
  • Infection or gross contamination
  • Radial nerve palsy (nerve possibly interposed between fracture fragments)

Advantages

  • No risk of shoulder problems than antegrade nailing
  • Better stabilization than plates in extreme osteoporosis
  • Less soft-tissue stripping than plate application

Disadvantages

  • Needs image intensification
  • Higher of radial nerve injury compared to ORIF
  • Risk of malreduction
  • Demanding opening of the medullary cavity
  • Risk of iatrogenic fracture around the nail entry portal
  • Postoperative painful elbow syndrome
  • Risk of iatrogenic fractures during nail removal
  • Risk of injury to soft tissues or bone of central segment
  • Risk of inadequate stability

Note: Closed reduction of segmental humeral fractures may be technically impossible. Attempting to pass a nail through the central segment may also risk additional injury.

MIO - Bridge plating
Indication summary Skill Equipment
Closed fractures where surgery is indicated, and closed reduction is possible Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Contraindications

  • Radial nerve palsy (nerve possibly interposed between fracture fragments)
  • Articular involvement
  • Extreme osteoporosis
  • Active infection

Advantages

  • Less soft-tissue stripping than open plating
  • Can be used for proximal and distal shaft fractures
  • Early callus formation

Disadvantages

  • Very demanding technique
  • May not reduce and stabilize displaced wedge fragment
  • Risk of radial nerve injury
  • Requires image intensification
ORIF - Plate fixation (proximal 1/3)
Indication summary Skill Equipment
Proximal fracture requiring fixation, surgeon’s preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Open fractures (once soft-tissue injury is under control)

Contraindications

  • Extreme osteoporosis
  • Active infection

Advantages

  • Accurate reduction
  • Relatively good hold in osteoporotic bone

Disadvantages

  • Larger incision
ORIF - Bridge plating (middle 1/3)
Indication summary Skill Equipment
Associated radial nerve injury, surgeon’s preference Highly experienced and skilled surgeon Simple surgical and imaging resources

Further indications

  • Radial nerve palsy (if exploration of nerve relative to fracture is indicated)
  • Open fractures (once soft-tissue injury is under control)

Contraindications

  • Extreme osteoporosis
  • Active infection
  • Noncompliant patient

Advantages

  • Less risk of radial nerve injury
  • Potentially better fixation

Disadvantages

  • Larger incision
ORIF - Plate fixation (distal 1/3)
Indication summary Skill Equipment
Distal fracture requiring fixation, surgeon’s preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Open fractures (once soft-tissue injury is under control)

Contraindications

  • Extreme osteoporosis
  • Active infection

Advantages

  • Accurate reduction
  • Relatively good hold in osteoporotic bone

Disadvantages

  • Larger incision
*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

v2.0 2018-12-28