Humeral Shaft Fractures: Open Reduction Internal Fixation

Derek E. Robinson

Peter J. O’Brien

Indications/Contraindications

Numerous studies have shown that the majority of humeral shaft fractures can be treated nonoperatively with high rates of union and excellent functional results. However, in specific clinical settings, open reduction and internal fixation (ORIF) are favored over closed functional methods. Good results can be expected (1,2,3) and outcomes are superior to comparable fractures treated with intramedullary nailing (4,5,6). Although there are no absolute indications for plate fixation, we favor its use in some patients and consider the fracture characteristics and the presence of concomitant injuries in our decision (Table 5.1).

Fracture Considerations

Internal fixation is indicated in patients with closed fractures in which a satisfactory reduction cannot be achieved or maintained. The most common cause of a poor reduction in an otherwise healthy individual is interposition of soft tissue. Failure to maintain an acceptable closed reduction sometimes occurs in obese patients or women with large breasts. Other indications include segmental and peri-articular fractures. The latter can be difficult to control, and the prolonged immobilization of the adjacent joint can lead to loss of motion.

Open fractures require surgical debridement and bony stabilization to allow optimal soft-tissue management. After thorough debridement, ORIF of the humerus is a good method of fracture stabilization for most grade I, II, and IIIA injuries with limited bony defects. It produces a stable limb, improving postoperative wound management. With extreme comminution or bone loss, acute shortening of up to 5 cm is usually well tolerated.

Experience has taught us that nonoperative treatment of pathologic humeral fractures frequently results in nonunion and persistent pain. There is widespread agreement that patients with a pathologic humeral fracture as a result of metastatic disease benefit from
surgical stabilization. Usually these fractures are best managed with a locked intramedullary nail, but occasionally, a fracture is not amenable to intramedullary nailing and is better managed with a long spanning plate (7).

Table 5.1. Indications for Surgical Stabilization of Humeral Shaft Fractures

Early	Late
Failure of closed treatment Multiple injuries, patient Multiple injuries, limb Open fracture Pathologic fracture Associated arthrodesis Periprosthetic fracture	Nonunion Malunion

Periprosthetic fractures around elbow or shoulder arthroplasty frequently require internal fixation. Fractures that occur around the stem of an implant occasionally require revision of the prosthesis.

Delayed unions and nonunions are additional indications for ORIF of a humeral fracture. Delayed union is generally accepted to mean that the fracture has failed to show progressive signs of healing within 3 to 4 months, whereas nonunion is defined when the healing is delayed or arrested beyond 6 months. Nonunions can occur because of fracture instability, poor bone vascularity, or marked displacement. Infection must be ruled out for nonunions of open fractures that have been surgically repaired. Union is usually obtained following revision ORIF and autogenous bone grafting (8), and in osteoporotic bone this may be done successfully with locking compression plates (9).

Malunion is rarely an indication for surgical intervention because angular deformity is often well tolerated after closed treatment. The amount of mal-alignment that can be accepted varies between patients and is influenced by level of activity and cosmesis. Most patients tolerate up to 20 degrees of varus, 15 degrees of anterior angulation, and 5 cm of shortening.

Concomitant Injuries

Internal fixation of humeral shaft fractures is also indicated in a variety of circumstances due to concomitant injuries. The patient with multiple injuries is the most common candidate for operative treatment of humeral shaft fractures (10,11,12). When patients sustain injuries to multiple body systems, early surgical stabilization of long bone fractures may be life-saving. Fixation should be undertaken early to reduce analgesic needs, allow early mobilization, and facilitate nursing care.

Patients with ipsilateral injuries to the shoulder, elbow, or forearm often require operative treatment of their humeral fracture. In bilateral humeral fractures or any contralateral upper-extremity injury, fixation may be necessary to allow activities of daily living and self-care. Humeral shaft fractures associated with a fracture of both forearm bones require fixation of both the forearm and the humerus to allow early range of motion. Finally, rehabilitation of injuries to the lower extremities can be accelerated by fixation of the humerus, which allows for the use of crutches through the stabilized humerus.

If an axillary or brachial artery injury is associated with a closed fracture, then this should be stabilized at the time of vascular repair. Internal fixation of the humerus through the vascular approach is recommended to protect the vascular repair, to facilitate ongoing assessment, and allow rehabilitation of the limb. Brachial plexus or peripheral nerve injuries in the ipsilateral limb are often an indication for internal fixation of a humeral fracture because concomitant brachial plexus injuries may be associated with high rates of delayed union, nonunion, and malunion of the humeral shaft when treated closed (13). To prevent these complications and to facilitate rehabilitation, operative treatment should be considered with this combination of injuries.

The management of humeral fractures with associated radial nerve injury remains controversial (14,15,16). The incidence of radial nerve injury in humeral fractures is approximately 10%, with a range reported between 2% and 26%. Humeral shaft fractures seen with a primary radial-nerve injury do not usually require nerve exploration. If the fracture reduction can be maintained, closed treatment will result in fracture healing and a good outcome with a greater than 80% chance of spontaneous nerve recovery. The majority of cases are neurapraxias, which should show signs of recovery by 3 to 4 months, with improvements in muscle grade up to 2 years after injury (11).

Some studies have shown that with modern microsurgical techniques and late exploration of radial nerve palsies, better than 90% recover (14,15). Therefore, we recommend initial observation and late exploration for nerve injuries that do not resolve. The injury should be documented clinically and electrophysiologically with electromyogram/nerve conduction studies (EMG/NCS) in the early stages. The hand should be splinted, and an intensive physiotherapy program should be initiated to maintain mobility at the elbow, wrist, and fingers. Patients are evaluated monthly and have a follow-up EMG/NCS at 6 and 12 weeks. If after 4 to 6 months there is no sign of radial nerve recovery, then we explore the nerve.

More controversial is the management of secondary radial-nerve palsy. Most commonly this occurs after closed reduction of a humeral fracture. Traditionally, a nerve palsy occurring in such a circumstance was considered an indication for nerve exploration and internal fixation. Although some have shown that the nerve can be trapped between the fracture fragments (17), and while it seems reasonable to explore the nerve and free it from any ongoing compression, there is no scientific evidence that the outcome is improved by early surgery. Secondary radial-nerve palsy, however, continues to be an accepted indication for early exploration.

Relative contraindications to plate fixation of humeral shaft fractures include grade IIIB open fractures with massive soft-tissue injury or extensive bone loss, soft-tissue or bone infection, as well as severe osteoporosis, that would preclude fixation.

Preoperative Planning

With all injured patients, a careful history and physical examination are mandatory. Associated injuries should be identified and carefully assessed. Physical examination should include the chest, neck, shoulder, arm, elbow, forearm, wrist, and hand. The physical signs of fracture are usually obvious after humeral shaft fractures with pain, swelling, crepitus, and motion at the fracture site. The neurologic examination of the limb must be meticulous. Radial nerve injury is the most commonly associated neurological injury, but any peripheral nerve, including the brachial plexus, can be injured in association with a humeral diaphyseal fracture. The vascular assessment includes palpation of the axillary, brachial, and radial pulses and an assessment of hand-tissue perfusion. The soft-tissue compartments of the arm and forearm should be evaluated for compartment syndrome.

Good quality radiographs of the humerus are essential. Anteroposterior (AP) and lateral views of the humerus should be obtained that include the shoulder and elbow joints. The anatomic location of the fracture, the fracture pattern, and the expected bone quality are critical when developing a preoperative plan.

Once a decision is made to operate on a humeral fracture, a surgical tactic should be developed that includes the patient position, the surgical approach, the steps necessary for fracture reduction, temporary fixation, and the implant to be used for final fixation.

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