Executive Editor: Chris Colton, Steve Krikler

Authors: Pol Rommens, Peter Trafton, Martin Jaeger

Humeral shaft - Simple fracture, spiral

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Glossary

General considerations

Many fractures are treated nonoperatively.

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.

Classically, absolute stability is recommended for two-fragment fractures, but experience with nail fixation and bridge plating applied biologically, with soft-tissue protection demonstrates excellent healing with relative stability.

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 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

  • >90% healing rate reported
  • Delayed surgery always possible
  • Cheap procedure
  • Simple technique

Disadvantages

  • Fracture deformity may exceed tolerable limits
  • Prolonged immobilization with limited use of arm
  • Prolonged pain due to fracture instability
  • Risk of stiffness of adjacent joints (shoulder and elbow)
  • Risk of internal malrotation
External fixation
Indication summary Skill Equipment
Unstable fracture, unstable patient, open fracture, usually temporary treatment Some specialized surgical experience 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
Indication summary Skill Equipment
Adequate medullary canal, diaphyseal fracture not too distal or proximal, pathological fracture, adequate closed reduction possible 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
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
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 - Lag screw(s) with protection plate
Indication summary Skill Equipment
Associated radial nerve injury, open fractures, surgeon’s preference Highly experienced and skilled surgeon Simple surgical and imaging resources

Further indications

  • Spiral fracture that is well suited to lag screw fixation, typically with the screw(s) outside the plate
  • Open fractures (once soft-tissue injury is under control)
  • Radial nerve palsy (if exploration of nerve relative to fracture is indicated)

Contraindications

  • Extreme osteoporosis
  • Active infection

Advantages

  • Accurate reduction

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