Diaphyseal Humerus Fractures Operative Treatment
Brian Snyder, MD, PhD
A vast majority of pediatric and adolescent humeral shaft fractures can be treated closed, including fractures Holstein-Lewis pattern and radial nerve injury.
Indications for IM Rodding or Open Reduction Internal or External Fixation
Open fracture (Figure 4-1)
Floating elbow associated with humeral shaft fracture (Figure 4-1)
Extensive soft tissue injury and loss
Marked malalignment after closed reduction: >20° sagittal (flexion/extension) angulation, >30° coronal (varus/valgus) angulation, and >3 cm shortening
Radial nerve injury after closed manipulation (relative)
Multitrauma patient requiring crutch ambulation (relative)
Options for Fracture Reduction and Fixation
Retrograde IM rodding with titanium elastic nails (TEIN)
Used in multiple trauma with relatively well-aligned fracture and no concerns of radial nerve entrapment in fracture
Open reduction internal fixation (ORIF) with plate and screws
Preferred in order to identify, mobilize, and protect the radial nerve
Antegrade rigid IM nailing
Adult operation, rarely used in skeletally immature patients due to open proximal humeral physis and ˜80% of growth occurring proximally
External fixation
Used most often (1) with major soft tissue loss and vascular compromise requiring reconstruction and (2) in near or complete amputation
Special Concerns
Status of the radial nerve
Most radial nerve injuries associated with humeral shaft fractures recover spontaneously over 3 to 4 months postinjury, so observation is recommended
Rarely radial nerves get entrapped in the fracture site or healing fracture callus (Figure 4-2)
Figure 4-1 ▪ Displaced open humeral shaft fracture (A) associated with distal forearm fracture treated by ORIF with plate and screws while identifying and protecting radial nerve.
Exploration is recommended, if signs of progressive recovery are not seen by 3 months earliest, 6 months latest in children
Advancing Tinel’s distant to the fracture site
Progressive motor recovery from ECRL > ECRB > EDC > EPL based on proximal to distal anatomic radial innervation
Position of radial nerve during IM rodding or ORIF is of concern and often leads us to make a direct exploration and decompression before fracture reduction and fixation
Always examine motor and sensory function and document status of radial nerve before and after closed or open reduction with internal fixation
IM Nailing Humeral Shaft
Equipment
Titanium elastic nails 3 to 4 mm diameter
Operative instruments in room if ORIF is needed
Figure 4-2 ▪ Humeral shaft fracture associated with radial nerve injury (A). Healed fracture with persistent radial nerve palsy and lucent area in callus noted at the fracture site consistent with entrapped radial nerve (Matev sign) (B). (Reprinted with permission from Waters PM, Skaggs DL, Flynn JM. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia, PA: Wolters Kluwer Health; 2019.)
Power drill
Fluoroscopy
Radiolucent hand table
Position
Patient on an OR table with the affected arm on the radiolucent table
If needed, use a sterile tourniquet
Patient moved over to the edge of the bed with head protected against traction movement
Surgeon on the side of table close to patient head and shoulder
Fluoroscopy enters from lower limb parallel to the patient, perpendicular to the table
Technique
Retrograde rodding from distal humerus
Usually two lateral entry, small sized K-wires or TEINs (Figure 4-3)
Can also enter posteriorly proximal to olecranon fossa (Figure 4-4)
Or medial and lateral epicondylar entry sites (Figure 4-5)
Isolate entry site with fluoroscopy
Choose appropriate diameter (3-4 mm) IM rod, so that two rods will fit at ˜80% fill at isthmus but pass easily
Small skin incision and blunt dissection to bone
Figure 4-3 ▪ A, Lateral entry site for placement of TEIN outlined by a freer elevator. (B) TEIN placement noted by image.
Predrill (3.2-4.5 mm) cortical opening slightly larger than the IM nail
Drill path obliquely up metaphysis avoiding cortex and olecranon fossa
Prebend two equal diameter TEINs
With lateral entry, one will be S-shaped and one C-shaped to allow divergence in the proximal fragment
With medial and lateral entry, both will be S-shapedRelated posts:
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