Bradley R. Merk

Indications

1. Humeral shaft fracture which failed nonoperative treatment (“acceptable” nonoperative treatment requires maintenance of fracture reduction with less than 20 degrees of sagittal and 30 degrees of coronal angulation and less than 5 cm of shortening)

2. Open humeral shaft fracture

3. Humeral shaft fracture associated with a vascular injury

4. Humeral shaft fracture in a polytrauma patient

5. Humeral shaft fracture associated with a floating elbow

6. Bilateral humeral fractures

7. Segmental humeral shaft fracture

8. Humeral shaft fracture associated with an ipsilateral brachial plexus injury

9. Humeral shaft fracture associated with pelvic or lower extremity injuries necessitating crutch ambulation

10. Pathologic humeral shaft fracture (intramedullary device generally preferred)

11. Humeral shaft fracture associated with a secondary radial nerve palsy (controversial)

12. Nonunion or malunion after a humeral shaft fracture

Contraindications

1. Acceptable fracture alignment in a closed isolated injury

2. Gustillo grade IIIB or IIIC open fracture with extensive wound contamination (external fixation generally preferred)

Preoperative Preparation

1. Careful documentation of the admitting neurovascular status (especially the radial nerve); the neuro-vascular status should be reevaluated and again documented after fracture reduction.

2. Careful assessment of soft tissue injuries (obvious or occult); administer appropriate antibiotics and tetanus prophylaxis in the event of an open fracture

3. Appropriate examination of the spine, pelvis, and other limbs to rule out associated injury

4. Radiographs to include AP and lateral views of the shoulder, humerus, and elbow

5. Displaced or angulated fractures should be reduced and provisionally splinted with a coaptation splint or a hanging arm cast prior to surgical stabilization.

6. Postreduction AP and lateral views of the humerus should be obtained to evaluate the postreduction fracture alignment.

7. The fracture should be classified by descriptive terminology (i.e., location, fracture pattern, soft tissue injury, and bone quality) or with the AO/OTA classification scheme.

Special Instruments, Position, and Anesthesia

1. Supine position on the operating room table for the anterolateral approach

2. Prone position for the posterior approach

3. The patient’s condition and preference dictate anesthetic choice.

4. Basic orthopedic surgical tray

5. Large fragment plate and screw set (preferred implant is the broad 4.5-mm DC plate although the 4.5-mm LC-DC plate may be required in smaller patients)

Tips and Pearls

1. In a patient with polytrauma, supine positioning is often preferred and may dictate an anterolateral approach.

2. The anterolateral approach is the classic extensile exposure and may be used to expose the entire humerus from the shoulder to the elbow.

3. However, for distal third fractures, a posterior approach affords better exposure and a flat surface for plate application.