5: Humeral Shaft Fractures

PROCEDURE 5 Humeral Shaft Fractures



Chad P. Coles, Robert G. McCormack



image


Open Reduction and Internal Fixation and Intramedullary Nailing




Indications



INDICATIONS FOR OPEN REDUCTION AND INTERNAL FIXATION (ORIF)




PITFALLS



• Compromised soft tissue envelope (burns, abrasions, etc.)

• Occult proximal or distal fracture extension

• Periprosthetic fractures involving prior elbow or shoulder arthroplasty

• Osteoporotic bone



Controversies



• A primary radial nerve palsy can be treated expectantly, and in isolation is not an indication for surgery. Even a secondary nerve palsy, after reduction and splinting, is not considered an absolute indication for surgery by many surgeons.

• Randomized trials have consistently shown that, for routine humeral shaft fractures, ORIF with plate fixation has superior results compared to IM nailing. The main reason for the difference is the higher incidence of postoperative pain and functional limitations, as well as increased rates of reoperation and fracture nonunion with humeral nails. ORIF remains the “gold standard” in the treatment of diaphyseal fractures of the humerus.


image Failure of nonoperative treatment
• Malreduction (>3 cm shortening, 30° angulation or rotation)

• Nonunion

image Polytrauma

image Open fracture (type II or greater)

image Ipsilateral upper extremity fracture
• Floating elbow or shoulder

• Associated intra-articular fracture

image Vascular injury

image Pathologic fracture

image Bilateral humeral fractures

image Neurologic indications
• Brachial plexus injury

• Parkinson’s disease

• Head injury

image Relative indications
• Segmental fracture

• Transverse fracture

• Obesity

• Secondary radial nerve deficit


INDICATIONS FOR HUMERAL INTRAMEDULLARY (IM) NAILING



image Pathologic fractures

image Segmental fractures

image Some complex fractures


Examination/Imaging



image Examination
• Initial assessment and resuscitation of the trauma patient by Advanced Trauma Life Support® or similar protocol

• History and physical examination, including prior injuries or surgery involving the injured extremity

• Vascular examination, including brachial, radial, and ulnar pulses and capillary refill

• Neurologic examination and documentation of motor and sensory function of the axillary, musculocutaneous, median, ulnar, and in particular radial nerves

• Examination of hand, wrist, elbow, and shoulder to exclude associated injury

image Imaging
• Plain radiographs, including anteroposterior (AP) (Fig. 1A) and lateral (Fig. 1B) views of the humerus, are the mainstay of diagnosis and decision making. These should include the elbow and shoulder joints, as well as any other suspected ipsilateral injuries detected on physical examination.

• A full-length radiograph may be helpful in planning for complex injury patterns.

• More advanced imaging with computed tomography or magnetic resonance imaging is rarely, if ever, required.

image

FIGURE 1




Treatment Options



• Fractures of the midshaft or more proximal humerus are best addressed through an anterolateral approach. This allows excellent proximal access, including fixation of proximal humerus fractures, but has limited distal access approaching the antecubital fossa.

• Fractures distal to the midshaft of the humerus are best addressed through a posterior approach. This allows excellent distal exposure, from the elbow joint distally to the surgical neck of the humerus, with proximal dissection limited by the crossing of the axillary nerve.

• Alternatively, a lateral approach may be used for distal fractures, with the advantage of supine positioning.

• Less frequently, a medial approach may be appropriate when there is an associated vascular injury that requires surgery or when the soft tissue envelope precludes the other approaches (e.g., burn patient). It is also advocated by some for the morbidly obese patient.


Surgical Anatomy




PEARLS



• Anterolateral approach
image The cephalic vein serves as an anatomic landmark to the deltopectoral interval proximally.

image Adequate visualization and mobilization of the radial nerve will result in a lower risk of nerve injury than blind retraction and potential stretching.

image Proper identification of the radial nerve, and certainty that the nerve is not entrapped in the fracture site or beneath the plate, will avoid the need to re-explore the nerve in the event of postoperative nerve palsy.

• Posterior approach
image The lateral brachial cutaneous nerve assists in locating the radial nerve proper.

image Adequate visualization and mobilization of the radial nerve is mandatory to ensure the nerve is not entrapped in the fracture site or beneath the plate, to avoid the need to re-explore the nerve in the event of postoperative nerve palsy. Careful but thorough mobilization will result in a lower incidence of nerve injury than blind retraction and potential stretching.

image Careful documentation in the dictated operative notes of the location of the crossing radial nerve in relation to the number of holes in the plate will assist in localization of the nerve in the event that revision surgery is required in the future.

• Lateral approach
image Identify the radial nerve distally, at the elbow, between the brachioradialis and brachialis.

• Medial approach
image Mobilize the ulnar nerve off the triceps to allow anterior retraction.


image Anterolateral approach (Fig. 2A)
• The cephalic vein is a useful landmark to the interval between the deltoid (axillary innervation) and pectoralis major (pectoral nerve innervation) proximally.

• The musculocutaneous nerve runs along the undersurface of the biceps and should be identified and retracted medially with the biceps muscle (musculocutaneous innervation).

• The radial nerve pierces the intermuscular septum, entering the anterior arm approximately 12 cm proximal to the lateral epicondyle, and should be identified in the interval between the brachioradialis and brachialis.

• The brachialis has dual innervation from the radial and musculocutaneous nerves.

image Posterior approach (Fig. 2B)
• The radial nerve crosses the posterior humerus obliquely in the spiral groove, from approximately 20 cm proximal to the medial epicondyle to 12 cm proximal to the lateral epicondyle, and then pierces the intermuscular septum, entering the anterior arm.

• The lateral brachial cutaneous nerve is a useful landmark in identifying the radial nerve.

• Reflecting the entire triceps muscle (radial innervation) off the lateral intermuscular septum and retracting it medially exposes the posterior surface of the humerus from the lateral condyle distally to the axillary nerve proximally.

image Lateral approach (Fig. 2C)
• The humeral shaft can be exposed laterally between the biceps and triceps muscles.

• The radial nerve should be identified in the interval between the brachioradialis and brachialis.

image Medial approach (Fig. 2D)
• The medial approach is within an intraneural plane, with the ulnar nerve posterior to the intermuscular septum, and the median nerve and brachial artery located anteriorly.

• The ulnar nerve is tethered to the triceps.

image

FIGURE 2



Positioning



FOR ORIF




PEARLS



• Anterolateral approach
image Ensure the patient is positioned far enough laterally on the operating table to allow imaging of the humerus through a radiolucent armboard.

image Freely drape the arm with exposure to the elbow and shoulder to allow extensile exposure, if needed.

• Posterior approach
image Prone positioning requires a secure airway, neutral position of the neck, and adequate eye protection.

image For lateral positioning, consider the use of a chest (axillary) roll to avoid brachial plexus compression (Fig. 6), and pad pressure points appropriately.

image Ensure that patient positioning allows adequate imaging before sterile draping.

Related posts:

16: Perilunate Injuries 29: Proximal Tibia Fractures: Intramedullary Nailing 11: Open Reduction and Internal Fixation of Olecranon Fractures 48: Treatment of Open Fractures 2: Glenoid Fracture 44: Anterior Approaches to the Acetabulum

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 5: Humeral Shaft Fractures

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