Chapter 36: Humeral Shaft Fractures

Christos Garnavos

Chapter Outline

Introduction to Humeral Shaft Fractures

Epidemiology and other social parameters related to diaphyseal humeral fractures have not been extensively studied as those related to fractures occurring in other parts of the human skeleton, such as the proximal femur or the distal radius. Nevertheless, the available bibliographical resources report that the general incidence of humeral shaft fractures remain in the area to 1% to 2% of all fractures occurring in the human body30,55,142 and 14% of all fractures of the humerus.175 
The first description of a diaphyseal humeral fracture goes back to ancient Egypt and has been recorded on the Edwin Smith Papyrus, the world’s oldest surviving surgical text that was written in Egyptian hieratic script around the 17th century BC.288 The papyrus was discovered by Edwin Smith in the 1860s and it was recently decoded by James P. Allen of the Metropolitan Museum of Art in New York. The author of the papyrus described the fracture of the humerus and proposed conservative treatment: “Thou shouldst place him prostrate on his back, with something folded between his two shoulder-blades; thou shouldst spread out his shoulders, in order to stretch apart his upper arm until that break falls into its place. Thou shouldst make for him two splints of linen, (and) thou shouldst apply one of them to the inside of his arm, (and) the other of them to the underside of his arm. Thou shouldst bind it with cloth, (and) treat afterward with honey every day until he recovers.” 
It is obvious that little has changed in the treatment of diaphyseal humeral fractures since ancient times, as humeral fractures heal within a short time. During the treatment patients are mobile whereas shoulder and elbow joints compensate for some malalignment. However, patients in modern times demand faster union rates and earlier return to preinjury activities while preserving functionality and motion of nearby joints. Therefore, over the last few decades, we have witnessed significant advances in the field of surgical management of diaphyseal humeral fractures. 

Epidemiologic Data Related to Humeral Shaft Fractures

Up to the age of 60 years, diaphyseal humeral fractures occur equally in men and women and the incidence does not seem to increase with age. After the age of 60 years 80% are women303 and humeral shaft fractures become more frequent (Fig. 36-1).74,145,278,303 The epidemiology of humeral fractures is discussed in Chapter 3
Figure 36-1
Age and gender distribution of fractures of the humeral shaft in 249 patients from Edinburgh.
 
(From Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br. 1998;80(2):249–253, with permission.)
(From Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br. 1998;80(2):249–253, with permission.)
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Figure 36-1
Age and gender distribution of fractures of the humeral shaft in 249 patients from Edinburgh.
(From Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br. 1998;80(2):249–253, with permission.)
(From Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br. 1998;80(2):249–253, with permission.)
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The most common reason for a humeral shaft fracture is a fall, followed by motor vehicle accident.74,145,238,300,303 Other causes that account for less than 10% of humeral shaft fractures include sporting activities, working accidents, fall from a height, violence, and bone pathology. Pathologic and open fractures of the humeral shaft are uncommon (6% to 8% and 2% to 5% of all diaphyseal humeral fractures, respectively).74,303 Kim et al.145 studied the annual incidence of humeral fractures in the United States on the basis of the Nationwide Emergency Department Sample and they estimated that the number of humeral fractures is increasing over the years and in 2030 will be almost double compared with 2008. 

Assessment of Humeral Shaft Fractures

Mechanisms of Injury for Humeral Shaft Fractures

The mechanisms of injury for the occurrence of diaphyseal humeral fractures vary and mainly depend on geographical and social parameters. While most studies agree that a ground-level fall is the commonest cause followed by a road traffic accident (RTA),74,139,145,238,300,303 socioeconomical and geographical conditions influence the prevalence of humeral shaft fractures. According to Kim et al.145 the ratio of a simple fall to an RTA is 9/1 in the United States, while Tytherleigh-Strong et al.294 reported that the same ratio is 3.5/1 in the United Kingdom and Reboso et al.229 reported this ratio for Spain as 1.2/1. While Kim et al. and Reboso et al. found that simple falls and RTAs account for more than 90% of all diaphyseal humeral fractures in USA and Spain respectively, in other countries falls from a height or sporting activities play an important role in the pathogenesis of the injury. So, in Sweden and the United Kingdom, falls from a height and sports account for 8% and 5% to 7% of humeral shaft fractures, respectively, and it is reported that patients with fractures caused by low-energy trauma tended to be older women and those with high-energy fractures were younger men.238,303 

Associated Injuries with Humeral Shaft Fractures

Severe injuries of the humeral diaphysis and neighboring anatomical structures threaten the function of the upper limb and may require an individualized and difficult approach for a satisfactory outcome. Not infrequently, these injuries result in restrictions in the range of motion (ROM) of the upper limb joints or neurologic symptoms. Disability from associated injuries may be substantial. 

Nerve Injury

The commonest associated injury to a closed diaphyseal humeral fracture is the injury of the radial nerve (10% to 12% of all closed humeral shaft fractures).74,208,265,275 The clinical manifestation is the inability to dorsiflex the wrist and digits while numbness occurs on the dorsoradial aspect of the hand and the dorsal aspect of the radial 3½ digits (Fig. 36-2). 
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Figure 36-2
The clinical picture of a radial nerve palsy.
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There has been a lot of controversy regarding the need for immediate exploration of the nerve when there are clinical symptoms of radial nerve palsy. Shao et al. reviewed all papers between 1964 and 2004 in both English and German that included at least 10 patients with the combination of humeral shaft fracture and radial nerve palsy. They concluded that a policy of initial expectant treatment should be preferred to early nerve exploration.275 They also proposed that the overall waiting time for the nerve to recover should not be longer than 6 months. Bumbasirevic´ et al. studied 117 cases of diaphyseal humeral fractures associated with radial nerve palsy. They did not recommend early exploration of the nerve but proposed secondary intervention by 10 to 12 weeks from injury in the absence of clinical or electromyographic signs of recovery.32 Venouziou et al. performed early exploration of the radial nerve and internal fixation of the accompanying humeral fractures in 18 patients with radial nerve palsy and concluded that in cases of high-energy trauma the radial nerve can sustain neurotmesis or severe contusion. They recommended that patients should be informed about the poor prognosis and the probability of tendon transfers.309 Other indications for early exploration of the nerve include concomitant vascular injury, gunshot wounds, open fractures or severe soft tissue injury, and sharp or penetrating injury.77,242,275 In 1963, Holstein and Lewis123 associated a special type of fracture of the distal humerus, a simple displaced spiral fracture, with the distal end deviating toward the radial side occurring in about 7% of all humeral shaft fractures, with an increased rate of radial nerve palsy (Fig. 36-3). They reported a high incidence of entrapment of the nerve within this type of fracture and recommended radial nerve exploration in the presence of clinical symptoms. Subsequent studies confirmed an increased risk of radial nerve injury with this type of fracture but supported the expectant policy even in the presence of clinical symptoms, as their findings indicated that the radial nerve usually recovers spontaneously regardless of the pattern and location of the humeral shaft fracture.75,275 
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Figure 36-3
The Holstein-Lewis fracture.
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Heckler and Bamberger114 surveyed practice tendencies in USA by sending a questionnaire to 2,650 physicians regarding their practice in cases of humeral shaft fracture associated with radial nerve palsy. From 558 responses, the authors concluded that most physicians agreed that the incidence of recovery is high and observation is justified. There was also a consensus that the nerve should be explored when operative intervention is indicated for the fracture and in cases of open fractures. 
Injuries of ulnar and median nerves associated with humeral shaft fractures are not as frequent as injuries of the radial nerve, and relevant information is limited. Noble et al.208 found that the ulnar and median nerves had been injured in 2.4% and 1.3% respectively in a population of 444 patients with diaphyseal humeral fractures. Omer215 studied nerve injuries of the upper extremity from any cause (high-velocity gunshot injuries, fracture dislocations, lacerations, etc.) and reported high rates of spontaneous recovery, similar for all nerves, especially in closed injuries. In the absence of more information a similar policy to that for radial nerve injury should be adopted in cases of ulnar or median nerve injury associated with humeral shaft fracture. 

Concomitant Dislocation of the Ipsilateral Shoulder

Fracture of the humeral diaphysis and a concomitant dislocation of the ipsilateral shoulder is an infrequent combination that has been reported in the literature in around 11 case reports since 1990. Sasashige et al.266 described two cases of such a combination, one with anterior and the other with posterior shoulder dislocation, and stressed the high index of suspicion that is required, especially in the case of a posterior dislocation, in order not to miss shoulder injury. 
It has been generally accepted that the shoulder dislocation should be reduced immediately under anesthetic, while the management of the diaphyseal humeral fracture remains a matter of controversy. Both nonoperative and operative management have been proposed, all with good outcomes (Fig. 36-4).42,152 
Figure 36-4
 
A: A case of fracture of the proximal humeral diaphysis with associated anterior dislocation of the ipsilateral shoulder. There is fracture of the greater tuberosity as well. B: Immediate reduction of the dislocated shoulder under sedation. C: Definitive management with intramedullary nailing 2 days later.
A: A case of fracture of the proximal humeral diaphysis with associated anterior dislocation of the ipsilateral shoulder. There is fracture of the greater tuberosity as well. B: Immediate reduction of the dislocated shoulder under sedation. C: Definitive management with intramedullary nailing 2 days later.
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Figure 36-4
A: A case of fracture of the proximal humeral diaphysis with associated anterior dislocation of the ipsilateral shoulder. There is fracture of the greater tuberosity as well. B: Immediate reduction of the dislocated shoulder under sedation. C: Definitive management with intramedullary nailing 2 days later.
A: A case of fracture of the proximal humeral diaphysis with associated anterior dislocation of the ipsilateral shoulder. There is fracture of the greater tuberosity as well. B: Immediate reduction of the dislocated shoulder under sedation. C: Definitive management with intramedullary nailing 2 days later.
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Other Soft Tissue Injuries of the Ipsilateral Shoulder

Other soft tissue injuries of the ipsilateral shoulder in patients with diaphyseal humeral fractures can be overlooked. However, these injuries can cause problems with the patient’s rehabilitation and outcome and also could influence the effectiveness of the humeral fracture treatment, especially in cases treated with antegrade intramedullary nailing. O’Donnell et al.209 investigated the ipsilateral shoulder after humeral shaft fracture with MRI scans and found that 63.6% had evidence of abnormality such as bursitis of the subacromial space, partial or complete tear of the rotator cuff, inflammatory changes in the acromioclavicular joint, and fracture of the coracoid process. The authors concluded that these injuries may contribute to pain and dysfunction of the shoulder following treatment, and antegrade nailing could be only partly responsible for these symptoms postoperatively. 

Floating Elbow

A combination of injuries that involve both the humeral diaphysis and the middle to proximal parts of the radius and ulna with or without significant concomitant injury of the soft tissues around the elbow joint is often the result of high-energy trauma, creating an unstable intermediate articulation, the so-called floating elbow. Although this injury is more common in the pediatric population, it has been studied in adults as well with a few retrospective case series studies over the last 30 years. 
Rogers et al.249 presented one of the biggest series in the literature (19 patients) of floating elbow injury. Eleven patients did not have concomitant elbow joint injuries while in ten at least one of the components of the injury was open, indicating the severity of this infrequent combination. The management of the injuries varied but, as a general rule, displaced forearm fractures were treated with internal fixation while undisplaced forearm fractures were treated with a cast. Half of the humeral fractures were treated operatively with plating or percutaneous pinning for closed fractures and external fixators for the open fractures, while conservative treatment was followed in the remainder. Apart from one, all the intra-articular fractures of the elbow were managed with internal fixation. The results revealed many significant complications such as seven humeral and one radial nonunions, three deep infections, one case of myositis ossificans, 11 cases of severe neurovascular problems with incomplete recovery in most cases, and two amputations. The main conclusion of the study was that patients with closed injuries did better than those with open injuries and patients treated with open reduction and internal fixation (ORIF) did significantly better than those treated conservatively. This was confirmed by Langer and Foster 1 year later in a smaller series of nine patients with “floating” elbow injuries. They reported satisfactory outcomes only in those who underwent surgery for all fractures.158 Although it seems logical that concomitant neurovascular injury would be an adverse prognostic factor for patients who have sustained floating elbow injury, Yokoyama et al.322 stated that the functional outcome of such patients is irrelevant to the existence of open fractures or neurovascular injuries. Solomon et al.281 debated the previous statement and supported that sustaining a nerve injury is a poor prognostic factor for patients with “floating” elbow injuries. 
Apart from the typical injury of the concomitant fractures of the diaphysis of the humerus, radius, and ulna, there have been sporadic reports that describe variations of floating elbow injuries, such as combinations of additional soft tissue injury to the elbow (e.g., concomitant dislocation) or additional fractures (mainly of the humeral condyles). The common denominator of all reports is that floating elbow is a severe injury that warrants surgical management and meticulous postoperative rehabilitation with a high complication rate and not infrequent suboptimal results (Fig. 36-5). 
Figure 36-5
 
A: Severe “floating” elbow injury. Fracture of the humeral and ulna diaphysis, open fracture of the radial head, and elbow dislocation. B: Ipsilateral fractures of the distal radius and ulna and fractures/dislocations of the carpal bones. C: After resuscitating the patient (who also suffered a severe pelvic injury) and provisional stabilization of the arm with splints, the humerus was fixed with intramedullary nailing. D: The elbow dislocation was reduced, the radial head replaced, and the ulna was stabilized with a long pin, that was fixing its fractured distal diaphysis as well. E: Eighteen months later the nail was removed to reveal a well-healed humeral fracture. F: Unfortunately, deep infection developed at the elbow that required removal of the radial head prosthesis. It settled with IV antibiotics but left a stiff and painful elbow. The patient declined further surgical assistance.
A: Severe “floating” elbow injury. Fracture of the humeral and ulna diaphysis, open fracture of the radial head, and elbow dislocation. B: Ipsilateral fractures of the distal radius and ulna and fractures/dislocations of the carpal bones. C: After resuscitating the patient (who also suffered a severe pelvic injury) and provisional stabilization of the arm with splints, the humerus was fixed with intramedullary nailing. D: The elbow dislocation was reduced, the radial head replaced, and the ulna was stabilized with a long pin, that was fixing its fractured distal diaphysis as well. E: Eighteen months later the nail was removed to reveal a well-healed humeral fracture. F: Unfortunately, deep infection developed at the elbow that required removal of the radial head prosthesis. It settled with IV antibiotics but left a stiff and painful elbow. The patient declined further surgical assistance.
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Figure 36-5
A: Severe “floating” elbow injury. Fracture of the humeral and ulna diaphysis, open fracture of the radial head, and elbow dislocation. B: Ipsilateral fractures of the distal radius and ulna and fractures/dislocations of the carpal bones. C: After resuscitating the patient (who also suffered a severe pelvic injury) and provisional stabilization of the arm with splints, the humerus was fixed with intramedullary nailing. D: The elbow dislocation was reduced, the radial head replaced, and the ulna was stabilized with a long pin, that was fixing its fractured distal diaphysis as well. E: Eighteen months later the nail was removed to reveal a well-healed humeral fracture. F: Unfortunately, deep infection developed at the elbow that required removal of the radial head prosthesis. It settled with IV antibiotics but left a stiff and painful elbow. The patient declined further surgical assistance.
A: Severe “floating” elbow injury. Fracture of the humeral and ulna diaphysis, open fracture of the radial head, and elbow dislocation. B: Ipsilateral fractures of the distal radius and ulna and fractures/dislocations of the carpal bones. C: After resuscitating the patient (who also suffered a severe pelvic injury) and provisional stabilization of the arm with splints, the humerus was fixed with intramedullary nailing. D: The elbow dislocation was reduced, the radial head replaced, and the ulna was stabilized with a long pin, that was fixing its fractured distal diaphysis as well. E: Eighteen months later the nail was removed to reveal a well-healed humeral fracture. F: Unfortunately, deep infection developed at the elbow that required removal of the radial head prosthesis. It settled with IV antibiotics but left a stiff and painful elbow. The patient declined further surgical assistance.
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Signs and Symptoms of Humeral Shaft Fractures

The alert patient can provide a detailed description of the accident that can characterize the injury as being of high or low velocity and turn our attention to specific elements that may require either immediate care or additional investigations. The majority of humeral shaft fractures occur as a result of ground-level falls or minor twisting injuries in older osteoporotic patients while the precipitating cause in younger individuals is often higher-energy injury and includes RTA, industrial accident, fall from a height, sports, and throwing injuries.76,150,265 The possibility of a fracture through pathologic bone should be also borne in mind in cases with a history of minimal trauma, and thorough investigation of the patient’s past medical history is of paramount importance. Additional information should be sought about comorbidities, medication, previous surgery, and habits that could interfere with anesthetic, fracture healing, or rehabilitation, such as smoking, alcoholism, or drug abuse. 
In nonpolytrauma patients the most striking clinical symptom is the excruciating pain at the fracture site. The patient’s upper arm appears swollen and often obviously deformed. The patient supports the injured arm with the opposite hand and tries to avoid any manipulation or movement of the ipsilateral shoulder and elbow joints. While the patient is reluctant to allow any examination of the injured arm by the physician, an effort should be made to exclude injury in other areas of the upper limb, or anywhere else in the body, such as head, neck, chest, or abdominal injury. The arm and axilla must be thoroughly inspected in the case of a wound that allows communication of the bone with the environment. In the most frequent scenario of closed fracture, attention is then paid to the neurovascular status of the arm. Radial and ulna arteries are palpated at the wrist and the hand is assessed for the adequacy of capillary refill. The neurologic status of the arm is then assessed. Although clinical examination should be performed for all main peripheral nerves, special attention should be paid to the functionality of the radial nerve, as because of its anatomical relationship to the humerus, it is more frequently injured. Dorsiflexion of the wrist and the interphalangeal joint of the thumb along with sensory examination of the dorsum of the hand can reveal potential injury of the radial nerve and any findings–negative or positive—should be recorded. The ipsilateral elbow, forearm, wrist, and hand are palpated for sensitivity and inspected for pathologic signs such as edema, bruises, wounds, or discoloration. 
In cases of polytraumatized patients it may be difficult or impossible to obtain any information from the patient. Therefore, the physician must collect data about the accident and the patient’s preinjury status from witnesses, paramedics, or relatives. Usually, the injury of the arm has low priority in relation to other injuries and the patient should be managed according to Advanced Trauma Life Support (ATLS) guidelines. Upon stabilization of the patient and after exclusion of life- or limb-threatening pathology, attention is directed to the injured arm. If the patient is co-operative the clinical examination will proceed as described above. With unconscious or distressed patient the examination can be difficult and important parameters such as assessment of neurologic status of the arm may be impossible. This may be a problem because if a nerve palsy is subsequently detected the surgeon will not know whether the nerve injury resulted from a manipulation of the fracture or a surgical intervention. The rest of the clinical examination must be meticulous; thorough circumferential inspection should reveal the existence of wound(s) and raise the possibility of an open fracture, whereas discoloration of the arm can indicate a vascular problem, and deformities pinpoint other sites of injury. The examining physician must be alert that in polytraumatized patients there is an increased incidence of injuries in other areas of the arm (floating elbow) or around the shoulder joint (shoulder dislocation, coexisting fracture of the proximal humerus), and that patients with closed fractures that occurred in high-velocity injuries may develop acute compartment syndrome. 

Imaging and other Diagnostic Studies for Humeral Shaft Fractures

Any patient with a suspected humeral shaft fracture should undergo x-ray investigation in two planes at 90 degrees to each other. The ipsilateral shoulder and elbow joints must be included in the x-ray image, in order to exclude either fracture extension or an associated injury to the joint. The majority of humeral diaphyseal fractures will not require further imaging and the two good-quality plain films will be adequate for fracture assessment and treatment planning. In the event of doubts about fracture morphology or the existence of associated injuries in the vicinity of the humerus or elsewhere, further x-rays centered on the shoulder, elbow, forearm, or the wrist and hand may be ordered. If x-rays reveal or raise a suspicion of a possible proximal or distal intra-articular fracture, more detailed investigation with a CT scan may be necessary. 
Clinical signs of vascular injury can be initially investigated with a pulse oximeter or a Doppler and in cases of severe injuries with angiogram (Fig. 36-6). If, following the stabilization of a humeral shaft fracture, there are clinical signs of nerve injury, ultrasonography can be useful in the detection of the injury and its extent.299 
Figure 36-6
Angiogram showing traumatic rupture of the subclavian artery.
 
Complete sternoclavicular separation can also be seen.
Complete sternoclavicular separation can also be seen.
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Figure 36-6
Angiogram showing traumatic rupture of the subclavian artery.
Complete sternoclavicular separation can also be seen.
Complete sternoclavicular separation can also be seen.
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Nerve conduction studies and electromyography (EMG) can be used for the assessment of the functional status of a nerve and its recovery rate and are used mostly after radial nerve palsy. However, these investigations do not significantly influence the decision regarding the management of the fracture. 

Classification of Humeral Shaft Fractures

Bone Injury

Classification systems have been introduced in orthopedic practice as valuable tools that could provide information about the severity of the injury, indicate treatment options, and predict outcomes. Categorization of fracture patterns with classification systems contributes toward better organization of research projects and more comprehensive analysis of their results. 
In 1990 the AO group presented the AO/Müller classification for long-bone fractures.203 The classification was revised in 1996 by the Orthopaedic Trauma Association (OTA) and was further improved and expanded in 2007 to include all fractures of the human skeleton (Chapter 2).180 The comprehensive classification of humeral diaphyseal fractures according to Fracture and Dislocation Classification Compendium 2007 is presented in Figure 36-7. The system designates the humerus as a bone (1), divided into three parts: Proximal (11), diaphyseal (12), and distal (13). The diaphyseal segment is further divided into three types: Simple fractures (12-A) consisting of two main fragments—proximal and distal, wedge fractures (12-B) where there are one or more intermediate fragments with contact between the main fragments after reduction, and complex fractures (12-C) where there is more comminution and no contact of the main proximal and distal fragments after reduction. The types are further divided into three groups depending on the morphology, from “benign” (1) to “difficult” (3), and each group into three subgroups that define the proximal, middle, or distal zone of the diaphysis, where the fracture happened. 
Figure 36-7
AO/OTA classification of diaphyseal humeral fractures.
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Since its introduction the AO/Müller classification system has been regarded as an invaluable tool for research and academic communication. However, over the years, it has received criticism for being complicated, with low inter- and intraobserver variation agreement and reliability.136,205,291,293 The latest version (2007) became more complex without being validated for users’ agreement and other important parameters such as treatment selection, outcomes, and ease of use in everyday clinical practice.180 Recently, we presented a new, simple classification system for diaphyseal long-bone fractures that could facilitate clinical communication, assist in the choice of treatment method, and predict complications and outcome (Table 36-1 and Fig. 36-8).91 The system divides the diaphysis of each long bone (femur, tibia, humerus, radius, ulna) into three zones of equal length. The proximal zone is assigned the capital letter P (for proximal), the middle zone the capital letter M (for middle), and the distal zone the capital letter D (for distal). The capital letters P, M, D describe the location of a fracture. When a fracture extends to more than one zone or occurs in the transition area between two zones the location is described appropriately by two or three initials from proximal to distal. Fractures are morphologically described as simple (S), intermediate (I), or complex (C), with these letters following the letter(s) defining the location. Simple fractures are those with no comminution (clear-cut fractures) and are further separated into transverse or slightly oblique (t) and spiral (s). One or two minor bony chips should not change the definition of a fracture as simple. Intermediate fractures have one or two sizable bony fragments, whereas complex fractures have >3 sizable bony fragments or greater comminution. We proposed that while the AO/OTA classification should be used for scientific projects and research the newly proposed classification could become a useful tool for everyday clinical practice and communication. 
Figure 36-8
Garnavos classification of diaphyseal humeral fractures.
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Table 36-1
Garnavos Classification
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Table 36-1
Garnavos Classification
Topography Morphology
P: Proximal
M: Middle
D: Distal
j: Extension toward the joint
S: Simple (no butterflies)
  •  
    t: Transverse or oblique
  •  
    s: Spiral

I: Intermediate (one or two sizable butterflies)
C: Complex (three or more any size butterflies or big comminution)
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Soft Tissue Injury

The severity of soft tissue injury is of paramount importance for treatment selection and outcome of a diaphyseal humeral fracture (Chapter 2). Open fractures have been classified since 1976 by Gustilo and Anderson into three grades.106,107 Grade I is an inside-out puncture wound to the skin caused by the fracture as result of a low-energy injury. Grade II is caused by higher velocity and the wound is greater than 1 cm without extensive soft tissue damage, flaps, or avulsions. Grade III is a severe injury with extensive soft tissue damage that is further divided into three subgroups: (A) with adequate soft tissue coverage, (B) with significant soft tissue loss with periosteal stripping and bone exposure that will require flap coverage, and (C) with vascular injury that will require repair. 
The Open Fracture Study Group of the OTA recently produced a proposal about a new classification for open fractures.216 The Study Group identified factors in the literature that had been used clinically to evaluate open fractures of the upper extremity, lower extremity, and pelvis. This list of factors was reviewed by a seven-member panel of orthopedic traumatologists, each of whom independently examined and prioritized each factor for inclusion or exclusion in the new open fracture classification scheme. The results of this analysis were discussed by an “open fracture work group” and a new open fracture classification system was proposed. This proposal was further revised after being tested through a process of clinical data collection. The proposed New Classification of Open Fractures is presented in Table 36-2
 
Table 36-2
OTA/OFS Group Classification of Open Fractures
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Table 36-2
OTA/OFS Group Classification of Open Fractures
Skin
  1.  
    Can be approximated
  2.  
    Cannot be approximated
  3.  
    Extensive degloving
Muscle
  1.  
    No muscle in area, no appreciable muscle necrosis, some muscle injury with intact muscle function
  2.  
    Loss of muscle but the muscle remains functional, some localized necrosis in the zone of injury that requires excision, intact muscle–tendon unit
  3.  
    Dead muscle, loss of muscle function, partial or complete compartment excision, complete disruption of a muscle–tendon unit, muscle defect does not approximate
Arterial
  1.  
    No injury
  2.  
    Artery injury without ischemia
  3.  
    Artery injury with distal ischemia
Contamination
  1.  
    None or minimal contamination
  2.  
    Surface contamination (easily removed, not embedded in bone or deep soft tissues)
  3.  
    1.  
      Embedded in bone or deep soft tissues
    2.  
      High-risk environmental conditions (barnyard, fecal dirty water, etc.)
Bone Loss
  1.  
    None
  2.  
    Bone missing or devascularized but still some contact between proximal and distal fragments
  3.  
    Segmental bone loss
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Tscherne and Gotzen301 classified the soft tissue damage in closed fractures, as it can play an important role in the course of treatment and the outcome of the injury (Table 36-3). 
Table 36-3
Tscherne and Gotzen Classification of Soft Tissue Damage in Closed Fractures
Grade 0: Minimal soft tissue damage, indirect violence, simple fracture pattern
Grade I: Superficial abrasion of contusion caused by pressure from within, mild to moderate fracture pattern
Grade II: Deep contaminated abrasions associated with localized skin or muscle contusion, impending compartment syndrome, severe fracture
Grade III: Extensive skin contusion or crush, underlying severe muscle, decompensated compartment syndrome, associated major vascular injury, severe fracture
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Outcome Measures for Humeral Shaft Fractures

Outcome assessment following the management of diaphyseal humeral fractures must consider parameters related to bone and soft tissue healing as well as the restoration of function of the ipsilateral shoulder and elbow joints. Functional assessment of the nearby joints is even more important in cases of complications such as nonunion or neurologic problems. 
The process of bone healing is typically assessed with plain x-rays and clinical examination at 4- to 6-week intervals until fracture union. Widely accepted radiologic signs for fracture union are the identification of bridging callus on two orthogonal views or in three of the four cortices.317 More specifically, for fractures of the humeral diaphysis, Sarmiento et al.265 defined fracture union as the osseous bridging between the main fragments, observed on at least one radiograph if there is no pain at the fracture site. CT scan can offer more detailed information and confirm delayed or nonunion but should be reserved for patients whose fracture healing is not progressing, as assessed by standard x-ray imaging and physical examination.14 
Functional recovery of shoulder and elbow joints can be affected either by the initial injury or by the treatment and is assessed with scoring systems. Perhaps the most popular scoring system to assess post-traumatic shoulder recovery has been proposed by Constant and Murley52 in 1987. The Constant-Murley score is a 100-point functional shoulder assessment tool in which higher scores reflect increased function. It includes pain score (15 points), functional assessment (20 points), Range of Motion (ROM) (40 points), and strength measures (25 points) (Table 36-4). A weakness of this system is that it requires a large amount of objective data collection by the clinician which may affect interobserver reliability. 
Table 36-4
The Constant-Murley Score for Assessing the Recovery of the Soulder Joint Following Trauma
Pain
15/100 points
Severe pain
Moderate pain
Minimal pain
No pain
0
5
10
15
Forward flexion 10 points Abduction 10 points
0–30
31–60
61–90
91–120
121–150
151–180
0
2
4
6
8
10
0–30
31–60
61–90
91–120
121–150
151–180
0
2
4
6
8
10
Motion
40/100 points
External rotation 10 points (hand not allowed to touch the head) Internal rotation 10 points
Not reaching the head
Hand behind head with elbow forward
Hand behind head with elbow back
Hand on top of head with elbow forward
Hand on top of head with elbow back
Full elevation from on top of head
0
2
2
2
2
End of the thumb to lateral thigh
End of the thumb to buttock
End of the thumb to lumbosacral junction
End of the thumb to L3 (waist)
End of the thumb to T 12
End of the thumb to T 7(interscapular)
0
2
4
6
8
10
Strength
25/100 points
Strength of abduction against resistance at the level of the scapula with the forearm pronated. The score is allocated on a sliding scale up to 25 points.
Function
20/100 points
Ability to work
Recreational activities
Ability to sleep
Ability to work at the level:
Of the waist
Of the xiphoid
Of the neck
Of the head
Above the head
0 to 4 points
0 to 4 points
0 to 2 points
2 points
4 points
6 points
8 points
10 points
X
Other popular shoulder scores used for assessing the efficacy of treatment after injury are the following: 

The American Shoulder and Elbow Surgeons Self-Report Form for the Shoulder (ASES-s)

This is a 100-point standardized shoulder assessment form, 50 points of which are provided from a patient self-report in the form of Visual Analog Scales (VASs) for pain and instability and a questionnaire about the ability to perform daily living activities.146 The physician assessment section includes an area to collect demographic information and assesses ROM, specific physical signs, strength, and stability. 

The Oxford Shoulder Score

This system relies on the patient’s subjective assessment of pain and impairment of daily living activities to provide the assessment.63 A clinical follow-up visit is therefore not necessary. The Oxford Shoulder Questionnaire adds up to a total score with a maximum value of 60, of which four pain-related questions make up 33 points while the remaining 27 points are derived from eight questions related to daily activities. It should be noted that the highest scores are attributed to the worst outcomes. 
Elbow function after trauma is usually assessed with flexion and extension lag. Popular scoring systems assessing the elbow joint recovery following trauma are the following: 

The Mayo Elbow Performance (MEP) Index

This is probably the most popular scoring system for assessment of the recovery of the elbow joint following trauma.198 This system assesses motion in terms of flexion and extension. Neither strength nor deformity is included in the content of the scale. Function and motion are weighted less heavily than pain (Table 36-5). 
Table 36-5
The Mayo Elbow Performance (MEP) Index for Assessing the Recovery of the Elbow Joint Following Trauma
Pain (max points 45) None
Mild
Moderate
Severe
45
30
15
0
Motion (max points 20) Arc of motion >100 degrees
Arc of motion >50 and <100 degrees
Arc of motion <50 degrees
20
15
5
Stability (max points 10) Stable
Moderate stability
Grossly unstable
10
5
0
Function (max points 25) Can comb hair
Can eat
Can perform hygiene
Can put on shirt
Can put on shoe
5
5
5
5
5
X

The American Shoulder and Elbow Surgeons Self-Report Form for the Elbow (ASES-e)

This scoring system was developed by the American Shoulder and Elbow Research Committee.146 The patient self-evaluation section contains VASs for pain and a series of questions relating to function of the extremity. The physician assessment section has four parts: Motion, stability, strength, and physical findings. Higher scores indicate worse function. 
Apart from scoring systems dedicated to the functional assessment of either the shoulder or the elbow joints, the Disabilities of the Arm, Shoulder and Hand (DASH) system (joint initiative of the American Academy of Orthopedic Surgeons [AAOS], the Council of Musculoskeletal Specialty Societies [COMSS], and the Institute for Work & Health [Toronto, Ontario]) assesses the symptoms and functional status of the whole injured arm.127 The DASH is a 30-item questionnaire with a five-item response option for each item. The test has a maximum score of 100, where higher scores reflect greater disability. The DASH index is a valid and reliable tool for assessing recovery after multiple injuries of the upper extremity. The QuickDASH (Table 36-6) is a shortened version of the DASH scoring system. It consists of 11 items to measure physical function and symptoms in people with any or multiple musculoskeletal disorders of the upper limb. Similar to the DASH, each item has five response options. The final score ranges between 0 (no disability) and 100 (the greatest possible disability). Only one missing item can be tolerated, and, if two or more items are missing, the score cannot be calculated. 
Table 36-6
The QuickDASH Scoring System Assesses the Symptoms and Functional Status of the Whole Injured Arm
1: No difficulty; 2: Mild difficulty; 3: Moderate difficulty
4: Severe difficulty; 5: Unable
  1.  
    Open jar
  2.  
    Pain intensity
  3.  
    Tingling intensity
  4.  
    Sleep
  5.  
    Socialize
  6.  
    Wash back
  7.  
    Forceful recreation
  8.  
    Heavy chores
  9.  
    Carry a bag
  10.  
    Use knife
  11.  
    Limited in work
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
X

Pathoanatomy and Applied Anatomy Relating to Humeral Shaft Fractures

The humeral diaphysis extends from the surgical neck of the humerus, just below the greater and lesser tuberosities to the supracondylar ridge at the elbow.91,104 A cross section of the humeral shaft is round proximally and changes gradually to be triangular distally, with the medullary canal becoming narrower at the distal part. For descriptive reasons the bone can be divided into three equal parts in length, the proximal, middle, and distal thirds. The surface of the humerus can be also divided into three longitudinal parts; anterolateral, anteromedial, and posterior. Each area is defined by bony ridges that extend from the tuberosities to the supracondylar region. Knowledge of the polymorphy of the cross section and the surface anatomy of the humeral diaphysis can facilitate internal fixation as plates fit better on flat surfaces while introduction of a retrograde nail can be troublesome if the narrower triangular shape of the distal humerus is overlooked. Important osseous landmarks of the humeral diaphysis are the deltoid tuberosity (point of insertion of the deltoid muscle) on the anterolateral surface at the junction of the proximal and middle thirds of the diaphysis and the spiral groove in the middle/posterior aspect that contains the radial nerve and the profunda brachii artery. 
The humerus is covered by a thick envelope of soft tissues that include strong muscles and a rather complicated arrangement of neurovascular structures (Fig. 36-9). Muscles that surround the humerus from proximal to distal include the deltoid, pectoralis major, teres major, latissimus dorsi, coracobrachialis, brachialis, brachioradialis, and the triceps brachii. Knowledge of the course and the site of insertion of each muscle can explain the displacement that occurs in diaphyseal fractures and also can facilitate preoperative planning and fixation technique. A typical example is the displacement in abduction of the proximal humeral fragment in cases of fractures occurring proximal to the insertion of pectoralis major because of the pull of the deltoid muscle. The muscles surrounding the humeral diaphysis form two compartments, the anterior and posterior that are separated by fascial membranes (septa). The anterior compartment contains the flexors of the elbow (biceps, brachialis, and coracobrachialis) and the posterior contains the triceps brachialis with its three heads (long, lateral, and medial). The radial nerve enters the posterior compartment and runs between the long and lateral heads of the triceps, enters the spiral groove which is posterior to the deltoid tuberosity, and runs its course posterolaterally adjacent to the bone before it exits the spiral groove on the lateral aspect of the humerus approximately 10 to 15 cm proximal to the lateral epicondyle.105 
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Figure 36-9
The neurovascular anatomy of the upper arm.
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X
It is important to note when planning surgical procedures at the distal humerus that as the radial nerve exits the spiral groove and becomes anterior, the distance from the articular surface of the distal humerus is never less than 7.5 cm.304 The median nerve and the brachial artery have a common course on the medial aspect of the anterior compartment and at the level of the elbow lie between the pronator teres and the biceps tendon. The musculocutaneous nerve also lies within the anterior compartment and crosses the distal humerus longitudinally, lateral to the median nerve and brachial artery. It can be endangered during anteroposterior (AP) distal interlocking in antegrade nailing or in the distal window of Minimally Invasive Plate Osteosynthesis (MIPO). The proximal part of the ulna nerve runs in proximity to the median nerve within the anterior compartment but at the arcade of Struthers, approximately 8 cm from the medial epicondyle, it enters into the posterior compartment and runs medially toward the cubital tunnel.230 
Although the proximal humerus is dealt with in Chapter 37 knowledge of its surgical anatomy is necessary for the management of humeral shaft fractures. Penetration of the rotator cuff is the standard approach for antegrade nailing, while proximal locking screws penetrate the deltoid and/or the subscapularis. Surgeons must be aware that the supraspinatus tendon is relatively avascular near its insertion into the greater tuberosity and therefore, it is recommended that the entry portal for antegrade nailing should be created toward its musculotendinous area.116 
The axillary nerve runs around the proximal humerus, circumferentially, from posterior to anterior at a distance of 4 to 7 cm from the tip of the acromion and it can be injured either from an extended lateral approach to the proximal diaphysis or from the drill bit and the screws used for proximal interlocking of an intramedullary nail.302 Likewise, the anterior and posterior circumflex arteries of the humeral head could be injured from the drill or the proximal locking screws of an antegrade nail. 

Humeral Shaft Fracture Treatment Options

Nonoperative Treatment of Humeral Shaft Fractures

Indications/Contraindications

It is generally accepted that acute, closed, uncomplicated fractures of the humeral diaphysis that occur in ambulatory, co-operative patients have high rates of union with good functional results, if treated nonoperatively.68,188,219 However, as for any treatment, the indications and contraindications for applying nonoperative treatment in fractures of the humeral diaphysis are constantly reviewed and subject to change, as surgical techniques are improving and the socioeconomic environment favors treatment options that can offer a faster recovery and earlier return to normal activities. 
A review of studies on the nonoperative treatment of diaphyseal fractures of the humerus published in the first decade of the 21st century was performed to define modern indications and contraindications for nonoperative treatment. Closed, acute, and isolated fractures were primary indications for nonoperative treatment in all studies. Sarmiento et al.265 reviewed 620 patients who had sustained humeral shaft fractures and were treated with functional bracing. Apart from the primary indications they also treated fractures that were open (155, 25%), segmental (6, 1%), associated with dislocation of the ipsilateral shoulder (12, 2%) and with primary radial nerve palsy (67, 11%). Patients who had suffered a nerve injury because of penetrating trauma or a high-velocity gunshot wound were excluded. Koch et al.150 reported that they treated patients with multiple injuries, open fractures, and cases with associated radial nerve palsy nonoperatively but do not recommend nonoperative treatment for patients with additional fractures of the ipsilateral arm. Toivanen et al. excluded multiply injured patients or pathologic fractures from nonoperative treatment. Interestingly they noted that there was a high rate of nonunion after conservative treatment when the fracture was located at the proximal third of the diaphysis (54%) and in AO type A fractures (23%).297 Similarly Ekholm et al.76 treated 78 patients who had sustained an acute, isolated, nonpathologic humeral shaft fracture, but excluded patients with multiple fractures, pathologic fractures, periprosthetic fractures, and previous fractures of the same humerus. In the study period there were nine patients (10%) with primary radial nerve palsy but only five of these were treated nonoperatively. Although the authors reported good results overall, they recognized that there was a trend toward an increased number of nonunions in patients with OTA type A fractures if compared with type B and C fractures. This finding was confirmed in a review of 18 studies of humeral shaft fractures treated with functional bracing. The authors found an overall union rate of 94.5%, but an average nonunion rate of 15.4% in type A fractures, in the five articles that reported the prevalence of nonunion with regard to AO classification.219 This raises the possibility that patients who suffer a type A humeral shaft fracture could have better results if treated operatively. 
Rutgers and Ring259 excluded open fractures, polytrauma patients, and periprosthetic fractures from nonoperative treatment and noted that noncompliant patients are hard to manage with nonoperative treatment. They also made a comment about a trend toward nonunion in long oblique fractures of the proximal third, confirmed in a subsequent study from the same institute.243 The same observation was made in an earlier study by Castella et al.35 Pehlivan223 reviewed 21 young, compliant patients who had sustained acute, closed, and isolated fractures of the distal part of the humerus and were treated nonoperatively. Having excluded from the treatment protocol multitrauma, open fractures, or fractures with neurovascular injuries all fractures united uneventfully. Decomas and Kaye65 recently tried to identify risk factors associated with failure of nonoperative treatment of diaphyseal humeral fractures. Their conclusions were in agreement with the previous data that short oblique fractures and fractures occurring at the proximal third of the diaphysis are at greater risk for nonunion. 
It should be noted that primary radial nerve injury in closed fracture should not be considered a contraindication for nonoperative treatment.76,150,265 While all studies regarded additional injury to the ipsilateral arm as a contraindication for nonoperative treatment,76,150,223,259,265,297 one study proposed that fractures with concomitant shoulder dislocation can be treated nonoperatively.265 Finally, regarding behavioral and morphologic characteristics, it is worth mentioning that noncompliant patients may not be suitable for nonoperative treatment of a humeral shaft fracture223,259 and, despite older reports, none of the most recent studies referred to obesity or women with large breasts as contraindications for nonoperative treatment. 
Using this information an updated list of the indications and contraindications for nonoperative management of humeral shaft fractures has been created, which requires evaluation in future studies (Table 36-7). 
Table 36-7
Indications, Relative Indications, and Relative Contraindications for Nonoperative Management of Diaphyseal Humeral Fractures
Strong Indication Relative Indications Relative Contraindications
Acute/closed/isolated fracture in a Cooperative and Ambulatory patient Type A fracture (AO classification)
Proximal third, long oblique fracture
Segmental fracture
Open fracture without neurovascular injury
Noncompliant patient
Multiple injuries
Vascular injury
Additional injuries to the ipsilateral arm
Persisting or increasing nerve dysfunction
Bilateral fractures
Pathologic fracture
Nonunited fracture
X

Techniques

Nonoperative treatment of diaphyseal humeral fractures can be accomplished with various techniques such as skeletal traction, Velpeau bandage, a sling and body bandage, abduction cast or splint, coaptation splint or U-slab, hanging arm cast, and functional bracing. Of these, skeletal traction and the abduction cast have been abandoned as their application is troublesome and cannot be easily tolerated by patients. Velpeau bandage, a sling and body bandage, U-slabs, and hanging casts are still in use, but over the last 2 to 3 decades functional bracing, as described by Sarmiento et al.,264 has dominated the nonoperative management of humeral shaft fractures. However, functional braces may not be immediately available and temporary immobilization of the arm is usually necessary. Therefore, a basic knowledge of alternative splinting techniques is required. 
Sling/Swathe and Velpeau Bandage.
A sling and swathe is an easy, inexpensive technique that can offer rapid immobilization of the arm. A sling supports the weight of the arm while a swathe immobilizes the arm against the chest. Padding should be placed in the axilla to provide some comfort to the patient. Velpeau bandage is a similar technique, except that the bandaging around the arm and the patient’s torso is more restrictive, the patient’s elbow is flexed, and the forearm lies against the chest (Fig. 36-10A). Both techniques are difficult for the patient to tolerate for more than few days and should be replaced by functional bracing as soon as possible. 
Figure 36-10
 
A: Velpeau bandage. B: U-slab. C: Hanging cast. D: Functional brace.
A: Velpeau bandage. B: U-slab. C: Hanging cast. D: Functional brace.
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Figure 36-10
A: Velpeau bandage. B: U-slab. C: Hanging cast. D: Functional brace.
A: Velpeau bandage. B: U-slab. C: Hanging cast. D: Functional brace.
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X
U-Slab/Coaptation Splint.
A U-slab is commonly used for temporary immobilization of humeral shaft fractures, especially if they are located in the middle or distal humerus (Fig. 36-10B). The arm is covered with a stockinette and wool bandage and a strip of plaster is applied from the axilla to the medial side of the arm, around the olecranon, and turned upward on the lateral side of the arm up to the level of the acromion. It is secured in this position with an elastic bandage. The disadvantage of this splint is that it loosens easily and slips downward requiring frequent adjustment or replacement. As with the Velpeau bandage technique, the U-slab should be replaced by functional bracing as soon as possible. 
Hanging Cast.
Hanging casts have been used for many decades for the management of humeral shaft fractures, especially in cases with shortening and displacement (Fig. 36-10C). Most frequently these are simple, oblique, or spiral fractures in the middle third of the humerus. In cases of transverse fractures with shortening, a hanging cast can be applied to reduce the humerus to the proper length and alignment. However, this technique requires close supervision because if neglected it can distract the fracture and contribute to healing problems. The hanging cast technique requires a full arm cast, with the plaster extending from above the fracture to the wrist, with the elbow flexed to 90 degrees, and the forearm in the neutral position. The patient should be instructed to keep the arm in a “hanging” position for as long as possible to allow gravity to restore humeral length and alignment. Most surgeons use hanging casts routinely for 1 week to 10 days to achieve fracture reduction and then continue with functional bracing. 
Functional Bracing.
Since it was first described in 1977 by Sarmiento et al.264 functional bracing has been the most popular definitive technique for the nonoperative management of humeral shaft fractures. Immediately after the accident the arm may be temporarily immobilized with one of the techniques described above. The duration of this temporary immobilization should not exceed 7 to 10 days. At that time the patient is examined in the outpatient department and, if the acute symptoms and edema have subsided, is provided with a prefabricated brace that consists of two plastic sleeves that fit on opposite sides of the arm, either medial and lateral or anterior and posterior. They are held together with adjustable Velcro straps (Fig. 36-10D). Tightening of the straps creates a “custom made” well-fitted splint that applies pressure to the muscle belly surrounding the humerus and immobilizes the fracture. Patients are provided with a collar-and-cuff sling but they are instructed to move their elbow every day to avoid stiffness of the joint. They are also taught how to adjust the plastic sleeves and tighten the Velcro straps in the case of loosening or loss of position of the brace. Pendulum movements of the arm are encouraged from the beginning. Patients are instructed to avoid abduction and active elevation exercises or resting the injured arm on the arm of a chair, a table, or their lap, because leaning on the elbow of a fractured extremity during the early stages of healing may cause varus angulation. After application of the brace regular review is required for examination and radiographic evaluation of the healing progress. The patient is advised to increase shoulder and elbow exercises during the recovery period. 

Outcomes

Functional bracing, as described by Sarmiento et al. is widely used by orthopedic practitioners for the management of acute diaphyseal humeral fractures.264,265 Sarmiento et al.265 have also presented the largest series of 620 patients treated with functional bracing with adequate follow-up. Apart from closed, uncomplicated fractures, open fractures (155, 25%) and closed fractures associated with radial nerve palsy (67, 11%) were included. Open fractures with concomitant nerve injury and polytrauma patients were not treated by functional bracing. The authors reported a low (2.6%) nonunion rate (1.5% in closed fractures and 5.8% in open fractures). The healing time was on average 9.5 weeks for closed fractures and 14 weeks for open fractures. There were no significant differences regarding healing times for fractures located in any of the proximal, middle, or distal parts of the humerus or for fractures with differing patterns (transverse, oblique, comminuted, or segmental). Bearing in mind that up to 20 degrees anterior or posterior angular deformity and 15 degrees of varus,15,147 can be tolerated well by the arm, the authors reported an average of 9 degrees of varus angulation in transverse fractures, 4 degrees in oblique fractures, and 8 degrees in comminuted fractures. The occurrence of valgus deformity was insignificant, while more than 80% of the patients had less than 15 degrees of anterior or posterior angulation. Regarding functional recovery 88.6% of the patients lost less than 10 degrees of motion of the shoulder joint, while 92% of the patients lost less than 10 degrees of motion of the elbow as compared with the opposite side. Over the last 3 decades there have been several studies with substantial number of patients that confirm and validate the effectiveness of functional bracing in the management of diaphyseal humeral fractures.15,76,82,131,150,223,259,263,315,323 The average healing time in all these studies was 93.5% (77.4% to 100%) while time to union was reported from 6.5 to 22 weeks (average 10.7 weeks). 
Within the first decade of the 21st century, there have been further valuable observations. Fjalestad et al.82 reported that of 67 diaphyseal humeral fractures that were treated with functional bracing, 61 (91%) united but a detailed functional assessment revealed that 21 patients (38%) experienced significant loss of external rotation of the ipsilateral shoulder joint. In an effort to explain this finding the authors performed CT in a selected group of patients and found that rotational malunion may be responsible for functional deficiency after nonoperative treatment and they proposed early application of the functional brace to avoid this problem. Sarmiento et al. had previously reported that in a series of 72 patients, 26 (45%) had lost from 5 to 45 degrees of external rotation of the shoulder and suggested that this happened because of shrinkage of the shoulder capsule. At the time, this clinical parameter was not considered significant.263 Loss of shoulder joint motion with the use of functional bracing for the treatment of humeral shaft fractures has also been reported by others. Koch et al. found that only 28 out of 48 patients (58.3%) regained symmetrical and normal range of shoulder motion.150 Pehlivan223 followed up 21 patients and reported that when the brace was removed, restriction of movement occurred in the shoulder that improved with use of the extremity. Rosenberg and Soudry253 reported that 9 of the 15 consecutive patients who had sustained diaphyseal humeral fractures and were treated with functional bracing were unable to return to their previous activities because of shoulder impairment. Furthermore, 13 of the 15 patients experienced noticeable shoulder pain (6 of them admitted VAS values higher than five). 
Functional bracing has been considered particularly useful for fractures located at the distal third of the humeral diaphysis.131,223,263 Sarmiento et al.263 were able to review 65 patients who had sustained 54 closed and 11 open fractures of the distal humeral diaphysis. Twelve patients with associated radial nerve palsy had recovered partially or completely at the latest follow-up. Union rate was 96% (with only one nonunion in the group of open fractures) while angular deformities were recorded as 4 degrees of maximum median angulation in 80% of the patients, 3 to 22 degrees of posterior angulation in 39% of the patients, and 1 to 30 degrees of anterior angulation in 41% of the patients. The authors also recorded 2 to 15 mm of shortening in 36% of the patients. Twenty-six patients (45%) lost 5 to 45 degrees of external rotation of the shoulder joint while abduction and forward flexion were also impaired from 10 to 60 degrees and 5 to 20 degrees in nine (15.5%) and eight (13%) patients respectively. Elbow joint motion was affected in 15 patients (26%) who experienced 5 to 25 degrees of reduced flexion while 14 patients (24%) had 5 to 25 degrees of limited extension. Pehlivan223 presented similar results after treating a small group of patients, who suffered a fracture of the distal humeral diaphysis, with functional bracing. The author raised concerns about difficulties with fracture reduction and the risk of axial deviation at the fracture site, as 8 out of 21 patients (38%) experienced significant varus angulation. 
Although the overall effectiveness of functional bracing is not disputed, recent studies have raised questions about more specific issues. Toivanen et al.297 noted that fractures located in the proximal part of the humerus had a higher nonunion rate (6 out of 13 united) than fractures located either in the middle (48 out of 59 united) or the distal third (18 out of 21 united). A similar finding was reported by Rutgers and Ring259 who also noticed that the ununited proximal third fractures had a long-oblique pattern. Castellá et al.35 reviewed humeral nonunions that occurred after nonoperative management and noticed that a significant proportion had occurred in a specific fracture pattern (hemi-transverse medial fracture with a long and sharp lateral butterfly) located at the junction of the proximal and middle thirds of the diaphysis. Likewise, Ring et al. found that spiral/oblique fractures that involve the middle or proximal third of the diaphysis are more likely not to unite with functional bracing.243 Ekholm et al.76 observed that AO type A fractures had a higher nonunion rate than other types of fractures when treated with functional bracing. It seems that apart from the latter study the literature does not support the general impression that simple transverse fractures of the humerus are slow to heal nonoperatively.219 It should be noted that two studies prior to 2000 suggested that fractures located in the middle or distal third of the humerus were at greater risk for nonunion,264,315 while other studies do not regard fracture location as a key predictor of fracture union.76,82,253 

Operative Treatment of Humeral Shaft Fractures

Indications/Contraindications

Indications for operative reduction and fixation of diaphyseal humeral fractures were first defined by Bandi16 and included diaphyseal fractures in an unacceptable position after conservative treatment, open fractures, transverse fractures, comminuted fractures with radial nerve palsy and pseudoarthrosis. By 1996 the previous list was enriched with segmental fractures, pathological fractures, bilateral fractures, floating elbow, polytrauma cases, neurologic loss after penetrating injury, associated vascular injury, and intra-articular fracture extension while some of the previous indications, such as open fractures or fractures associated with radial nerve palsy, were reassessed.327 Over the last 10 to 20 years surgeons have paid attention to the details and secondary characteristics of fracture patterns and although the basic list of indications for operative treatment has not changed, more “relative” indications have been added (Table 36-8). 
Table 36-8
Indications and Relative Indications for Operative Management of Diaphyseal Humeral Fractures
Indications Relative Indications
Inability to maintain satisfactory reduction by closed means
Multiple injuries
Bilateral fractures
Floating elbow
Intra-articular fracture extension
Progressive nerve palsy or nerve palsy after closed manipulation
Significant vascular injury
Neurologic deficit after penetrating injury
Nonunion
Pathologic fractures
Open fractures
Segmental fractures
Noncompliant patients
Obesity or large breasts
Periprosthetic fractures
Type A fracture in the middle third of the humerus
Long oblique fracture of the proximal humerus
X
Inability to maintain satisfactory reduction by closed means is one of the main indications for surgical treatment. With nonoperative treatment angular deformity of more than 15 to 20 degrees in any direction and rotational malalignment of more than 30 degrees should not be accepted unless the patient is willing to accept visible deformity. The maximum humeral shortening that can be accepted is not precisely known. Although it has been reported that humeral shortening up to 5 cm can pass unnoticed, it sounds more reasonable to limit shortening to no more than 2 to 3 cm.188,323 
Patients with multiple injuries should benefit from surgery, as these patients lie recumbent for many days or weeks and are prone to malunion.19,163 These patients are likely to undergo surgery for other injuries and therefore, they will inevitably undergo anesthesia which is considered to be one of the disadvantages of operative treatment of humeral shaft fractures in isolated injury. Furthermore, nursing care, cleanliness, and comfort are facilitated with surgical treatment. 
Bilateral humeral fractures or fractures associated with other injuries of the ipsilateral arm (floating elbow, combined fractures/dislocations of the proximal humerus and humeral shaft) constitute indications for operative management of all injuries to allow early mobilization of joints and rapid recovery of independence and comfort. Furthermore, if the joints ipsilateral to the humeral shaft fracture are injured, surgical treatment will permit earlier initiation of physiotherapy and avoidance of joint stiffness.31,86,93,158,168,249 Segmental fractures of the humeral diaphysis with minimal displacement could be managed nonoperatively but this can be difficult if the middle fragment is displaced.93,168 
Progressive neurologic deficit, nerve palsy after manipulation, or significant vascular laceration after penetrating trauma will require exploration and repair of the injured structures.36,50,51,256,312 Secure stabilization of the fracture is then mandatory to protect the repair and allow frequent wound inspections and changing of dressings without disturbing the surgical site or risking damage from mobile bone fragments. Likewise, humeral shaft fractures associated with brachial plexus injury should be stabilized operatively to allow rapid mobilization of the entire arm and prevent nonunion, as the arm loses a part of its muscular support because of neurologic deficit.188 Pathological fractures should be stabilized operatively for palliative care if the patient’s life expectancy is more than 6 months and their general condition allows operative treatment.11,144,213 
Open fractures are heterogeneous injuries. Depending on the severity, as classified by Gustilo and Anderson,106 (Chapter 10) open humeral fractures can be treated with different treatment methods. For example, grade I fractures can be managed well with functional bracing, grade II can be treated either conservatively or operatively depending on the wound contamination, and grade III fractures should be treated operatively.199,256,265,272 
Noncooperative and indigent patients constitute another relative indication for operative treatment. Sarmiento et al.265 mentioned that indigent patients were frequently lost to follow-up and proposed that these patients should not be treated with functional bracing. However, indigent and noncompliant patients may not follow the rehabilitation program after operative fixation of their fractures and therefore, may be at equal risk of suffering postoperative complications. 
Obese patients and ladies with large breasts may benefit from the operative stabilization of their humeral shaft fracture as, because of their body mass, they have greater risk of malunion or nonunion.103,132 However, it could be argued that angular deformity should be less visible within a substantive soft tissue envelope and that these patients may be at greater risk for complications from the anesthesia or the sizeable wounds.138 It is my opinion that patients with increased body mass should be treated individually bearing in mind their comorbidities, after thorough discussion with the anesthetist and the patient. 
Periprosthetic fracture is a relative indication for immediate operative management, as there seems to be a consensus that if the prosthesis is stable, conservative management can be attempted. In cases with a loose prosthesis or failure of conservative management operative treatment is necessary with revision of the prosthesis to a cemented longer stem, plating, and strut grafts.66,260 
Transverse or oblique midshaft fractures or long-oblique proximal shaft fractures should be included nowadays in the list of relative indications for surgical management, as it has been reported that these fractures have high risk of nonunion if treated conservatively.35,219,243 
Old age and osteoporosis are not included in the list of indications or relative indications for operative management of humeral shaft fractures because there is no strong evidence that osteoporosis significantly influences the healing process. However, older people often cannot tolerate bracing and can be noncompliant. Therefore, the decision about the best treatment option for osteoporotic people with fractures of the humeral diaphysis must be based on careful assessment of the fracture characteristics and the patient’s comorbidities and personality. 

Plate Osteosynthesis

Preoperative Planning.
Winston Churchill said during World War II that “failing to plan is planning to fail.” Preoperative planning is a mandatory step that has to precede any surgical procedure to minimize intraoperative problems and maximize the possibility of a successful outcome. It should be stressed that initially the patient should be fully informed about the procedure and the postoperative rehabilitation course. Consultation with the anesthetist should take place concentrating on the patient’s comorbidities and technical issues that could interfere with anesthesia (such as patient positioning or placement of the endotracheal tube away from the injured side). 
At least two x-ray views of the whole humerus should be available, one neutral AP and one oblique-lateral. The length of the humerus should be measured from the available x-rays, taking into account the magnification, and depending on fracture extension and location the surgeon should estimate the length of the plate that will be required for the fixation of the fracture. If the fracture is close to the proximal or the distal metaphysis, there should be consideration of the adequacy of the implant to fix the shorter segment and in doubtful situations there should be alternative fixation options readily available. Whenever fracture lines extend toward the shoulder or elbow joints further x-ray views, centered in the suspected area, must be obtained. If there are still doubts about the integrity of the joints, a CT scan should be performed. 
The surgeon must be certain that the appropriate operating room with a suitable orthopedic table that can accommodate the planned procedure is available. The practice of accurate preoperative drawing of the fracture and the fixation technique now appears old-fashioned in the digital era and radiographic films are replaced by computer images. Relevant software programs that allow digital picture modification, measurement, and drawing are becoming available allowing preoperative planning to move from paper to screen.110 
In any case, the surgeon must decide in advance how the fracture will be approached, must be familiar with the anatomy and able to predict difficulties (such as structures at risk) that could be met during the operation. Preoperative drawings of fracture reduction and fixation can be a good approximation of the type and size of implant that will be needed and the tools that will be required (such as reduction forceps), so the surgeon should be able to check suitability, compatibility, and availability of the necessary tools and implants. A complete preoperative planning of plate fixation should also consider the type and order of screw insertion. Finally, the surgeon should make certain that the image intensifier will be on the site and working as there may be the need for intraoperative x-ray imaging. 
The development of a checklist that can be provided in advance to the operating room personnel (Table 36-9) leads to better organization of the operating procedure and the immediate availability of the necessary equipment. 
Table 36-9
Preoperative Planning Checklist for Plate Fixation of Diaphyseal Humeral Fracture
1. Operating Theater
Operating Room Table
  •  
    Regular orthopedic
  •  
    Radiolucent arm support
  •  
    Forearm extension
  •  
    Other
2. Position/Positioning Aids
  •  
    Supine
  •  
    Prone
  •  
    Beach chair
  •  
    Lateral (right side up)
  •  
    Lateral (left side up)
  •  
    Positioning aids
3. Equipment
  •  
    Battery drill
  •  
    Bone graft instruments
  •  
    Large bone reduction tools
  •  
    Other
X-ray
4. Implants
  •  
    Large fragment locking set
  •  
    Large fragment standard set
  •  
    Small fragment locking set
  •  
    Small fragment standard set
  •  
    K-wires
  •  
    Cerclage wires
  •  
    Other
5. Other
X
Positioning.
Patient positioning depends on the surgical approach. More specifically, plating fractures of the middle and proximal humeral diaphysis is usually performed via an anterolateral approach with the patient in the supine position with some padding underneath the scapula to support the torso and elevate the limb. The arm lies on a radiolucent arm board, abducted 45 to 60 degrees which will facilitate intraoperative x-ray imaging, if necessary. Fractures located at the proximal humeral diaphysis can be plated using the proximal part of the anterolateral approach with the operating table inclined headend up by 20 to 30 degrees in the so-called “beach chair” position. The arm is adducted with the injured arm protruding from the operating table and the forearm is positioned on a forearm support. The inclined position makes proximal extension of the approach easier and if the operating table is not too broad and the arm of the image intensifier is sufficiently curved, the image intensifier can be positioned on the opposite side of the table and be readily available at any time without interfering with the operating field. Fractures located in the middle third of the humeral diaphysis can be approached by a straight anterolateral incision with the patient supine and the arm abducted on a radiolucent extension. Fractures at the distal humeral diaphysis are better approached with the patient prone, because with this position the whole arm can be brought free of the operating table on a radiolucent extension, allowing good visualization with the image intensifier. Alternatively, the posterior approach can be performed equally well with the patient in the lateral position with the shoulder flexed and abducted and the elbow flexed over a support but intraoperative imaging may be more challenging in this position. For the minimal invasive plate osteosynthesis (MIPO) procedure the patient lies supine with the arm on a radiolucent table as in traditional plating of a fracture located in the middle of the humerus. The only difference is that the arm must be adducted to facilitate the insertion of the plate through the proximal humerus. 
Surgical Approaches for (ORIF).
The most frequently used approaches are the anterolateral (for middle and proximal diaphyseal fractures) and the posterior (for distal diaphyseal humeral fractures or for exploration of the radial nerve). However, a direct lateral approach has also been described (mostly used for the exploration of the radial nerve) and a medial approach for the exploration of the neurovascular structures on the medial side. Recently, approaches have also been described for MIPO of diaphyseal humeral fractures.124,172,188,195,270,326 
Anterolateral Approach.
The surgeon can use any part of this approach depending on the fracture location. The skin incision starts at the tip of the coracoid process and runs distally in line with the deltopectoral groove to the lateral aspect of the humerus at the deltoid insertion (Fig. 36-11A). From there, the incision continues distally following the lateral border of the biceps until about 5 cm proximal to the flexion crease of the elbow joint. 
Figure 36-11
Anterolateral approach to the right humerus.
 
A: Incision. B: Retraction of the deltoid laterally and the long head of biceps medially will reveal the tendon of pectoralis major proximally and brachialis more distal. C: Partial detachment of the tendon of pectoralis major and split of brachialis will expose the anterolateral humeral shaft.
A: Incision. B: Retraction of the deltoid laterally and the long head of biceps medially will reveal the tendon of pectoralis major proximally and brachialis more distal. C: Partial detachment of the tendon of pectoralis major and split of brachialis will expose the anterolateral humeral shaft.
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Figure 36-11
Anterolateral approach to the right humerus.
A: Incision. B: Retraction of the deltoid laterally and the long head of biceps medially will reveal the tendon of pectoralis major proximally and brachialis more distal. C: Partial detachment of the tendon of pectoralis major and split of brachialis will expose the anterolateral humeral shaft.
A: Incision. B: Retraction of the deltoid laterally and the long head of biceps medially will reveal the tendon of pectoralis major proximally and brachialis more distal. C: Partial detachment of the tendon of pectoralis major and split of brachialis will expose the anterolateral humeral shaft.
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At the proximal part of the approach division of the superficial fascia will reveal the cephalic vein which runs within the deltopectoral groove. The humerus is then approached by retracting the deltoid laterally and the pectoralis major medially (Fig. 36-11B). Care must be taken not to apply excessive retraction to the deltoid as this may cause compression injury to the axillary nerve and paralyze the anterior half of the muscle. The periosteum lateral to the tendon of the long head of biceps is then incised and the insertion of the pectoralis major is detached from the lateral aspect of the bicipital groove. The anterior circumflex artery will be encountered during the deep dissection and should be ligated. 
In the middle third the deep fascia is incised in line with the skin incision and the biceps is mobilized medially to expose the brachialis muscle that covers the anterior humerus. The brachialis is split longitudinally in the midline to expose the anterior humeral diaphysis. A midline incision in brachialis protects the innervation of the muscle provided by the radial nerve laterally and musculocutaneous nerve medially (Fig. 36-11C). Exposure can be facilitated by flexion of the elbow. The radial nerve is protected more proximally by the lateral half of the brachialis muscle. Closer to the elbow the radial nerve on the lateral aspect and the musculocutaneous nerve medially should be protected as the approach continues between the brachialis medially and the brachioradialis laterally. 
Posterior Approach.
The posterior approach exposes the distal two-thirds of the posterior humeral shaft from the olecranon fossa to the junction of the proximal and middle thirds of the humerus. The patient is positioned in the prone or lateral position with the arm abducted 90 degrees on a radiolucent support. The incision is longitudinal in the midline of the posterior aspect of the arm from the tip of the olecranon to about 5 to 10 cm distal to the acromion (Fig. 36-12A). The dissection begins at the proximal end of the incision where the interval between the long and lateral head of the triceps is identified and developed by blunt dissection. The common tendon of the triceps muscle should be incised sharply in the midline, as it runs distally and inserts into the olecranon. Retraction of the lateral head of triceps laterally and the long head medially, at the proximal part of the incision, will reveal the radial nerve and the profunda brachii artery as they run together in the spiral groove (Fig. 36-12B). The medial head of the triceps is deep to the lateral and long heads and originates just distal to the spiral groove. Longitudinal midline dissection will reveal the periosteum of the posterior humeral shaft. Incision of the periosteum and its retraction will give access to the distal humerus and also will protect the radial, ulnar, and the lateral brachial cutaneous nerves (Fig. 36-12C). 
Figure 36-12
Posterior approach to the distal humerus.
 
A: Skin incision. B: Development of the interval between the long and lateral heads of triceps will reveal the radial nerve as it emerges within the spiral groove. C: Longitudinal midline dissection of the medial head of triceps will reveal the periosteum of the posterior humeral shaft.
A: Skin incision. B: Development of the interval between the long and lateral heads of triceps will reveal the radial nerve as it emerges within the spiral groove. C: Longitudinal midline dissection of the medial head of triceps will reveal the periosteum of the posterior humeral shaft.
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Figure 36-12
Posterior approach to the distal humerus.
A: Skin incision. B: Development of the interval between the long and lateral heads of triceps will reveal the radial nerve as it emerges within the spiral groove. C: Longitudinal midline dissection of the medial head of triceps will reveal the periosteum of the posterior humeral shaft.
A: Skin incision. B: Development of the interval between the long and lateral heads of triceps will reveal the radial nerve as it emerges within the spiral groove. C: Longitudinal midline dissection of the medial head of triceps will reveal the periosteum of the posterior humeral shaft.
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A variation of the standard posterior approach is the “triceps-sparing” or “paratricipital” approach that provides good exposure to the distal humerus posteriorly, avoids injury to the triceps muscle with less risk of denervating a portion of the triceps or the anconeus, and therefore, may improve postoperative elbow function. Although most commonly used at the elbow proximal extension of this exposure is possible, particularly on the lateral side, by mobilizing the radial nerve and elevating the triceps off the humerus. 
In a cadaveric study the location of the radial nerve was defined during the posterior approach to the humerus.274 The posterior anatomic location of the radial nerve was found to be 39 ± 2.1 mm from the point of confluence between the long and lateral heads of the triceps and the triceps aponeurosis. This information should assist surgeons in identifying the radial nerve especially if they are not familiar with the specific anatomic area. 
Lateral Approach.
The lateral approach extends from the deltoid insertion along the humeral diaphysis to the lateral epicondyle and can be extended proximally either anteriorly along the anterior border of the deltoid or posteriorly in a triceps-splitting exposure. The patient is positioned supine, and the humerus is approached through the interval between the lateral intermuscular septum and the triceps. The radial nerve can be found within the fat immediately adjacent to the triceps as it emerges from behind the humerus and can be followed between the brachialis and brachioradialis in the anterior compartment of the arm (Fig. 36-13). It can be mobilized by releasing the lateral intermuscular septum and its retraction will expose the distal two-thirds of the humerus. 
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Figure 36-13
The lateral approach to the humeral diaphysis.
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Anteromedial Approach.
This approach is rarely chosen for routine fracture fixation but provides access to the brachial artery and median and ulnar nerves and is mainly used in cases of injury to these important neurovascular structures.50,140 The surgical incision runs along the medial margin of the biceps and is directed to the medial epicondyle. The subcutaneous tissue is incised in line with the skin incision. The ulnar nerve is identified underneath the superficial fascia and is retracted posteromedially. The median nerve and brachial artery are identified and retracted anterolaterally. Within the surgical field there are many small branches of the artery that require ligation. The medial intermuscular septum can be partially resected to improve bone exposure and facilitate plate application. The triceps is stripped from the shaft and reflected posteriorly as required, and the coracobrachialis is reflected anteriorly (Fig. 36-14). Apart from the excellent exposure of the medially located neurovascular structures, this approach is good cosmetically as the scar is well hidden on the medial side of the arm. However, because there are so many neurovascular structures that have to be identified and protected and proximal extension is difficult, the approach is rarely used. 
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Figure 36-14
The anteromedial approach to the humeral diaphysis.
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Technique for Open Reduction and Internal Fixation.
Regardless of fracture location and surgical approach, ORIF of a diaphyseal humeral fracture follows the guidelines set by AO/ASIF many years ago.202 It is of paramount importance that, during dissection, care should be taken not to devitalize any bony fragments by avoiding excessive soft tissue or periosteal stripping. Reduction of fracture fragments to their anatomical position is not obligatory if this could cause devascularization that could lead to necrosis and bone healing problems. Therefore, accurate reduction that requires direct manipulation of the fracture fragments should be done mainly for the reduction of the main fragments and with minimal soft tissue stripping. Other fracture fragments should be reduced indirectly which can be accomplished with the use of either manual traction or an external fixator or distractor. Reduction of the fracture, once obtained, can be temporarily maintained with reduction forceps or K-wires. If the temporary reduction is maintained with the use of reduction forceps, if possible, the plate should be applied to the bone first and used as an indirect reduction tool because it may not be possible to apply it to the bone with reduction forceps in situ. Alternatively, if K-wires are used for maintaining a temporary reduction, care should be taken to insert the wires so that they do not interfere with the placement of the plate. 
For diaphyseal humeral fractures the traditional 4.5-mm narrow dynamic compression plate (DCP) or the more recent limited contact dynamic compression plate (LC-DCP) is used.250 There should be a minimum of three to four holes proximal and distal to the fracture (Fig. 36-15A, B). In simple fractures an 8- to 10-hole plate should be sufficient, while in comminuted fractures it is recommended that the plate should span the area of comminution (bridging plate) requiring longer plates. In the past, the 4.5-mm DCP was used in the humerus, as its configuration permitted insertion of staggered screws. However, for patients with a narrow humerus the 4.5-mm narrow DCP is preferred, as its screws can be inserted divergently and achieve a similar effect. LC-DCP plates can also be used as they are easier to contour and offer the additional advantages of decreased stress shielding and preservation of blood supply of the periosteum because of the limited plate–bone contact.224 
Figure 36-15
 
A: Transverse fracture of the mid-distal humeral diaphysis. B: Fixation with traditional plating technique.
A: Transverse fracture of the mid-distal humeral diaphysis. B: Fixation with traditional plating technique.
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Figure 36-15
A: Transverse fracture of the mid-distal humeral diaphysis. B: Fixation with traditional plating technique.
A: Transverse fracture of the mid-distal humeral diaphysis. B: Fixation with traditional plating technique.
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Depending on the fracture site, the plate may need to be precontoured which is easiest with the use of special flexible templates that most manufacturers provide. If reduction has not been achieved prior to plate application the plate is applied to the bone on one side of the fracture and the other side is aligned with its longitudinal axis. It is then provisionally secured to the bone with reduction clamps and fixed in this position with one screw. The next step is to reduce the fracture by aligning the bone on the other side of the fracture with the plate. If the alignment is satisfactory, the unsecured end of the plate is clamped to the bone. Care should be taken with the use of reduction clamps not to injure any of the neurovascular structures, which in the humerus may be close to the bone. Alignment is confirmed, either visually or with the image intensifier, and the remainder of the screws can be inserted. In cases with a simple fracture pattern the plate should be applied in compression, with the use of either self-compressing holes in a DCP or lag screws. The final reduction and the plate and screw lengths are confirmed with the image intensifier prior to wound closure. If the fixation involved the exploration of a nerve that was nearby or crossing the plate (for instance, the radial nerve during the posterior approach), the exact relationship of the nerve to the plate must be confirmed and recorded to avoid inadvertent placement of the plate on the nerve and reduce the risk of accidental nerve damage during plate removal at any time in the future (Table 36-10). 
Table 36-10
Surgical Steps for Open Reduction and Internal Fixation of Diaphyseal Humeral Fracture
Surgical Steps
  •  
    Expose the humeral diaphysis through the selected approach
  •  
    Identify and protect neurovascular structures that are nearby or cross the surgical field
  •  
    Avoid soft tissue or periosteal stripping
  •  
    Reduce the fracture manually by traction
  •  
    Apply external fixator or distractor across the fracture to maintain reduction if required
  •  
    Reduce the fracture and provisionally stabilize with reduction forceps or K-wires. Use the plate as indirect reduction tool
    •  
      Avoid iatrogenic damage to the nerves and vessels with the reduction forceps
  •  
    Implant of choice is the 4.5-mm narrow dynamic compression plate or the 4.5-mm low-contact plate
  •  
    Secure the plate provisionally with one or two screws in each main fragment, check reduction and alignment, then proceed to insert the remainder of the screws
  •  
    Avoid screws in areas of comminution
  •  
    Confirm fracture reduction and plate/screw length with image intensifier prior to wound closure
X
The number of screws required on either side of the fracture remains controversial and, among other parameters, depends on the fracture pattern and location, the length of the plate, and the bone quality. Although there have not been substantive studies to investigate this issue, most surgeons would agree that, without a lag screw, at least four screws (eight cortices) proximally and distally to the fracture are required while the presence of a solid lag screw could reduce the number of screws to three (six cortices) proximally and three screws (six cortices) distally. Fracture comminution, poor screw purchase, poor bone quality, or other negative factors should prompt longer plate application with more screws.193 
Locking compression plates (LCPs), in which screws with threaded heads can be screwed into the plate holes to create a fixed-angle implant, appeared at the beginning of the 21st century. Regarding the use of LCPs in the treatment of diaphyseal humeral fractures an initial biomechanical study did not demonstrate any obvious biomechanical benefit in comparison with nonlocking plates.211 However, subsequent biomechanical studies not only reported that locking plates provide improved mechanical performance over nonlocking plates in osteoporotic cadaveric fracture models62 but also that only two locking screws for each main bony segment provide adequate stability.109 The clinical studies by Ring et al.245 and Spitzer et al.284 confirmed the usefulness of locking plates in the management of difficult fractures and nonunions of the humeral diaphysis. 
Fractures of the distal humeral diaphysis, close to the metaphyseal area, have received special attention because of the “difficult” anatomy of the elbow and the many nearby neurovascular structures (Fig. 36-16). Levy et al. recognized that traditional centrally located posterior plates often encroach on the olecranon fossa, limiting distal osseous fixation. They proposed the use of a modified tibial plate that could allow posterior plating of the distal humeral diaphysis and angled to fit along the lateral column.161 Prasarn et al. addressed the same problem with the application of a lateral 2.7-mm or 3.5-mm pelvic reconstruction plate which reduced and fixed the fracture provisionally. This plate was contoured to extend along the lateral column proximally up to the humeral shaft and fixed in position with the necessary bicortical and lag screws. Having the fracture provisionally reduced and stabilized, a second more rigid plate was then applied posterolaterally.233 Spitzer et al. tried a “hybrid” plate containing 3.5-mm locking holes on one end and 4.5-mm locking holes on the other end in metadiaphyseal fractures of the proximal and distal humerus. They applied the side of the plate with the smaller diameter screws toward the metaphysis to obtain more screws within the short bone segment, and they reported excellent results. Although interesting, all these proposals need further validation.284 
Figure 36-16
 
A: Fracture of the distal humeral diaphysis. B, C: Fixation with a posterolateral plate that allows screw fixation of the lateral column.
A: Fracture of the distal humeral diaphysis. B, C: Fixation with a posterolateral plate that allows screw fixation of the lateral column.
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Figure 36-16
A: Fracture of the distal humeral diaphysis. B, C: Fixation with a posterolateral plate that allows screw fixation of the lateral column.
A: Fracture of the distal humeral diaphysis. B, C: Fixation with a posterolateral plate that allows screw fixation of the lateral column.
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Surgical Approaches for Minimally Invasive Plate Osteosynthesis (MIPO).
Within the first decade of the 21st century percutaneous plate fixation of humeral shaft fractures using two or three small incisions has been reported, similar to the technique described for lower limb long-bone fractures.6,282 
The technique is mostly used for fractures located around the middle portion of the humerus and uses two incisions, one proximal and one distal. The proximal incision is 3 to 5 cm in length and lies between the lateral border of the proximal part of the biceps and the medial border of the deltoid. The distal incision is also 3 to 5 cm in length and is made along the lateral border of the biceps 5 cm proximal to the elbow crease. The interval between biceps and brachialis is identified and care is taken to avoid injury to the musculocutaneous nerve (Fig. 36-17A). The brachialis is split longitudinally in the midline. The musculocutaneous nerve is retracted with the medial half of the brachialis while the radial nerve is protected by the lateral half of the brachialis. A cadaveric study by Apivatthakakul et al.7 confirmed previous data that the musculocutaneous nerve is at risk by a “small” distal approach and the authors advise full supination of the forearm and an open approach to identify and protect the nerve. Recently, some studies have reported placement of the plate laterally with two or three incisions. The proximal incision is made 3 to 5 cm below the acromion and the distal 2 to 3 cm between the brachioradialis and brachialis muscles at the distal humerus. A middle window has been proposed at the level of the middle segment of the humerus to facilitate the passage of the plate between the biceps and triceps muscles. Leaving a thin layer of muscle beneath the plate is recommended to avoid direct contact between the radial nerve and the plate.134,282 
Figure 36-17
The anterior approach for minimally invasive plate osteosynthesis.
 
A: The proximal and distal windows. B: Insertion of the plate is facilitated with the use of a tunneling instrument.
A: The proximal and distal windows. B: Insertion of the plate is facilitated with the use of a tunneling instrument.
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Figure 36-17
The anterior approach for minimally invasive plate osteosynthesis.
A: The proximal and distal windows. B: Insertion of the plate is facilitated with the use of a tunneling instrument.
A: The proximal and distal windows. B: Insertion of the plate is facilitated with the use of a tunneling instrument.
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Technique for Minimally Invasive Plate Osteosynthesis.
After the soft tissue preparation is completed in the proximal and distal windows an extraperiosteal tunnel is opened along the surface of the humerus to prepare the insertion of the plate. Apivatthakakul et al.8 proposed that after the exit of the tunneling instrument from the near window, the selected plate should be tied with a suture to a hole at the tip of the tunneling instrument. Withdrawal of the tunneling instrument will pull the plate toward the far window, along the track that it has created (Fig. 36-17B). When the position of the plate is confirmed with the image intensifier, it is secured in one of the two main fragments with a bicortical screw. Under constant x-ray and visual control to avoid axial and rotational malalignment, the plate is aligned with the other main fragment and is secured with a bicortical screw. After verification of the correct positioning of the plate and the fracture reduction including restoration of length and rotational alignment of the humerus, the remaining proximal and distal screws are inserted. Final reduction and plate and screw lengths are confirmed with image intensifier prior to wound closure (Table 36-11). 
Table 36-11
Surgical Steps for Minimally Invasive Plate Osteosynthesis of Diaphyseal Humeral Fracture
Surgical Steps
  •  
    Expose the proximal and distal “windows” through the selected approach (anterior/lateral)
  •  
    Identify and protect neurovascular structures that are nearby or cross the surgical field (musculocutaneous nerve anteriorly, radial nerve laterally)
  •  
    Reduce the fracture manually by traction
  •  
    Apply external fixator or distractor across the fracture to maintain reduction
  •  
    Create an extraperiosteal tunnel alongside the surface of the humerus
  •  
    Use the tunneling instrument to align and position the plate on the humerus
    •  
      Avoid iatrogenic damage to the nerves and vessels with the tunneling instrument or the plate
  •  
    Implant of choice is the 4.5-mm narrow dynamic compression plate or the 4.5-mm low-contact plate
  •  
    Secure the plate provisionally with one screw in one main fragment, reduce fracture, and secure the plate with a screw to the other main fragment. Check reduction and alignment, then proceed to insertion of the remainder of the screws
  •  
    Check screw insertion and screw length with the image intensifier regularly
  •  
    Avoid screws in areas of comminution
  •  
    Confirm fracture reduction and plate/screw lengths with image intensifier prior to wound closure
X
Utilization of a lateral placement of the plate with the MIPO technique follows the same basic steps of the anterior approach. However, extra care should be taken to protect the radial nerve which is vulnerable with this approach.134,282 
Postoperative Care.
Postoperatively, patients treated by either ORIF or MIPO should have their arm placed in a collar and cuff support. Those with stable internal fixation can begin physiotherapy 2 to 3 days after the operation with shoulder and elbow movements, as tolerated. While most surgeons do not allow other than simple ROM exercises for 3 to 4 weeks, Tingstad et al.296 reported no significant differences in malunion and union rates in patients who progressed with immediate weightbearing of the arm and those who did not, following plating of a diaphyseal humeral fracture. Regarding the MIPO procedure Apivatthakakul et al. suggested that when the fixation has been accomplished by only two screws in any fragment, flexion and extension of the elbow and pendulum exercises of the shoulder should be allowed, but rotation of the arm should start after the appearance of visible callus formation, usually after 6 weeks.8 
Potential Pitfalls and Preventative Measures.
One of the major issues that can affect treatment outcome with ORIF of a diaphyseal humeral fracture, before even fracture reduction and fixation, is the stripping and devitalization of bone fragments during the surgical approach. It is imperative that the bone fragments, especially free large bony segments, should be protected during dissection, and unnecessary bone stripping must be avoided. Another pitfall that could delay or inhibit bone healing is the inadequate reduction of the fracture. Although fracture reduction does not have to be anatomical in the humerus, lack of bone contact or a gap at the fracture site has a poor prognosis for union. Bone defects up to 2 to 3 cm should be dealt with shortening, as the arm can accommodate small discrepancies without functional consequences. Larger bone defects should be bridged with bone grafting, preferably autologous. The fixation technique must provide adequate stability with the plate being strong (4.5 mm DCP) and long enough to allow at least four holes and three to four screws in each main fragment although not every screw hole has to be filled. Additional screws (e.g., lag screws) that enhance stability can be used. As a general principle, the chosen plate for the fixation should be positioned symmetrically to allow an equal number of screws on both sides of the fracture. Therefore, ORIF of distal humeral fractures could require screw placement in one or both condyles or even double plating to provide the necessary stability to the fracture. Iatrogenic injury to neurovascular structures and most particularly to the radial nerve as it runs around the humerus must be avoided by identifying and protecting the neurovascular structures in most approaches. Apart from direct injury to the radial nerve during dissection, it should be noted that cerclage wiring or drills and screws inserted from the opposite cortex can also injure the nerve (Table 36-12). 
Table 36-12
Potential Pitfalls and Preventions for Plating Diaphyseal Humeral Fractures with Open Reduction and Internal Fixation
Pitfalls Preventions
Excessive soft tissue and periosteal stripping Familiarity with the anatomy of the arm
Careful dissection
Unacceptable fracture reduction Adequate surgical exposure
Use the image intensifier
2–3 cm of shortening is acceptable in the humerus
Bone graft for larger gaps
Unstable fixation 4.5 mm dynamic compression plate
3–4 screws in each main fragment
Use lag screws, if feasible
Incorporate the condyles in the fixation or double plate distal humeral fractures
Iatrogenic neurovascular injury Careful dissection
Identify and protect nearby nerves/vessels
Avoid excessive retraction
Avoid cerclage wiring
Be careful with drills and screws from the opposite cortex
X
MIPO shares many of the pitfalls described for the open plating technique, such as problems from inadequate reduction, fixation, and intraoperative neurovascular injury. Although reduction of a transverse fracture is a straightforward step during open plating it can be difficult with the closed technique. Transverse fractures must be brought out to length otherwise they will unite with an angular deformity. The musculocutaneous nerve must be identified and protected in the distal anterior window before splitting the brachialis. MIPO should not be used for fractures associated with radial nerve palsy preoperatively because the risk of further injury to the nerve is substantial. Pointed retractors must not be used because the tips can injure the radial nerve either on the medial side of the proximal incision or on the lateral side of the distal incision. AP drilling and bicortical screw insertion should be avoided in the middle third of the humerus because of the high risk of radial nerve injury (Table 36-13). 
Table 36-13
Potential Pitfalls and Preventions for Plating Diaphyseal Humeral Fractures with the MIPO Technique
Pitfalls Preventions
Unacceptable fracture reduction Use the image intensifier
Bring the fracture out to length with traction
Slight shortening of comminuted fractures is acceptable
Unstable fixation 4.5-mm dynamic compression plate
2–4 screws in each main fragment
Iatrogenic nerve injury Identify and protect the musculocutaneous nerve with the anterior approach and the radial nerve with the lateral approach
Avoid excessive retraction and pointed retractors
Avoid anteroposterior drilling and bicortical screw insertion in the middle third of the humerus
CRIF in the presence of radial nerve palsy Exclude by good clinical examination prior to surgery
X
Treatment-Specific Outcomes.
The efficacy of a treatment method is evaluated by careful review of a number of parameters, which include the nature of intervention (aggressive/minimal), intraoperative and immediate postoperative incidents and adverse events, iatrogenic hazards, potential problems and complications during the rehabilitation period, the time needed for the patient to achieve the best outcome, and the quality of life at the end of treatment. These must be under constant review to assess not only the effectiveness of a specific treatment method but also to allow comparison with alternative treatment options. 
Open Reduction and Internal Fixation.
Plating has been regarded as the surgical treatment of choice for diaphyseal humeral fractures. It is associated with a high, uncomplicated union rate, minimal shoulder or elbow morbidity, and rapid return to previous activities. It can be used in periarticular fractures and has been successfully used in open fractures.19,86,104,185,188,191,267,307 Outcomes of plating have been published in many studies during 70s and 80s. However, development of new techniques for plating “difficult” fractures, modern implants (e.g., locking plates), and MIPO have been evolving in recent years and will be reviewed in this section. 
An important target of all treatment methods for fractures is fracture union. The union rate of ORIF of humeral shaft fractures exceeded 95% in most clinical studies over the last few decades.19,86,115,191,307 Complications were infrequent and included radial nerve palsy (2% to 5%, usually neurapraxia) and infection (1% to 2% for closed fractures, 2% to 5% for open fractures). However, at the turn of the century, Paris et al.220 tempered the enthusiasm for the technique when they reported a large series of 156 patients (21 with polytrauma) who were treated with ORIF. The union rate was 87% with eight postoperative transient radial nerve palsies, two deep infections, and 10 implant-related revisions. While 88% of the patients were satisfied with their outcome, only 54% obtained complete anatomical and functional recovery. Niall et al.206 restored the reputation of the technique by treating 49 diaphyseal humeral fractures (15 polytrauma injuries) with plating, 96% of which united in an average of 9 weeks. There were no major complications and all patients without significant comorbidities regained a full range of shoulder and elbow movements and returned to previous activities. Idoine et al.129 found a 94.7% union rate at an average of 16.9 weeks in a large series of 96 polytrauma patients with humeral shaft fractures. The authors used an anterior approach but in two-thirds of the patients the plate was applied on the medial side of the humerus by retracting the biceps laterally. 3.5 mm plates were used in most cases because the authors stated that there was not enough biomechanical evidence to justify the use of larger, stiffer plates. However, they experienced four implant failures within 3 months of surgery along with two infections and two incidences of iatrogenic injury to the lateral antebrachial cutaneous nerve. Bearing in mind that the patients were polytraumatized the functional results can be considered satisfactory, as 80.2% regained within 10 degrees of the full range of shoulder motion barring flexion where only 60.5% regained an almost full range. All patients regained elbow ROM to within 10 degrees compared to the contralateral elbow while the median DASH score was 23.8 (0 to 79). Levy et al.161 used a modified 4.5-mm tibial head buttress plate to treat 12 patients with distal third diaphyseal humeral fractures. They proposed that such a plate design accommodates the anatomy of the distal humerus better and provides more stable fixation. Prasarn et al.233 described the addition of a 2.7/3.5 mm pelvic reconstruction plate laterally that can serve as a reduction tool prior to the insertion of a precontoured extra-articular distal humeral locking plate with a “hockey stick” distal configuration, similar to that described previously by Levy et al.161 They treated 15 patients with the dual plate fixation and only one patient complained of tenderness over the distal posterolateral humerus and underwent implant removal. A further study exploited the potential advantages provided by modern implants and tried a “hybrid” locking plate, that could provide 4 to 5 mm screws for the longer fragment segment and 3.5 mm screws for the shorter one, in a cohort of 24 patients with proximal and distal metaphyseal recent fractures and nonunions.284 All recent fractures (14) united in an average of 19.5 weeks (13 to 26) with one iatrogenic transient radial nerve palsy as the sole complication. The patients managed a mean of 145 degrees of forward elevation of the shoulder and 138 degrees of total elbow ROM. 
Apart from case series, the outcome of treating humeral shaft fractures with plating has been investigated in studies that compared the technique with alternative treatment methods. Three studies have compared plating with intramedullary nailing.38,41,187 The results of the comparison will be discussed below but the outcomes of plating are of the interest to this discussion. In all three studies a total of 92 patients were treated with plating. The union rate was 92.4% (85/92) and the average time to union was similar for the two studies that provided the relevant information (10.4 weeks for Chapman et al. and 8.9 weeks for Changulani et al.). One incident of iatrogenic transient radial nerve palsy and three to five infections occurred in each of those two studies respectively. All three studies reported satisfactory clinical outcomes. Similar results of the ORIF technique were reported in two studies that compared traditional plating with the newly introduced MIPO.135,214 From 46 fractures that were included in the two studies and treated with traditional plating 43 united with an average time to union of 16.7 and 21.3 weeks for Oh et al. and Jiang et al., respectively. It is important to mention that the latter study reported five incidences of postoperative radial nerve palsy, that all recovered spontaneously from 12 to 52 weeks. Otherwise, both studies confirm the good radiologic and functional outcomes of ORIF in the treatment of humeral shaft fractures. 
An under-reported outcome of plating diaphyseal humeral fractures is the ability of patients to immediately bear weight on their injured arm. Tingstad et al.296 investigated this parameter by studying 83 humeral diaphyseal fractures (70 in polytrauma patients) which were treated in a 10-year period with ORIF, 86% with 4.5-mm DC plates. The postoperative weight-bearing status of the involved humerus was decided on the basis of the presence or absence of a lower extremity injury that required restricted weightbearing and not on the basis of the humeral fracture pattern or comminution. Apart from a high union rate (94%) and low complication rate, the main outcome from this study was that ORIF of a diaphyseal humeral fracture followed by immediate weightbearing through the involved humerus is a safe procedure. 
Review of older and more modern studies of the treatment of diaphyseal humeral fractures with ORIF revealed that the reported outcomes can be categorized in two groups: 
• Principal outcomes that are provided by all studies and offer the basis for evaluation, comparison, and conclusions. These include fracture union rate, time to union, and complications. Restoration of joint motion and functional results fall within an intermediate grey zone with some studies providing adequate information and others not. 
• Nonprincipal outcomes, such as duration of the operation, blood loss, timing of initiation and duration of physiotherapy, hospitalization, return to previous activities, and patient-related outcomes, are not provided by many studies. However, these outcomes can offer substantial information that could significantly influence the overall opinion regarding the quality and efficacy of a treatment method and should be reported in modern studies. Otherwise critical evaluation of the effectiveness of any treatment will be incomplete. 
Minimally Invasive Plate Osteosynthesis (MIPO).
Adopted from the technique initially introduced for femoral and tibial fractures, the MIPO has also been utilized for the treatment of diaphyseal humeral fractures. The humerus, however, has complicated anatomy and MIPO has been considered risky for the neurovascular structures and in particular for the radial and musculocutaneous nerves. Although there has been skepticism about the use of the technique in the humerus, studies that have appeared in the last few years have dealt with the problematic technical issues to develop a useful and safe MIPO technique suitable for humeral shaft fractures. 
Livani and Belangero172 reported the use of MIPO in the treatment of 15 patients with humeral shaft fractures, 8 of which were polytraumatized. They used 4.5 mm DC plates with two screws in each main fragment and they reported only one screw loosening. They also encountered one superficial infection and one nonunion. The healing time for the united fractures ranged from 8 to 12 weeks and all but two patients regained full range of elbow motion. Subsequent studies also included small number of patients apart from one by Concha et al. that included 35 patients.8,49,134,135,148,231,324 All these studies had good outcomes with few complications. More specifically, four of these studies described the management of a total of 60 humeral shaft fractures between them with an anterior minimally invasive technique.49,135,148,231,324 They all used 4.5 mm plates. Union rate was 96.6% (58/60) in an average of 15 weeks (11 to 32). As one of the theoretical advantages of MIPO in the humerus is the reduced operating time in comparison with ORIF, this parameter was provided by three of the four studies that reported very similar operating times (117.5, 127.6, and 113.8 minutes, respectively).135,148,324 Two of the studies provided information about the blood loss that was 170 mL and 490 mL on average.135,148 Significant complications did not occur in these studies and the patients were instructed to start movements of their injured arm as early as tolerated. All patients regained an excellent ROM of their shoulder and elbow. Concha et al.49 presented the largest series of 35 patients, 15 of which were polytraumatized. They used MIPO with two screws on each side of the fracture. Union rate was 91.5% (32/35) at an average of 12 weeks (8 to 16). The authors reported some complications that included two infections and three cases of varus malunion of more than 15 degrees. They also reported that only 20/32 patients had full extension of the elbow and 20/32 patients obtained 130 degrees of flexion. While it was concluded that MIPO is a safe and efficient procedure for humeral shaft fracture treatment, with high union and low complication rate, it was noted that elbow flexion contracture could be a problem and might indicate the need for a formal elbow rehabilitation protocol. 
Ji et al.134 used the MIPO technique to treat distal humeral shaft fractures via a lateral approach as they found the anterior approach unsuitable for proximal and middle third fractures because of the anatomical restrictions of the anterior surface of the distal humerus. They initially tried the approach in 14 cadaveric arms and subsequently treated 23 humeral shaft fractures with 4.5 mm LCPs. All fractures showed bridging callus at an average time of 6.3 weeks (4 to 11). The only information about the clinical recovery was that “the function and ROM of the shoulder and elbow joints were satisfactory” but one patient developed a postoperative radial nerve palsy. Spagnolo et al.282 had similarly good outcomes with the use of MIPO (4.5 mm LCP) in 16 patients with humeral shaft fractures and the lateral approach. The authors described the lateral approach to the humerus with three windows: One proximal, through the deltoid for the insertion of the plate, a second in the middle for facilitating the passage between the biceps and triceps muscles, and the third distally for the direct visualization of the radial nerve and the distal end of the plate. All fractures healed at 14.9 weeks on average (11 to 20). Good functional recovery was reported with excellent UCLA scores in 62.5% and good in 37.5%, and excellent Mayo scores in all of the patients. There were no neurovascular complications. According to these two studies the lateral approach is advantageous because it can accommodate fractures of the proximal and distal humerus without significant risks of injury to the radial nerve if precautions are taken such as the supination of the forearm during the procedure, visualization of the radial nerve (as proposed by Spagnolo et al.), and no screw insertion close to the nerve. 
As the main reason for caution with the use of MIPO for humeral shaft fractures is the risk of neurologic damage from the plate and screws, ultrasound has been used to investigate the relationship between the radial nerve and the implants.172 In a group of 19 patients who had undergone MIPO fixation of humeral shaft fracture, it was found that regardless of the location of the fracture (middle or distal thirds of the humeral diaphysis), the radial nerve is in close proximity to the implants (plate or screws). This distance was measured between 1.6 and 19.6 mm (mean 9.3 mm) for midshaft fractures and between 1 and 8.1 mm (mean 4 mm) for distal fractures. In a cadaveric study the danger zone for locking screw placement in MIPO of humeral shaft fractures was examined and the authors concluded that the danger zone for the musculocutaneous and radial nerves could be determined as a percentage of the humeral length.7 The danger zone for the musculocutaneous nerve averaged 18.37% to 42.67% of the humeral length from the lateral epicondyle. The danger zone for the radial nerve averaged 36.35% to 59.2% of the humeral length, and the most dangerous screws that penetrated or touched the radial nerve lay 47.22% to 53.21% of the humeral length from the lateral epicondyle. An AP locking screw placed percutaneously endangered both the musculocutaneous and radial nerves. 
Both studies revealed that despite clinical evidence that the MIPO technique is safe in the treatment of diaphyseal humeral fractures, the risk for injury to radial and musculocutaneous nerves is substantial and should not be underestimated. 

Intramedullary Nailing

Preoperative Planning.
Preoperative planning for intramedullary nailing of a diaphyseal humeral fracture is no different from what was described previously for plating. However, it should be reiterated that the patient must be fully informed about the nature, expected outcomes, and potential complications of the operation while the anesthetist should be fully involved in the whole process of preoperative assessment and planning, because each surgical technique (e.g., antegrade or retrograde nailing) requires a different anesthetic approach. 
The main preoperative planning starts with at least two x-ray views of the whole humerus, one neutral AP and one lateral. In most cases, no further imaging studies should be required. Preoperative measurement of the humeral length and the width of the narrowest part of the intact humeral canal (taking into account the magnification on the x-ray) will help to determine the desired nail length and diameter. Whenever fracture lines extend toward the shoulder or elbow joints further x-ray views, centered in the suspected area, may be needed. If there are still doubts about the integrity of the joints, a CT scan should be performed. 
Preoperative checking of operating room facilities and other actions that can facilitate the procedure, such as the drawing of the fixation, confirming implants and tools availability, and image intensifier working status, have been described in the relevant section regarding ORIF. As with ORIF, a checklist will allow better organization of the operating procedure and ensure immediate availability of the necessary equipment (Table 36-14). 
Table 36-14
Preoperative Planning Checklist for Intramedullary Nailing of Diaphyseal Humeral Fractures
1. Operating Theater
Operating Room Table
  •  
    Regular orthopedic
  •  
    Radiolucent arm support
  •  
    Forearm extension
  •  
    Other
2. Position/Positioning Aids
  •  
    Supine
  •  
    Prone
  •  
    Beach chair
  •  
    Lateral (right side up)
  •  
    Lateral (left side up)
  •  
    Positioning aids
3. Equipment
  •  
    Battery drill
  •  
    Guidewires of same length
  •  
    Humeral reamers
  •  
    Distal targeting device
  •  
    Bone graft instruments
  •  
    Large bone reduction tools
  •  
    Other
X-ray
4. Implants
  •  
    Long nails complete set
  •  
    Short nails complete set
  •  
    Locking screws
  •  
    K-wires
  •  
    Other
5. Other
X
Positioning.
Intramedullary nailing of diaphyseal fractures of the humerus can be performed either via the humeral head (antegrade nailing) or via the supracondylar area of the distal humerus (retrograde nailing). Each technique requires different patient positioning. 
Antegrade Nailing.
The patient is positioned supine with a padded support under the shoulder. The patient’s torso is on the operating table, while the injured arm overhangs the main table. Some surgeons prefer the “beach chair” position with the arm hanging on the side or supported by a forearm support while others prefer the patient supine or slightly inclined upward with the whole arm supported on a radiolucent arm support. The elbow, the humerus and the shoulder are within the sterile field. The location of the image intensifier varies, depending not only on personal preference but also on the width of the operating table and the concavity of the C-arm. I prefer the C-arm on the opposite side (Fig. 36-18), as it does not crowd the operating area. The anesthetist must be familiar with the procedure because the uninjured arm must be positioned next to the patient on the operating table and is not easily accessible. This problem is solved with line extensions that allow drug injection from a distance. If it is anticipated that the image intensifier will be on the opposite side, the compatibility of the C-arm curvature with the width of the operating table must be checked in advance to confirm that imaging of the overhanging injured arm is feasible. Care should also be taken to assemble the operating table in advance to avoid obstacles such as the leg of the table that may obstruct use of the image intensifier. 
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Figure 36-18
Positioning the patient for antegrade nailing.
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X
Retrograde Nailing.
The patient can be positioned either prone or in the lateral decubitus position. Prone positioning is generally preferred as it offers unobstructed viewing of the whole humerus. The image intensifier remains on the same side as the injured arm. The arm is positioned on a radiolucent support that must allow at least 100- to 110-degree elbow flexion, to facilitate insertion of the nail (Fig. 36-19). Correct rotational alignment is achieved in this position without further manipulation of the arm. If the general condition of the patient or any other reason does not allow prone positioning, it is possible to perform retrograde nailing of the humerus on the lateral decubitus position. However, visualization of the humerus with the C-arm is more difficult. It is of paramount importance to ensure preoperatively that good images of the humerus and shoulder can be obtained. 
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Figure 36-19
Positioning the patient for retrograde nailing.
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Surgical Approaches
Antegrade Nailing.
A 2- to 3-cm incision is made from the anterolateral edge of the acromion obliquely forward and the deltoid muscle is split longitudinally along its fibers to reveal the subacromial bursa and the rotator cuff (Fig. 36-20). Before incising the cuff the location of the entry portal of the nail should be verified with a blunt instrument and a single AP view on the image intensifier to minimize the possibilities of a poorly placed incision that will cause unnecessary damage to the rotator cuff (Fig. 36-21). This location ideally should be on the sulcus or toward its medial border. The rotator cuff is then incised in the direction of the supraspinatus fibers. Direct visualization of the humeral head is not necessary and should be avoided. The long head of biceps tendon can be palpated and protected. In most cases, the correct entry portal will bring the awl in direct contact with the acromion. The direction of the awl should be slightly oblique aiming toward the medial cortex of the humerus. In the infrequent case of a broad acromion the arm can be placed in a “downward hanging” position to access the humeral head anterior to the acromion or with the use of a small bone hook or lever the humeral head can be pulled laterally. Adduction of the arm to facilitate the access to the humeral head is usually unsuccessful, as the thorax does not allow sufficient adduction in the neutral position. Elevation of the arm to avoid the acromion moves the humeral head posteriorly and may also displace the fracture. 
Figure 36-20
The approach for the antegrade nailing.
 
A: Skin incision. B: Exposure of the rotator cuff.
A: Skin incision. B: Exposure of the rotator cuff.
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Figure 36-20
The approach for the antegrade nailing.
A: Skin incision. B: Exposure of the rotator cuff.
A: Skin incision. B: Exposure of the rotator cuff.
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X
Figure 36-21
Verification of the entry portal of the nail with a blunt instrument before incising the rotator cuff.
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These technical difficulties along with concerns about damage to the rotator cuff generated proposals for alternative approaches to the humeral head or “sophisticated” nail designs that aimed to bypass these problems. Stannard et al.285 described a lateral entry point just distal to the insertion of the rotator cuff and used an articulated nail that could accommodate such an eccentric introduction. Dimakopoulos et al.70 proposed a similar entry portal and used a rigid nail to treat a series of 29 patients with diaphyseal humeral fractures without any major complications regarding the approach. Others approached the humeral head through the rotator cuff interval with a rather extensive exposure of the proximal humerus.221,258 Despite the theoretical advantages of these approaches to the humeral head, they have not become popular. With the use of the lateral approach there are a number of possible reasons: Firstly the fear of iatrogenic fracture either on the medial humeral cortex or around the entry portal, secondly the difficulty of treating proximal humeral diaphyseal fractures, and finally the increased cost of the articulated nail and fears about the difficulties with removal. Regarding the approach through the rotator cuff interval, it seems that the extensive exposure of the proximal humerus compromises the concept of minimal invasiveness of the intramedullary nailing technique. 
Retrograde Nailing.
The patient is positioned prone, with the arm on a radiolucent support, as described for posterior plating (Fig. 36-19). The skin incision is 4 to 5 cm, longitudinal from the tip of the olecranon, extending in a proximal direction (Fig. 36-22). The fascia over the triceps tendon is incised longitudinally and the underlying tendon and muscle are split with blunt dissection in line with the skin incision until the olecranon fossa can be seen. As there are no vulnerable structures in the area, there are no variations of this approach. 
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Figure 36-22
The skin incision for retrograde nailing.
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Technique
Antegrade Nailing.
The entry portal for standard antegrade nailing is opened with the hand awl (Fig. 36-23A). More medial location of the entry portal would facilitate nail insertion but it is usually not possible because of the presence of the acromion. The hand awl must penetrate the humeral head for at least 4 to 5 cm to create the pathway for the guidewire in the case of a cannulated nail or for a solid nail. Most humeral nails are cannulated and a guidewire is used to facilitate the passage of the nail through the fracture site by closed means (Fig. 36-23B). The correct alignment of the arm is obtained by traction, supination of the forearm, and 90 degrees of elbow flexion applied and maintained by the assistant (Fig. 36-23C). A lateral view at the fracture site cannot be easily obtained in the humerus so the passage of the guidewire to the distal fragment can be confirmed with rotation of the arm by 40 to 50 degrees or allowing some angulation at the fracture site. Careful reaming of the humeral canal follows when required. Each nail manufacturer provides instructions for the selection of the most suitable nail size although it is prudent to ream to 1 to 1.5 mm larger than the nail. After the insertion of the nail to its final position it must be locked to provide adequate stability to the fracture and allow immediate mobilization (Fig. 36-23D–G). 
Figure 36-23
Antegrade nailing of a proximal diaphyseal humeral fracture.
 
A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
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A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
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Figure 36-23
Antegrade nailing of a proximal diaphyseal humeral fracture.
A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
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A: Opening the entry portal with the hand awl. B: Passage of the guidewire to the distal fragment. C: Reduction of the fracture before the passage of the nail. D: Nail passage to the distal fragment. E: Proximal interlocking. F, G: Freehand distal interlocking.
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The complex anatomy and unique biomechanical properties of the arm have created significant controversy regarding the “locking” feature of humeral nails. Use of drills and screws for the standard locking technique has an increased risk of neurovascular and/or musculotendinous injury. Furthermore, distal locking of an antegrade nail with the “freehand” technique is considered difficult because of the combination of three factors. 
  1.  
    A round and “slippery” distal humeral cortex
  2.  
    The small diameter of the locking nail hole
  3.  
    Difficult imaging
Apart from risking iatrogenic injury to vulnerable soft tissues, all these factors potentially increase radiation exposure, prolong operating time, and result in high rates of targeting failure. All these factors generated the making of humeral nails (that I call “bio” nails) that offer alternative options for distal interlocking but provide inferior biomechanical stability to the fracture site when compared with nails that use locking bolts distally (that I call “fixed” nails) (Figs. 36-24A–C and 36-25A–E).25,61,96,97,325 However, if we consider that functional bracing does not rigidly immobilize a humeral shaft fracture, it seems that the optimal stability that is provided by locking bolts in the humerus may not be vital for the healing process of humeral diaphyseal fractures. Nevertheless, the necessity of finding a new balance between stability and biology in fracture treatment has been emphasized recently225 but until this is achieved, the debate between supporters of “fixed” and “bio” humeral nailing continues. “Fixed” nailing supporters claim that optimal stability provided by the locking bolts allows faster rehabilitation and results in higher fracture union rates. The opponents claim that “bio” nailing eliminates neurovascular complications, reduces radiation, and reduces operating time, while the fracture healing process is not influenced.88,92,95,96,269 
Figure 36-24
“Fixed” nails.
 
A: Russell-Taylor nail. B: Unreamed Humeral nail. C: T2 nail.
A: Russell-Taylor nail. B: Unreamed Humeral nail. C: T2 nail.
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Figure 36-24
“Fixed” nails.
A: Russell-Taylor nail. B: Unreamed Humeral nail. C: T2 nail.
A: Russell-Taylor nail. B: Unreamed Humeral nail. C: T2 nail.
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Figure 36-25
“Bio” nails.
 
A: Seidel nail. B: Fixion nail. C: Marchetti-Vincenzi nail. D: True-Flex nail. E: Garnavos nail.
A: Seidel nail. B: Fixion nail. C: Marchetti-Vincenzi nail. D: True-Flex nail. E: Garnavos nail.
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Figure 36-25
“Bio” nails.
A: Seidel nail. B: Fixion nail. C: Marchetti-Vincenzi nail. D: True-Flex nail. E: Garnavos nail.
A: Seidel nail. B: Fixion nail. C: Marchetti-Vincenzi nail. D: True-Flex nail. E: Garnavos nail.
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After implantation of the nail, the locking process follows. While proximal interlocking for antegrade nails and distal interlocking for retrograde nails is uniformly straightforward through reliable targeting devices, distal interlocking of antegrade nailing or proximal interlocking of retrograde nailing each depends on the nail design. “Fixed” nails are locked with locking screws which are usually inserted with the “freehand” technique (Fig. 36-23F, G). Because of the difficulties with targeting some manufacturers provide long targeting devices but their success has not been consistent, possibly because of their long length and the narrow screw holes of humeral nails.93,97,197 Distal locking of “bio” antegrade nails or proximal locking for “bio” retrograde nails varies. Nail expansion (Seidel nail) or inflation (Fixion nail), activation of diverging rods (Marchetti nail), or a special design (True-Flex nail, Garnavos nail), have all been tried in an effort to improve the performance of intramedullary nailing in the humerus (Fig. 36-25A–E). 
Table 36-15
Surgical Steps for Antegrade Intramedullary Nailing of Diaphyseal Humeral Fracture
Surgical Steps
  •  
    Expose the subacromial bursa and the rotator cuff
  •  
    1-cm stab incision to the rotator cuff
  •  
    Open the entry portal of the nail with a hand awl
  •  
    Reduce the fracture under image intensifier control
  •  
    Pass the guidewire through the fracture to the distal fragment
  •  
    Ream the canal, if necessary
    •  
      Start reaming when the reamer is within the humeral head
    •  
      Avoid injuring the radial nerve with the reamer whenever the fracture is located at the middle/distal humeral diaphysis
    •  
      On withdrawal, stop reaming while the reamer is still within the humeral head
    •  
      Meticulous washing out the reaming by-products from underneath the rotator cuff
  •  
    Introduce the selected nail to its final position
    •  
      Maintain fracture reduction during the insertion of the nail
    •  
      Do not allow destruction at the fracture site
    •  
      Do not allow protrusion of the nail from the humeral head
  •  
    Lock the nail proximally with the use of a targeting device and distally according to the type of the nail (“fixed” or “bio”)
    •  
      Long targeting devices are not reliable
    •  
      Never leave a nail unlocked
    •  
      Avoid neurologic injury with the use of locking screws
X
At the end of the procedure the rotator cuff should be repaired. The deltoid muscle is sutured with one or two absorbable stitches and the superficial layers are closed as usual. Suction drainage is not necessary (Table 36-15). 
Retrograde Nailing.
The entry portal for retrograde nailing must accommodate the eccentric insertion of the nail into a narrow canal. It is usually formed by multiple drill holes which are connected with an osteotome and its dimensions should be at least 10 mm by 20 to 25 mm (Fig. 36-26A). It is important to smooth the edges of the entry hole and de-roof the bone at its proximal end with a burr to facilitate the insertion of the nail. Reduction of the fracture is then performed either with gentle manipulation or with the use of a reduction rod (“joystick”) under image intensifier control. If the nail is cannulated a guidewire is inserted and passed through the fracture site to the proximal fragment. As with antegrade nailing, reaming of the humeral canal is a controversial issue. However, as there are not any vulnerable structures in the posterior distal humerus, gentle reaming of the narrow distal humeral canal can be performed to ease the insertion of the nail. Care should be taken not to create an iatrogenic fracture at the supracondylar area either with aggressive reaming or with careless introduction of the intramedullary nail. The appropriate size of nail is introduced and advanced toward the proximal humerus (Fig. 36-26B, C). The proximal and distal interlocking procedures have been described above for antegrade nailing (Fig. 36-26D–F). The fascia of the triceps tendon is repaired and approximation of the fat tissue and the skin is performed as usual. Suction drainage is optional (Table 36-16). 
Figure 36-26
Retrograde nailing of a mid-distal diaphyseal humeral fracture.
 
A: The entry portal for the nail. B: Nail insertion. C: Nail passage to the proximal fragment. D: Final position and distal interlock under direct vision. E: Proximal interlock with freehand technique distal to the surgical neck for avoidance of iatrogenic injury to the axillary nerve. F: Good bone healing process at 8 weeks from surgery.
A: The entry portal for the nail. B: Nail insertion. C: Nail passage to the proximal fragment. D: Final position and distal interlock under direct vision. E: Proximal interlock with freehand technique distal to the surgical neck for avoidance of iatrogenic injury to the axillary nerve. F: Good bone healing process at 8 weeks from surgery.
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Figure 36-26
Retrograde nailing of a mid-distal diaphyseal humeral fracture.
A: The entry portal for the nail. B: Nail insertion. C: Nail passage to the proximal fragment. D: Final position and distal interlock under direct vision. E: Proximal interlock with freehand technique distal to the surgical neck for avoidance of iatrogenic injury to the axillary nerve. F: Good bone healing process at 8 weeks from surgery.
A: The entry portal for the nail. B: Nail insertion. C: Nail passage to the proximal fragment. D: Final position and distal interlock under direct vision. E: Proximal interlock with freehand technique distal to the surgical neck for avoidance of iatrogenic injury to the axillary nerve. F: Good bone healing process at 8 weeks from surgery.
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Table 36-16
Surgical Steps for Retrograde Intramedullary Nailing of Diaphyseal Humeral Fracture
Surgical Steps
  •  
    Expose the posterior supracondylar humeral cortex
  •  
    Open a 1 × 2 cm entry portal by connecting multiple drill holes with an osteotome
  •  
    Reduce the fracture under image intensifier control
  •  
    Pass the guidewire through the fracture to the distal fragment
  •  
    Ream the canal, if necessary
    •  
      Take care not to create a fracture at the supracondylar area with the reamers. Hand reaming is preferred
    •  
      Avoid injuring the radial nerve with the reamer whenever the fracture is located at the middle/distal humeral diaphysis
    •  
      Meticulous washing out of the reaming by-products
  •  
    Introduce the selected nail to its final position
    •  
      Take care not to create a fracture at the supracondylar area
    •  
      Maintain fracture reduction during the insertion of the nail
    •  
      Do not allow destruction at the fracture site
  •  
    Lock the nail distally with the use of a targeting device and proximally according to the type of the nail (“fixed” or “bio”)
    •  
      Long targeting devices are not reliable
    •  
      Never leave a nail unlocked
    •  
      Avoid neurologic injury from the use of locking screws
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Postoperative Care.
Thromboprophylaxis or antibiotics should not be necessary for uncomplicated, isolated, closed fractures. Postoperatively, patients should have their arm on a collar and cuff support. Passive flexion and abduction exercises of the shoulder and flexion and extension exercises of the elbow can commence on the second postoperative day. More active exercises should start after 10 to 15 days and rotational exercises should be instructed when soft callus is visible on radiographs.92,168,251,269 “Fixed” nailing is preferred for patients unable to walk to allow the use of crutches with an axillary support as soon as pain allows, generally within 2 to 3 weeks from surgery. Patients unable to walk who have been treated with “bio” nailing should postpone loading and the use of crutches until radiographic signs of fracture healing are evident.269 The physiotherapy program should be modified in patients with multiple injuries to accommodate the patient’s general condition and accompanying comorbidities.92 
In all cases the aim is to mobilize the shoulder and elbow joints as early as possible following the nailing procedure. Routine follow-up consists of radiographic and clinical assessment in the outpatient clinic at 4 to 6 week intervals until fracture healing. Thereafter, the follow-up visits must continue at 2 to 3 month intervals until the completion of functional recovery of the arm. 
Potential Pitfalls and Preventative Measures (Table 36-17).
Table 36-17
Potential Pitfalls and Preventative Measures for Intramedullary Nailing of Diaphyseal Humeral Fractures
General Pitfalls Preventions
Problems with the image intensifier Position the patient in such a way that metal items will not obstruct the viewing
If the image intensifier remains on the same side as the injured arm, allocate precisely the position of the assistant and scrub nurse and avoid contamination of the operating field by its volume
If the image intensifier remains on the opposite side of the injured arm (antegrade nailing) take care that it can pass underneath the operating table without obstacles (such as the table leg)
Not locking “fixed” nails distally in antegrade nailing or proximally in retrograde nailing “Bio” nails are better than unlocked “fixed” nails
Never try to incarcerate “fixed” nails within the humeral canal to avoid locking screws
Antegrade Nailing Pitfalls Preventions
Unnecessary violation of the rotator cuff Select the location of the rotator cuff incision carefully. It should not be >1 cm
“Blind” insertion of locking screws nearby important neurovascular structures Open approach for screws close to vulnerable soft tissues
Retrograde Nailing Pitfall Preventions
Underestimate the danger for supracondylar iatrogenic fracture Open a sizable entry portal
Enlarge the distal humeral canal with careful hand reaming
Flex the elbow >100 degrees during nail insertion
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Intramedullary nailing requires unobstructed imaging of the operating field with the image intensifier; so the location of the image intensifier in relation to the patient, the surgeon, the assistant, and the scrub nurse is of paramount importance. The patient’s positioning should allow viewing without any metal items obscuring the image. If the image intensifier is located on the opposite site of the operated arm, it should provide images of the whole humerus without obstacles (e.g., the leg of the operating table). 
A frequent pitfall with the antegrade nailing is unnecessary damage to the rotator cuff. This can be avoided by carefully selecting the location of the rotator cuff incision and minimizing the size of the incision to avoid problems with shoulder movement and postoperative shoulder pain. 
Locking screws should be carefully used in both antegrade and retrograde nailing to avoid iatrogenic soft tissue damage. If the design of the nail allows the choice of “safe” screws, these screws should be preferred; screws that are close to vulnerable soft tissues should be inserted with small but adequate incisions that will allow direct visualization of the area and identification of neurovascular structures. 
“Fixed” nails require locking screws. If the surgeon is not comfortable with the freehand insertion of locking screws, then a “bio” nail should be used. Unlocked “fixed” nails increase the possibility of fracture healing problems. In addition, if the surgeon attempts to insert a very tight “fixed” nail within the humeral canal in an effort to avoid locking screws there is a significant risk of causing fracture comminution or the creation of a new fracture (Fig. 36-27). 
Figure 36-27
New fracture at the tip of a “fixed” nail that was inserted deliberately tight to avoid distal locking with screws.
Rockwood-ch036-image027.png
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The most important pitfall during retrograde nailing is the underestimation of the danger of creating a fracture at the supracondylar area either during the reaming or during the insertion of the nail. The reasons for this devastating complication include the narrow distal humeral canal, the hardness of the bone in the area, and the eccentric introduction of the tools and implants within the humeral canal because of the presence of the olecranon. Preventative measures include the opening of a wide/long entry portal, use of hand reamers to enlarge the distal humeral canal, and flexion of the elbow during nail insertion as much as possible (>100 degrees) to minimize the olecranon interference. 
Treatment-Specific Outcomes.
Since the Seidel nail, considered by many as the first intramedullary rod specifically made for the treatment of diaphyseal humeral fractures, was introduced around 1990, much has changed regarding the theoretical and practical aspects of intramedullary nailing of the humerus. Initial enthusiasm was followed by skepticism and fears that intramedullary nailing of the humerus might not be as successful as the same technique when applied in the diaphyseal fractures of the long bones of the leg.17,59,120,130,133,240,247,308 
The use of flexible intramedullary rods for the treatment of diaphyseal humeral fractures has continued despite reports about high complication rates and significant problems with functional recovery of shoulder and elbow joints.31,112,287 Liebergall et al.163 and Chen et al.43 used Ender nails in 25 and 118 diaphyseal humeral fractures respectively. There were some implant-related complications such as proximal migration and impingement of a small number of nails, but both studies reported an excellent union rate (92% and 96% respectively), a low complication rate, and good functional recovery of the neighboring joints. However, Liebergall et al. used bracing or a plaster as added protection for 3 to 6 weeks while Chen et al. used no external protection and started mobilization with physiotherapy immediately after surgery. In a later study Ender nails were compared with dynamic compression plating and interlocking nails.40 Patients treated with the flexible intramedullary rods had a shorter mean operation time, less mean blood loss, and a shorter mean hospital stay. The rates of union and general complications were comparable. Although the authors state that all patients followed uniform rehabilitation program with an arm sling postoperatively, immediate pendulum and elbow movements, and active shoulder exercises 3 weeks postoperatively, they unfortunately do not provide detailed information about restoration of shoulder and elbow motion or functional recovery of the patients. They concluded that all three methods are reliable within their limitations in the management of diaphyseal humeral fractures. Pinning of the humeral diaphysis with multiple Rush pins in 200 patients was presented by Gadegone and Salphale.89 Open reduction was necessary in 14 patients. There were eight pin migrations into the shoulder and one into the elbow, four postoperative radial nerve palsies, and 10 cases with notable malrotation of the fracture. However, only four nonunions occurred (union rate of 98%) and 92% of the patients had excellent-to-good ROM of the shoulder and elbow. The authors concluded that fixation of humeral shaft fractures with Rush pins can be a good treatment option bearing in mind the cost of the implant. Chaarani,37 proposed the use of a single antegrade Rush pin for the management of distal diaphyseal humeral fractures with the Rush pin being impacted into the lateral humeral condyle. Thirty-seven patients were treated with this method. All fractures united in an average of 5.7 weeks although the earliest stated union time of 2 weeks casts some doubt on the method of assessing fracture union. The only problems were two postoperative transient nerve palsies and a varus deformity of up to 13 degrees in 11 patients. The patients regained full shoulder and almost full elbow movements. 
Despite the encouraging results from the use of flexible intramedullary pins in the treatment of diaphyseal humeral fractures, it is generally accepted that operative management of fractures should, in general, provide more stability to the fracture site. A stable environment promotes fracture union and allows early mobilization and return to activities without the need for close medical supervision. This has resulted in ongoing investigation of nailing of diaphyseal humeral fractures with many studies indicating the need to modify both the technique of lower limb nailing and the design of lower limb nails to accommodate the unique anatomical and biomechanical characteristics of the humerus.2,56,79,83,85,98,121,170,194,226 
In the previous section describing the technique of intramedullary nailing, “fixed” (distal end locked with screws) and “bio” (distal end locked without screws) were defined to allow better understanding of the biomechanical and biologic differences between the two groups. The terms “fixed” and “bio” refer to nail design in contrast to the terms “static” and “dynamic” or “locked” and “unlocked” that refer to the surgical technique. Modabber and Jupiter196 proposed that humeral rods should be grouped into “rigid” and “flexible” based on the stiffness of humeral rods used at the time. Hackethal nails, Ender nails, and Rush rods were included in the “flexible” group while nails such as the Seidel and the Russell-Taylor nail were included in the “rigid” group. This grouping is not meaningful today, as the use of traditional “flexible” rods is less popular. Furthermore, most modern “rigid” types of nails are made of titanium and therefore, are not as rigid as older nails that were made of stainless steel. 
A “fixed” nail that has been in use since the mid 1990s is the unreamed humeral nail (UHN). Blum et al.24 presented satisfactory outcomes from using the UHN with both antegrade and retrograde techniques in 84 diaphyseal humeral fractures. Operating time was less than 90 minutes in 85% of the cases and union rate 91.2% in an average of 13 weeks. A number of complications occurred and included the need for open reduction, fissuring, or additional fracture during retrograde nailing, difficult distal interlocking, transient secondary radial nerve palsy, and the need for additional hardware to enhance fracture stability. While most patients regained shoulder motion and functionality, 3.7% had poor shoulder function after antegrade nailing and 1.8% had poor elbow function after retrograde nailing. Subsequent studies with the UHN had similar outcomes.67,81,251,261 Although the UHN offers a mechanism that enables compression of specific fracture types (AO/OTA A2 or A3), most authors do not describe the use of this mechanism, suggesting that compression may not be considered necessary. Mückley et al.208 reported good outcomes with the use of another “fixed” humeral nail (T2) which is cannulated and also allows compression of the fracture. The series consisted of 36 fractures treated with both the antegrade and retrograde techniques. Only one fracture did not unite and complications included fracture during nail insertion in 2 of the 14 retrograde cases and one breakage of a locking screw because of overbending when using the compression mechanism. Functional recovery was satisfactory with an average Constant score of 88 for the shoulders and an average Morrey score of 97 for the elbows. There were no significant differences in the functional outcomes of the shoulder and the elbow between antegrade and retrograde techniques. 
Stannard et al.285 reported on an articulated, and thus flexible, “fixed” nail (Flexnail) that used a more lateral entry portal just distal to the insertion of the rotator cuff into the greater tuberosity, to avoid iatrogenic injury to the rotator cuff. The Flexnail is inserted with articulations which become rigid with the use of a stiffening mechanism when the nail is in its final position. It can be then locked proximally and distally with screws. The nail can also accommodate retrograde insertion. The authors followed up 41 patients who underwent antegrade (19) and retrograde (22) nailings for diaphyseal humeral fracture with the Flexnail. Complications included one deep infection, two nonunions, and two nail breakages, all of which occurred in fractures treated with smaller 7.5-mm diameter nails. Thirty-nine fractures united within 12 weeks on average. Nine of the ten patients who had some loss of motion of the shoulder and elbow joints had undergone retrograde nailing. Despite the lateral insertion, 20 patients had shoulder pain; three of four patients with moderate-to-severe shoulder pain had undergone retrograde nailing. The authors concluded that this type of nail was an option for locked intramedullary nailing of the humerus but in smaller diameter canals other methods of treatment should be considered. Few complications and better functional outcomes with the retrograde use of Flexnail were reported by Müller et al.201 Matityahu and Eglseder186 used the Flexnail to treat 43 diaphyseal humeral fractures in multiply injured patients, 27 with the antegrade and 16 with the retrograde technique. They encountered seven nonunions, five of them with the retrograde technique. The authors recommended the use of flexible nailing with the antegrade technique in polytrauma cases where plate fixation may be problematic. The two nail breakages reported by Stannard et al.285 and the fracture at the insertion site during removal reported by Müller et al.201 suggest that the flexibility of the nail may be difficult to restore after longer periods of implantation. This raises concern about the ease of removal of these devices. 
“Bio” nails appeared in the late 1980s because of distal locking difficulties and the fear of injury to neurovascular structures with locking screws. The Seidel nail is regarded as the first “bio” nail, providing distal locking effect with expansion of distal fins.273 Although there are studies with satisfactory results from the use of Seidel nail,229,237 its use has been associated with several problems and complications mainly related to its bulky proximal design, rigidity (stainless steel), and the distal locking mechanism that, apart from its questionable effectiveness, was a problem at the time of nail removal because of bone formation around the expanded fins.153,290,295,318 Other “bio” nails, such as the antegrade True-Flex and the retrograde Marchetti-Vicenzi nails appeared in the early 1990s. These nails provide distal interlock by tight contact with the endosteum or by long, flexible, expanding fins respectively.95,125,184,269,294. The exclusive retrograde insertion of the Marchetti Vicenzi nail helps to avoid rotator cuff problems. Three studies reported satisfactory outcomes from treating substantive number of patients with humeral shaft fractures with the Marchetti-Vicenzi nail.125,184,294 Fracture union rate exceeded 95% with average healing times of 19, 11, and 16 weeks respectively with good functional outcomes. In the series by Martinez et al.,184 which was the largest including 143 patients, shoulder function was excellent in 66.4%, moderate in 30%, and poor in 3.5%, and elbow function was excellent in 62.2%, moderate in 33.5%, and poor in 4.2%. Complications included penetration of the shoulder by the nails in five cases, intraoperative fracture at the insertion site in two cases, and fracture during nail removal in one case. They also reported 16 cases of varus or valgus of more than 10 degrees and five cases of anterior/posterior malunions of more than 10 degrees.184 Simon et al.276 presented good results from the use of the Marchetti-Vicenzi nail but focused on its problematic removal after fracture union. They stated that all 20 attempted removals were difficult procedures while one was impossible and in seven cases supracondylar fractures occurred at removal. The Halder nail had similarities with Marchetti-Vicenzi nail, as it could be used only with the retrograde technique and provided interlocking at its far end with the deployment and expansion of three wires within the humeral head.111 It was used to treat 39 acute diaphyseal humeral fractures that united within 6 to 8 weeks. Ninety-five percent of the patients were virtually pain-free and 90% could do simple household tasks at 3 weeks from surgery. However, at the end of 1 year, mean shoulder abduction was 115 degrees while seven patients suffered >13 degrees elbow extension loss. Similar to the Marchetti-Vicenzi nail there were three incidences of breakage of the expanding wires and five penetrations of the humeral head by the nail and/or the wires. It should be noted that one of the co-authors of the study was unable to replicate these results in his own centre and reported an unacceptably high rate of fixation failure, nonunion, and need for removal in 21 patients.313 
At the beginning of the new century Franck et al.88 published their experience with a novel “bio,” noncannulated humeral nail (Fixion) that could provide distal interlocking by expansion within the humeral canal with the use of a pump and saline. The authors used the Fixion nail in 25 acute osteoporotic fractures (18 antegrade and 7 retrograde) and reported bone healing in an average of 16 weeks while all patients regained their pre-existing shoulder and elbow ranges of motion without any significant complications. The same group had previously reported similarly good outcomes from the use of the same nail in 23 metastatic humeral fractures.87 Further studies also reported satisfaction with the use of Fixion nail.34,137,174 However, a more recent study has reported more complications with the Fixion nail.176 Although only eight patients with acute humeral shaft fractures were treated, there were two nonunions, two intraoperative implant failures, and two postoperative radial nerve palsies. The authors concluded that they could not replicate the advantages of the nail as described in previous studies. Although the Fixion nail is also being used in the treatment of fractures of the lower limb recent reports are less favorable.218,227,279 
The latest development regarding “bio” nails is the “Garnavos” humeral nail, a cannulated, square rod with concave sides that provides distal interlocking by a tight fit within the humeral canal.92 If a tight fit cannot be achieved either because of sizing error, excessive comminution, or a short humeral fragment, locking screws can be used distally and the nail is converted to a “fixed” type. Additional features of the nail are modularity, with two different “cups” for antegrade or retrograde insertion and the avoidance of proximal locking screws during the antegrade technique. Garnavos et al. reported good results and few complications from the use of the nail in 63 acute humeral shaft fractures but further validation of the nail is necessary. 
Despite the vast number of different humeral nails, comparative studies are scarce. The first study comparing two different nails was organized by Scheerlinck and Handelberg. A “fixed” UHN and a “bio” (Marchetti-Vicenzi) nail, inserted with the antegrade and retrograde techniques respectively, were used for the management of 52 diaphyseal humeral fractures.269 Anesthetic time was longer in the UHN group (107.7 vs. 89.2 minutes). Iatrogenic fracture occurred three times in each nail group. There were four cases of protrusion of the UHN at the insertion point while in two cases the pins of the Marchetti-Vicenzi nail perforated the greater tuberosity. One patient developed a transitory radial nerve paresis. In 43 evaluated patients there were three nonunions (two in the Marchetti-Vicenzi group and one in the UHN group). Primary fracture healing within 3 months was achieved in 88% of the reviewed patients in the Marchetti-Vicenzi group compared with 66.7% in the UHN group. Functional evaluation at 2 years revealed that Marchetti-Vicenzi nail resulted in better shoulder function and similar elbow function compared with the antegrade UHN. In a prospective, randomized study 44 antegrade nailed cases were compared with 45 retrograde nailed cases using the same “fixed” nail in 89 acute fractures of the middle third of the humeral diaphysis.45 The only statistically significant difference perioperatively was a longer operating time for retrograde nailing. Fracture union rate was similar (95% and 93% respectively) and time to healing did not differ significantly (10.8 and 12 weeks respectively). Although the average Neer score was similar in both groups the antegrade group needed a significantly longer time for shoulder functional recovery. Similarly, for elbow joints, the average postoperative MEP score (96.3 vs. 94.8) did not differ significantly between the two approaches, but the retrograde approach needed a significantly longer time for elbow functional recovery. However, all patients, except those with associated injuries, resumed their pretrauma occupations or activities. Bearing in mind significant and insignificant differences in the two treatment groups the authors recommended that retrograde nailing should be used in patients with a wide medullary canal or pre-existing shoulder problems and antegrade nailing should be used in patients with young age or a small medullary canal. 
Plating or Nailing.
Antegrade “fixed” nailing (with the Russell-Taylor nail) has been compared with standard plating techniques in three studies since 2000.38,41,187 Surprisingly, the three studies produced diverging results. Chapman et al. reported on 84 humeral diaphyseal fractures treated with either open reduction and plating (46) or intramedullary nailing (38). They found equivalence in time to fracture healing but intramedullary nailing was significantly associated with shoulder pain and stiffness. Plating was significantly associated with elbow stiffness especially in distal third fractures but not with elbow pain. The authors concluded that both intramedullary nailing and compression plating provide predictable methods for achieving fracture stabilization and ultimate healing.41 In the same year a prospective randomized study of 44 fractures treated with either plating or intramedullary nailing found a significantly higher rate of complications in the nailing group including shoulder impingement. The authors suggested that plating remained the best treatment for unstable fractures of the humeral shaft because intramedullary nailing was technically more demanding and had a higher rate of complications.181 In contrast, Changulani et al.38 found a higher rate of complications with plating and concluded that nailing is a better surgical option for the management of diaphyseal fractures of the humerus. 
Further evidence was provided by Heineman et al.118,119 when they updated their own synchronous meta-analysis examining the dilemma of plating or nailing for humeral shaft fractures. While in the initial meta-analysis the authors concluded that pooling of the data failed to provide a firm conclusion because of the heterogeneity of implant types and fracture patterns, the addition of 34 patients from a recent study by Putti et al.,236 changed the conclusions in favor of plating. More recently, Kurup et al.155 reviewed five relevant studies and concluded that intramedullary nailing is associated with an increased risk of shoulder impingement, with an increase in restriction of shoulder movement and also increased need for removal of metalwork while there was insufficient evidence to determine if there were any differences including functional outcome. 
A recent study compared the more modern “fixed” UHN and Expert humeral nail with plate fixation in a substantive group of 91 patients who had sustained humeral shaft fractures. The results were in favor of plating and the authors proposed that nails should be used in pathologic fractures, in morbidly obese and osteopenic patients, and large segmental fractures of the humerus.69 In 2012 Chen et al.44 reviewed the catalogues of a USA social insurance program to identify patients who had sustained a humeral shaft fracture between 1993 and 2007 and were treated with ORIF or nailing. They identified 451 patients (172 with plates and 279 with nails) who had complete 1-year follow-up data. Analysis of the findings regarding operating time, reoperation rate, and 1-year mortality revealed that nailing has a shorter mean operative time and the two surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality. 
Shoulder joint impairment is the main problem with antegrade nailing. In a study designed to compare the functional outcomes of the shoulder joint in 73 patients, 44 patients underwent antegrade nailing and 29 ORIF with a DCP.84 There was no statistically significant difference in shoulder pain, functional scores, or isometric strength parameters between the two groups. Shoulder joint motion and strength did not recover to normal after humeral shaft fracture and the authors concluded that antegrade nailing, if performed properly, should not be considered responsible for shoulder joint impairment. However, a more recent study by Li et al.162 disputed these findings and showed that patients who underwent nailing, apart from having lower shoulder functional scores and a decreased range of shoulder motion, also had a greater degree of malrotation of the humeral fracture than patients who underwent plating. 
It appears that the available data regarding the comparison of plating with intramedullary nailing for the humeral shaft fractures have not produced conclusive results possibly because of the small number of acute fractures that are treated operatively, the ongoing appearance of new implants and techniques, and the long learning curve required for the new techniques. It may be some time before definitive evidence establishes which technique is better for the management of humeral diaphyseal fractures. 

External Fixation

Indications and Preoperative Planning.
External fixation has a limited role in the management of acute humeral diaphyseal fractures and is mainly used in open fractures with extensive soft tissue and bone loss, during the damage control approach in multiple injured patients and in nonunions especially if they are infected.47,48,192 Ruland also included as indications fractures of the distal humerus, bilateral humeral fractures, the post-traumatic paralysis of the radial nerve, fractures associated with vascular injuries, burns, and fractures with soft tissue interposition.256 In general, external fixation should be used for provisional stabilization of diaphyseal humeral fractures and should be substituted with the definitive treatment in due course (Fig. 36-28).141,256 
Figure 36-28
 
A: Severe open fracture (IIIb according to Gustilo and Anderson classification) of the distal humeral diaphysis and the olecranon. B: Immediate plating of the olecranon and external fixation to the humerus. C: Conversion to “fixed” intramedullary nailing and autologous grafting 4 weeks later. D, E: Clinical picture at 2 months post nailing. The final ROM was 20 to 115 degrees.
A: Severe open fracture (IIIb according to Gustilo and Anderson classification) of the distal humeral diaphysis and the olecranon. B: Immediate plating of the olecranon and external fixation to the humerus. C: Conversion to “fixed” intramedullary nailing and autologous grafting 4 weeks later. D, E: Clinical picture at 2 months post nailing. The final ROM was 20 to 115 degrees.
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Figure 36-28
A: Severe open fracture (IIIb according to Gustilo and Anderson classification) of the distal humeral diaphysis and the olecranon. B: Immediate plating of the olecranon and external fixation to the humerus. C: Conversion to “fixed” intramedullary nailing and autologous grafting 4 weeks later. D, E: Clinical picture at 2 months post nailing. The final ROM was 20 to 115 degrees.
A: Severe open fracture (IIIb according to Gustilo and Anderson classification) of the distal humeral diaphysis and the olecranon. B: Immediate plating of the olecranon and external fixation to the humerus. C: Conversion to “fixed” intramedullary nailing and autologous grafting 4 weeks later. D, E: Clinical picture at 2 months post nailing. The final ROM was 20 to 115 degrees.
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In the acute setting external fixation is an emergency procedure used to save either the limb or the patient’s life. Under these circumstances, there may be insufficient time for planning, especially if it is expected that definitive fixation of the fracture will follow. However, especially in some cases of multiple injured patients, it may not be feasible to return to the operating room for definitive fixation and the external fixator may be the definitive treatment. For this reason, even in the acute setting of a damage control situation, surgeons must try to apply the external fixation efficiently, bearing in mind that there may not be another opportunity to correct problems related to fracture reduction and limb alignment. Preoperative preparation must include adequate imaging of the fractured humerus, as the surgeon must be aware of the integrity of the proximal and distal parts of the bone where the pins of the external fixator will be inserted. 
Complete and detailed preoperative planning is needed in cases where the external fixation is performed as an elective procedure; for example, for treatment of a nonunion of a humeral fracture. The planning must include the removal of previously inserted implants with provision of suitable instruments for removal, organization of the necessary equipment, and tools for the surgical debridement, decortication, and harvesting of bone graft. Availability of allograft or bone substitutes should also be ensured. Finally, there should always be an alternative plan in case of unexpected problems. Table 36-18 shows a preoperative planning checklist for acute or elective external fixation of a diaphyseal humeral fracture. 
Table 36-18
Preoperative Planning Checklist for External Fixation of Diaphyseal Humeral Fractures
1. Operating Theater
Operating Table
  •  
    Regular orthopedic
  •  
    Radiolucent arm support
  •  
    Forearm extension
  •  
    Other
2. Position/Positioning Aids
  •  
    Supine
  •  
    Beach chair
  •  
    Positioning aids
3. Equipment
  •  
    Battery drill
  •  
    Bone graft instruments
  •  
    Large bone reduction tools
  •  
    Tools for the removal of existing implants
X-ray
  •  
    C-arm location
  •  
    Left
  •  
    Right
  •  
    Plain films
4. Implants and Tools
  •  
    Monolateral external fixation
  •  
    Hybrid external fixation
  •  
    “Sarmiento” rings
  •  
    Humeral external fixation pins
  •  
    Large fragment standard set
  •  
    Small fragment standard set
  •  
    K-wires
  •  
    Other
5. Other
X
Surgical Technique and Postoperative Care.
The patient is positioned supine with the arm on a radiolucent support. In the acute setting two or three pins are inserted above and below the fracture under image intensifier control for confirmation of fracture alignment and correct placement of the pins. If any of the pins is close to neurovascular structures, open placement of the pin is advised. Adherence to proper surgical technique and regular review of the fracture healing process will allow adjustments of the fixator to improve alignment or provide compression whenever indicated. As pin track infection is one of the anticipated problems postoperatively, daily pin track care should be undertaken. 
Treatment-Specific Outcomes.
On reviewing outcomes of the management of humeral shaft fractures with external fixation it must be remembered that most studies deal with complex cases (e.g., open fractures or multitrauma patients) that are prone to complications and adverse outcomes. Mostafavi and Tornetta199 and Marsh et al.179 evaluated 18 and 15 such patients respectively. Almost half of the patients in both studies developed pin track infections, while there were two refractures after the removal of the fixator, four nonunions, and three malunions. Mostafavi and Tornetta199 also reported good to excellent function in only 12 of the 18 patients. Nonunion occurred in four out of seven diaphyseal humeral fractures that were treated with external fixation by Choong and Griffiths.47 Somewhat better results were reported by Ruland256 in a mixed group of 16 closed and open fractures of the humeral shaft that were treated with external fixation. 
Outcomes from the use of external fixation in less complicated humeral shaft fractures are better. Catagni et al.36 undertook a retrospective review of 84 acute diaphyseal humeral fractures that were treated with external fixation. Only four were open injuries. There was an average operative time of 30 minutes (18 to 50) and the hospital stay for the isolated humeral fractures was 3.5 days. All fractures healed by 6 months from the accident while 80% of the patients achieved excellent or good shoulder functional outcome based on the Constant score and 93% obtained excellent or good elbow functional outcome. The only complication recorded was superficial pin track infection in 12%. Similarly good results have been presented by de Azevedo et al.64 who applied external fixation in 58 acute fractures (45 open and 13 closed). 
Despite the encouraging results from these more recent studies, modern plating and nailing techniques are more popular while nonoperative treatment is still considered an excellent option for the treatment of uncomplicated humeral diaphyseal fractures. Nevertheless, external fixation has a role in the management of open fractures and in damage control for multiple trauma patients. However, even in these cases most surgeons would wish to replace the external fixation with another definitive form of fixation when circumstances allow. Suzuki et al.289 tried to verify the safety, efficacy, and best timing for the removal of the “temporary” external fixator and insertion of a definitive implant. They revised unilateral external fixation to plating within 2 weeks of injury in 17 patients who had sustained multiple trauma and severe open fractures. Two infected nonunions occurred while the other fractures healed at an average time of 11.1 weeks. They concluded that immediate external fixation with planned conversion to plate fixation within 2 weeks is a safe and effective approach for the management of humeral shaft fractures in selected patients with multiple injuries or severe soft tissue injuries that preclude early definitive treatment. 

Management of Expected Adverse Outcomes and Unexpected Complications in Humeral Shaft Fractures

Adverse outcomes and complications after diaphyseal humeral fractures can be separated into two categories, those that occur with all treatment methods and those that are related to specific surgical or nonsurgical techniques (Table 36-19). 
Table 36-19
Common Adverse Outcomes and Complications of Humeral Shaft Fractures
A. General
  •  
    Nonunion
  •  
    Infection
  •  
    Secondary neurologic injury
B. Implant-specific
  •  
    Plating
    •  
      Loss of fixation
  •  
    Nailing
    •  
      Injury to arteries, muscles, or tendons by the locking screws
    •  
      Nail protrusion and impingement (antegrade)
    •  
      Shoulder dysfunction (antegrade)
    •  
      “backing out” of proximal locking screws (antegrade)
    •  
      Fracture at the supracondylar area during insertion (retrograde)
    •  
      Complications attributed to each specific nail design
  •  
    External fixation
    •  
      Pin track infection
    •  
      Re-fracture after removal of the fixator
X

General Adverse Outcomes and Complications Related to Humeral Shaft Fractures

Nonunion

The prevalence of nonunion for diaphyseal humeral fractures has been reported as 1% to 10% after nonsurgical and 10% to 15% after surgical management.122,259,265 Increased incidence of nonunion post surgery may reflect a selection bias, as more “benign” fractures are managed conservatively and more “difficult” fractures are treated operatively. Fractures that are open, segmental, transverse, highly comminuted, with significant displacement, bone loss, or in patients with multiple injuries have a higher risk of nonunion.4 Factors like smoking, diabetes, medications (such as nonsteroidal anti-inflammatory drugs), malnutrition, and noncompliance with physicians’ instructions may contribute to healing compromise. Other conditions that inhibit fracture healing are pre-existing shoulder or elbow stiffness and local infection.4 Nonunion following operative treatment is often the result of technical error (such as inadequate fixation or fracture site distraction) or mechanical failure.22,85,86,188 Therefore, the incidence of nonunion can be reduced with appropriate evaluation and assessment of the risk factors, careful selection of patients who would benefit from a specific treatment method, attention to the surgical technique, and proper implant selection. 
The management of nonunion of a diaphyseal humeral fracture is based on providing mechanical stability while stimulating biology at the nonunion site, because most humeral shaft nonunions are atrophic.139,217,222,244,305,321 The most popular management for a humeral shaft nonunion has been ORIF with autologous bone grafting.1,4,20,113,126,164,181,217,232,244 Patients with atrophic nonunion should be warned about the need for using autograft, allograft, bone morphogenetic proteins (BMPs), or the necessity for shortening if there is a bone defect.94,100,232,284,306 The traditional technique starts with wide exposure of the nonunion site and removal of previously inserted implants. Surgical debridement with removal of all dead bony fragments and fibrous tissue must be performed until healthy bleeding bone appears on both sides of the nonunion. The plate must be strong (4.5-mm DCP broad or narrow) with at least four screws above and four below the nonunion site (Figs. 36-29 and 36-30). With insertion of a lag screw it is possible to reduce the number of the screws to three on each side of the plate. Over recent years locking plates have been used increasingly, especially in osteoporotic patients.58,204,245,284 
Figure 36-29
 
A: Nonunited fracture after 6 months of functional bracing. B: Early postoperative x-ray showing open reduction internal fixation and autologous bone grafting. Note the middle lag screw and four screws on each side of the nonunion. C: Confirmation of excellent bone healing process 6 months later.
A: Nonunited fracture after 6 months of functional bracing. B: Early postoperative x-ray showing open reduction internal fixation and autologous bone grafting. Note the middle lag screw and four screws on each side of the nonunion. C: Confirmation of excellent bone healing process 6 months later.
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Figure 36-29
A: Nonunited fracture after 6 months of functional bracing. B: Early postoperative x-ray showing open reduction internal fixation and autologous bone grafting. Note the middle lag screw and four screws on each side of the nonunion. C: Confirmation of excellent bone healing process 6 months later.
A: Nonunited fracture after 6 months of functional bracing. B: Early postoperative x-ray showing open reduction internal fixation and autologous bone grafting. Note the middle lag screw and four screws on each side of the nonunion. C: Confirmation of excellent bone healing process 6 months later.
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Figure 36-30
 
A: Nonunited fracture in a polytrauma patient who was treated with intramedullary nailing 4 months after the accident and the nailing operation. B: Intraoperative picture (posterior approach) the nail has been removed, the radial nerve identified, and the nonunion debrided. C: The plate and bone graft has been applied and all screws tightened. D: Six months later, sound union of the fracture.
A: Nonunited fracture in a polytrauma patient who was treated with intramedullary nailing 4 months after the accident and the nailing operation. B: Intraoperative picture (posterior approach) the nail has been removed, the radial nerve identified, and the nonunion debrided. C: The plate and bone graft has been applied and all screws tightened. D: Six months later, sound union of the fracture.
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Figure 36-30
A: Nonunited fracture in a polytrauma patient who was treated with intramedullary nailing 4 months after the accident and the nailing operation. B: Intraoperative picture (posterior approach) the nail has been removed, the radial nerve identified, and the nonunion debrided. C: The plate and bone graft has been applied and all screws tightened. D: Six months later, sound union of the fracture.
A: Nonunited fracture in a polytrauma patient who was treated with intramedullary nailing 4 months after the accident and the nailing operation. B: Intraoperative picture (posterior approach) the nail has been removed, the radial nerve identified, and the nonunion debrided. C: The plate and bone graft has been applied and all screws tightened. D: Six months later, sound union of the fracture.
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Hierholzer et al.122 compared autologous iliac crest bone graft with demineralized bone matrix (DBM) in two groups of patients who had developed atrophic humeral nonunions and were treated with ORIF. Having achieved 100% and 97% union rates respectively, the authors concluded that DBM can be used for standard graft augmentation in the treatment of humeral nonunions and delayed unions to avoid harvesting iliac bone graft and its associated donor site morbidity.9,71 Allografts have also been used successfully in the management of diaphyseal humeral nonunions.171,178,306 
Complications that can occur after plating and grafting a diaphyseal humeral nonunion include persistence of the nonunion (up to 20%),60,246 infection (3% to 10%),1,126,164,178 and postoperative transient radial nerve palsy (0% to 17%).1,60,126,164 Results regarding functional outcomes vary from excellent or good126,178,217,246 to poor1,39 and this dissimilarity possibly reflects the many factors involved such as the duration of nonunion, the number and invasiveness of previous operations, and the quality of the rehabilitation program. 
Intramedullary nailing has been also used for the management of humeral shaft nonunion. While there have been reports with favorable results from the use of “fixed” nailing with or without bone grafting,143,166,171 other studies did not achieve high nonunion rates.85,189,310 Disappointed with their results Dujardin et al.73 stated that “rather than abandoning the technique, it would be advisable to conduct further research to determine what factors are determinants in its failures.” Recently there has been an effort to improve the role of nailing in the management of humeral shaft nonunions by using supplementary implants or introducing technical improvements. “Fixed” nailing and grafting were supplemented with interfragmentary wires to treat nonunions of the humeral diaphysis with an overall union rate of 96.9%, minimal complications, and good functional outcomes.171 Apard et al.5 used the compression feature provided by the nail that was in situ to successfully treat seven patients with humeral shaft nonunion. Fenton et al.80 used an intramedullary nail with a compression mechanism to achieve healing in 12 patients with humeral shaft nonunion. However, not all diaphyseal humeral nonunions can be compressed and not all humeral nails provide a compression mechanism. In addition, dynamization for delayed fracture healing process is not effective in the upper limb and the use of reaming is controversial in the humerus.96 Bearing these factors in mind Garnavos et al.94 proposed that the advantages of “fixed” nailing could be exploited in cases of delayed unions (3 to 6 months from the accident) with the adjuvant contribution of concentrated bone marrow, introduced percutaneously in the nonunion site. In five cases of delayed union the use of this technique was successful in achieving union. 
External fixators are not popular in the treatment of humeral nonunions because of the complex humeral anatomy, fear of pin track complications, or patients’ adverse comments about the fixator. Nevertheless, Lavini et al. treated 20 atrophic diaphyseal humeral nonunions with unilateral external fixation, decortication, and bone grafting while seven patients with hypertrophic nonunion were treated with unilateral external fixation only. All nonunions healed at an average time of 4.9 months with only six superficial pin track infections.159 Mariconda et al.177 also had good results with the use of unilateral external fixation in the management of 12 patients with nonunion of the humeral shaft but failed to show any benefit from the supplementary use of platelet gel. Ilizarov external fixation has been used more frequently than unilateral fixators for the management of all nonunion types (atrophic, hypertrophic, and infected) with good results and few complications (Fig. 36-31).149,157,222,298 
Figure 36-31
 
A: A transverse fracture of the middle third of the humeral diaphysis, treated with functional bracing, as appeared on the follow-up 3 months post accident. B: Open reduction and internal fixation with a six-hole plate. C: Three months later the fixation became painful, while the arm was swollen and warm. The x-ray showed loss of reduction and nonunion. D: The bone scan confirmed the clinical diagnosis of infected nonunion. E: The plate was removed, the nonunion site debrided thoroughly, IV antibiotics were administered and Ilizarov type external fixator applied. F: Six months later the infection was eradicated and the fracture healed.
A: A transverse fracture of the middle third of the humeral diaphysis, treated with functional bracing, as appeared on the follow-up 3 months post accident. B: Open reduction and internal fixation with a six-hole plate. C: Three months later the fixation became painful, while the arm was swollen and warm. The x-ray showed loss of reduction and nonunion. D: The bone scan confirmed the clinical diagnosis of infected nonunion. E: The plate was removed, the nonunion site debrided thoroughly, IV antibiotics were administered and Ilizarov type external fixator applied. F: Six months later the infection was eradicated and the fracture healed.
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Figure 36-31
A: A transverse fracture of the middle third of the humeral diaphysis, treated with functional bracing, as appeared on the follow-up 3 months post accident. B: Open reduction and internal fixation with a six-hole plate. C: Three months later the fixation became painful, while the arm was swollen and warm. The x-ray showed loss of reduction and nonunion. D: The bone scan confirmed the clinical diagnosis of infected nonunion. E: The plate was removed, the nonunion site debrided thoroughly, IV antibiotics were administered and Ilizarov type external fixator applied. F: Six months later the infection was eradicated and the fracture healed.
A: A transverse fracture of the middle third of the humeral diaphysis, treated with functional bracing, as appeared on the follow-up 3 months post accident. B: Open reduction and internal fixation with a six-hole plate. C: Three months later the fixation became painful, while the arm was swollen and warm. The x-ray showed loss of reduction and nonunion. D: The bone scan confirmed the clinical diagnosis of infected nonunion. E: The plate was removed, the nonunion site debrided thoroughly, IV antibiotics were administered and Ilizarov type external fixator applied. F: Six months later the infection was eradicated and the fracture healed.
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Other Techniques.
The use of an intramedullary fibular graft for the treatment of humeral shaft nonunions has been proposed to offer a reliable solution for “difficult” humeral nonunions.60,140,311,321 Vascular bone grafts, in general, have been used sporadically for the management of persistent nonunions with some success. However, the technique is only recommended in selective cases of recalcitrant nonunion by experienced plastic and/or orthopedic surgeons, because of the extensive dissection and the small number of cases that require such management.160 
The use of electrical bone stimulators in the treatment of nonunited long-bone fractures remains controversial. However, bone stimulators should not be used when the nonunion is the result of poor technique.102,277 
Comparative Studies.
Atalar et al.10 presented a retrospective comparison of 21 cases of compression plating, 36 cases of circular external fixation, and 24 cases of unilateral external fixation, for the treatment of atrophic humeral shaft nonunions. There was one case of persistent nonunion in each group and between three and five neurologic complications from the radial and ulnar nerves in each group of which 11 recovered spontaneously. The total complication rate was 24% for the plating group, 31% for the circular fixation group, and 25% for the unilateral fixation group. These differences were not considered statistically significant. There were no statistical differences in union times or the DASH score between the three groups. The conclusion highlighted that, if performed properly, both forms of external fixation and plating can produce good results in the management of humeral shaft nonunions. Rubel et al. compared single to dual plating in 18 and 19 patients respectively with humeral shaft nonunions.254 There was a total 92% union rate and the authors concluded that although the dual plating construct is mechanically stiffer, there does not seem to be any detectable benefit from its use. Martinez et al. treated 50 patients who had developed atrophic humeral shaft nonunion, 24 with “fixed” UHN and autologous bone graft, and 26 with plating and autologous bone graft. While they achieved 100% union rate and had minimal complications with both methods, they concluded that nailing achieves earlier union with fewer complications.182 The same group some years later presented good results of double plating and bone grafting in a series of 22 patients with diaphyseal humeral nonunion.183 

Infection

Infection is a devastating complication that usually develops either after open fractures or after operative treatment, related to the size of the open wound, soft tissue stripping, devitalization of bony fragments, and duration of surgery. The prevalence of infection is low in the humerus because of the excellent blood supply and adequate soft tissue coverage. When deep infection develops after surgical intervention the general principles of treatment of infection must be followed by establishing the diagnosis, defining the responsible micro-organism with cultures, administration of intravenous antibiotics, and surgical debridement of the infected wound. Augmenting standard techniques with the addition of an antibiotic impregnated, osteoconductive bone substitute can provide a very high local concentration of antibiotics at the infection site. Eradication of infection in 23 of 25 cases of infected humeral diaphyseal infections was reported using this method.192 
If there has been previous surgical intervention and the fixation is stable, the implant should be left in situ; otherwise the implant should be removed and replaced by external fixation that can be used either as temporary or as definitive treatment (Fig. 36-31). High rates of eradication of the infection and fracture union have been reported with the combined use of unilateral fixators or Ilizarov frames, wound debridement, and antibiotics.18,29,157 However, complications encountered in the management of infected humeral nonunions are not infrequent and include pin track infections and cases of persistently infected nonunion. Other complications include neurologic injury, fractures after the removal of the fixator, and suboptimal functional results.29,108,157 Despite the challenges and complications of surgical management, it is generally accepted that deep humeral infections should not be treated conservatively.108 The management of infected fractures is dealt with in more detail in Chapter 26

Secondary Neurologic Injury

Secondary nerve injury can occur because of medical intervention that can be anything from a simple manipulation to a more invasive surgical procedure. Unfortunately, information in the literature about these injuries is limited as they are infrequent and may be under-reported. Shao et al.275 reviewed 30 articles dealing with the management of radial nerve injury and were unable to find sufficient data to justify recommendations about the management of secondary radial nerve palsy. However, Böstman et al.28 treated 16 cases of secondary radial nerve palsy that developed after closed manipulation of a humeral shaft fracture and proposed expectant treatment as the principal initial policy. Gregory104 also recommended observation, while Schatzker268 advocated immediate exploration because of the possibility of the nerve being trapped within the fracture when a later exploration would be more difficult in the presence of new bone formation. 
Secondary nerve palsy that develops after surgery is usually transient, although it has been reported that it can be permanent in 2% to 3% of patients.220,280 To avoid this complication, surgeons must be familiar with the anatomy of the arm and, during surgical procedures, nearby nerves should be identified and protected. Care should be taken to avoid excessive tension on the soft tissues during retraction. Although there have been reports regarding the danger of neurologic injury from the locking screws of intramedullary nails26,79,170,257 or external fixator pins48 their prevalence is unknown. 
Expectant treatment of secondary nerve palsy remains the preferred choice unless there is an obvious technical mistake.316 If the nerve does not recover by 4 to 6 months, there should be consideration of exploration of the nerve and repair or tendon transfers. Although controversial, it has been reported that tendon transfer provides better and earlier functional recovery in comparison to nerve repair.154 

Implant-Specific Adverse Outcomes and Complications Related to Humeral Shaft Fractures

Loss of fixation happens more frequently with plating than with nailing or external fixation (Table 36-19).129,220 Suboptimal surgical technique, weak implants, and poor bony purchase mainly because of osteoporosis have been recognized as the main reasons for this problem.109,246 
Intramedullary nailing has more implant-specific complications.79,170 Dysfunction and pain at the shoulder has been regarded as the most common problem of antegrade intramedullary nailing of diaphyseal humeral fractures.79,247,287 However, many authors believe that nailing alone may not be responsible for this problem.76,84,96,253,314 Nevertheless, iatrogenic injury to the rotator cuff could be avoided with the implementation of the retrograde technique or other approaches that spare the rotator cuff.70,221 Other complications that originate from the use of locking screws include neurologic damage and other soft tissue complications such as injury to arteries, muscles, and tendons.26,78,167,241,257 Injury to the long head of the biceps and the axillary nerve can be reduced by avoiding the proximal antero-posterior locking screw that many antegrade nails provide. Retrograde “fixed” nails reduce but do not abolish the incidence of injury to vulnerable soft tissues around the shoulder girdle.173 Another problem of antegrade nailing is protrusion of the nail and impingement at the acromion.2,79,128,229 However, it is now recognized that antegrade nails must be embedded within the humeral head and protrusion and impingement should be regarded as technical error. Another under-reported problem of antegrade nailing is backing out of the proximal screws, because of the poor purchase within the cancellous bone of the head, especially in osteoporotic patients.56,67,170 To overcome this problem some nails provide either locking proximal screws or a polyethylene augmentation that covers the proximal screw holes and keeps the screws in situ. Specific to retrograde humeral nailing is the complication of iatrogenic fracture at the supracondylar area during the insertion of the nail.24,79,81,165,170 This problem can be reduced by flexing the elbow beyond 100 degrees during nail insertion, opening a wide entry portal, de-roofing of the entry portal, reaming the distal humeral canal, and the use of a nonrigid nail.96 Sporadic complications of “fixed” nails include heat-induced segmental necrosis of the diaphysis and heterotopic ossification of the deltoid, both attributed to the reaming process212,239,271 and fracture at the tip of the nail (Fig. 36-27).190 “Bio” nails that provide stability without the use of locking screws have specific complications. The diverging pins of the Marchetti-Vicenzi humeral nail can penetrate the humeral head,184,276,294 while its removal can be difficult or even impossible.184,276 For the Fixion and True-Flex nails implant-specific sporadic complications include intraoperative failures and rotational instability.95,99,176,218 
Specific problems that complicate external fixation in the management of diaphyseal humeral fractures are pin track infection and re-fracture after the removal of the fixator.36,179,199,256 Meticulous pin track care and care after removal of the fixator could reduce the incidence of these complications. 

Author’s Preferred Treatment for Humeral Shaft Fractures

 
 

My preferred method of operative treatment for diaphyseal humeral fractures is intramedullary nailing (Fig. 36-32). The technique offers the significant advantages of being minimally invasive and respecting the biology while it can accommodate all humeral shaft fractures. Unfortunately, it should be admitted that humeral nailing, in general, has not so far reproduced the results that have established the technique as the “gold standard” treatment for femoral and tibial diaphyseal fractures6,7,16,58,72,143,163,242,284,296,314 possibly because of the complexity of the humeral anatomy and the unique biomechanical characteristics of the arm. In addition, there has been no consensus regarding the fundamental principles of the surgical technique of humeral nailing (e.g., selection of antegrade or retrograde technique, reamed or unreamed nailing, avoidance of complications) or the important technical aspects (such as biomechanical requirements of the humeral nail or nail selection criteria).96

 
Figure 36-32
The author’s preferred treatment for diaphyseal humeral fractures with indications for surgery.
Rockwood-ch036-image032.png
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In an effort to improve the efficacy and outcomes of intramedullary nailing of diaphyseal humeral fractures I have proposed that humeral nails must be differentiated in two categories based on their biomechanical properties: “fixed” nails that use screws for interlocking their end opposite to the entry portal and “bio” nails that provide interlocking distal to the insertion site without screws.97 Important considerations that differentiate humeral nailing from the nailing of the femur and tibia and should be taken into account to justify the use of “bio” nailing in the humerus are the following:

  1.  
    The humerus is a non–weight-bearing bone
  2.  
    Because of the wide ROM of the shoulder and elbow joints, the humerus can tolerate certain degrees of axial and rotational malalignment
  3.  
    A few centimeters of humeral shortening can pass unnoticed
  4.  
    Freehand locking is more difficult and risky in the humerus
  5.  
    Functional bracing of a humeral shaft fracture does not provide strong axial or rotational stability to the fracture site but is still an effective treatment for humeral diaphyseal fractures
 

All of these parameters enhance the role of “bio” nailing in the management of humeral shaft fractures. However, it is my opinion that both “fixed” and “bio” nails are reliable implants for the humerus but that each type of nail must be used correctly. “Fixed” nails provide optimum stability with the proximal and distal locking screws and, if their design allows, the site of insertion (antegrade or retrograde technique) depends on surgeon preference. The stability provided by “bio” nails depends on their distal locking facility. Stability can be achieved in the Seidel nail if the distal expanding fins engage the endosteum, in the Marchetti-Vincenzi nail if the pins are long enough to diverge and embed into the humeral head, and in the Fixion nail if its expanded body fits tightly in the distal canal. The benefit of “bio” nailing, my preferred technique, is the avoidance of distal locking screws, a procedure that is time-consuming and difficult in the humerus, endangers the radial and lateral cutaneous nerves in antegrade nailing, and the axillary nerve in retrograde nailing.23,26,151,170,173,197,257

 

Iatrogenic injury of the rotator cuff has been considered responsible for suboptimal clinical outcomes and shoulder joint discomfort after antegrade humeral nailing.79,247,315 However, apart from ongoing efforts to find less traumatic approaches to the proximal humerus or invent new implants that avoid violating the rotator cuff,70,221,285 it is my opinion that the consequences from the approach through the rotator cuff can be eliminated if96,97:

  1.  
    The entry portal is created as medially as possible (to approach the humeral head through the musculotendinous rather than the tendinous area of the rotator cuff).
  2.  
    The incision in the rotator cuff is made with a sharp blade and is not more than 1 cm. It is important to be precise about the location of the entry portal and avoid more than one incision.
  3.  
    Reaming is totally avoided. Although relevant studies are missing, it is logical to assume that sharp reamers create further damage to the rotator cuff during insertion and withdrawal. Furthermore, the reaming products can lodge in the rotator cuff and may contribute to shoulder joint problems postoperatively. In addition, reaming risks injury to the radial nerve by the reamer if a comminuted fracture is located at the middle third of the humerus.
  4.  
    Meticulous repair of the rotator cuff is performed at the end of the operation.
 

There is supportive evidence that antegrade intramedullary nailing, if performed correctly, may not be responsible for shoulder joint complications.82,84,92,150,200,211,220,253,263,285

 

Iatrogenic injury of vulnerable soft tissues (axillary nerve, circumflex artery, long head of biceps, deltoid) around the proximal humerus by the proximal locking screws in antegrade nailing and “fixed” retrograde nailing3,27,78,167,173,235 can be reduced by the use of necessary screws only and avoidance of an AP proximal locking screw if possible. Alternative proximal locking options for antegrade nailing that aim to reduce the problems from the proximal locking screws have been proposed but have not been validated with further studies.92,95 Problems from the proximal locking screws during antegrade nailing in middle and distal diaphyseal humeral fractures can be eliminated with the use of the retrograde technique. In these cases the nail can be shorter so that the proximal locking screws can be inserted just below the surgical neck of the humerus and avoid injury to the axillary nerve.96 Another good reason for choosing the retrograde technique for fractures located at the mid-distal humeral diaphysis is the biomechanical evidence that nailing from short to longer bone segments can improve the mechanical properties of the fixation construct because of better nail/bone interface purchase.169 This information is more valid for “bio” nails without distal locking screws and supports the use of retrograde nailing in more distal fractures.

 

In retrograde nailing, the entry portal must be wide enough to accommodate the eccentric insertion of the nail. The narrow humeral canal at the distal humerus can be enlarged with staged reaming because in this area there are no vulnerable soft tissues that can be harmed by the reamers. However, extra care is needed for the avoidance of fissuring or fractures at the supracondylar area, and meticulous washing out of the reaming debris must be performed at the end of the procedure.24,96

 

My last recommendation regarding the use of intramedullary nailing for the management of diaphyseal humeral fractures refers to the timing of surgery. As I do not favor humeral reaming and dynamization cannot be applied effectively in the arm, union of a humeral fracture relies a lot on the fracture hematoma. Therefore, the chances of uncomplicated healing for humeral shaft fractures are maximized if nailing is performed in fresh fractures, which in my practice is up to 2 to 4 weeks from accident. In cases where the fracture union progress seems delayed or can be characterized as delayed (3 to 6 months), I use “fixed” intramedullary nailing and percutaneous autologous concentrated stem cells at the fracture site.94

 

Established nonunion of a humeral shaft fracture is usually atrophic and in my opinion requires surgical debridement, autologous corticocancellous bone grafting, and rigid fixation that can be provided effectively by compression plating.

 

I treat open fractures without significant contamination with a U-slab and antibiotics for a few days (maximum 10 to 12 days), until the wound allows definitive treatment with intramedullary nailing. For open fractures with severe contamination and soft tissue compromise, I use external fixation with conversion to nailing or plating with the timing of the conversion depending on the extent and location of the soft tissue injury.

 

For pathologic fractures I also use intramedullary nailing (usually “fixed”) that offers a reliable, quick, and atraumatic solution that serves as palliative treatment.92,95

Special Considerations

Open Fractures

Despite reports that open humeral fractures are not amenable to treatment with functional bracing,223,243,259,297 there have been studies that present good results with nonoperative treatment.15,76,150,263,315,323 Sarmiento et al. in two studies treated 11 and 155 open fractures respectively with functional bracing.263,265 The authors reported excellent healing rates (10/11 and 146/155 respectively) with no infections. Zagorski et al.323 treated 43 open diaphyseal humeral fractures with functional bracing, 35 of which were gunshot injuries. The patients underwent operative exploration, debridement, intravenous antibiotics, and provisional immobilization with a plaster splint. All wounds were left open to heal by secondary intention. Bracing was initiated at the time of the first change of dressings at 2 to 3 days after injury. Following this protocol, only one nonunion developed in this substantive series of open fractures. 
For most physicians, the treatment regime for open humeral shaft fracture depends on the severity of the injury, as has been classified by Gustilo and Anderson106 (Chapter 2). Grade I fractures can be managed well with functional bracing, grade II fractures can be treated either conservatively or operatively depending on the wound contamination, and grade III fractures should be treated operatively.51,199,265,272 The preferred method of treatment for severely open humeral shaft fractures is external fixation either as definitive treatment or as temporary stabilization that is converted to plating or nailing, as soon as the condition of the injured soft tissues allows.72,256,289 
Immediate plating has been used in the management of open humeral shaft fractures.19,220 However, until recently, there was insufficient evidence about its performance as many reports were of sporadic cases mixed with closed fractures.19,220 Recently, Connolly et al.51 documented good results from traditional plating techniques in 46 patients with open humeral fractures. Apart from six cases of delayed union all other fractures healed uneventfully at a mean time of 18.4 weeks (12 to 26). Idoine et al.129 reported equally good results after treating 20 open humeral shaft fractures (within a cohort of 46 multitrauma patients) with immediate plating. Immediate intramedullary nailing has also been used successfully for the treatment of open humeral fractures.57,251,272 However, similarly to plating, the literature lacks adequate evidence regarding the use of the technique in open humeral fractures. 

Osteoporotic Fractures

Although it was generally believed that osteoporosis alone does not interfere with the healing process of a fractured bone, more recent data challenged this assumption and introduced doubts that could influence the management of fragility fractures in the future.54,207,292 The choice of implant and technique for the management of osteoporotic humeral shaft fractures when surgical treatment is indicated is always difficult. The main reason is the weak bone and potential loss of screw purchase resulting in fixation failure.53,252 Intramedullary nailing has been considered a reliable option for the management of humeral fractures and nonunions in the elderly because the intramedullary rod is a load-sharing implant.88,94,226,251 Locking plates, in which screws with threaded heads can be screwed into the plate hole to create a fixed-angle implant, seem to be advantageous in osteoporotic fractures and nonunions in general and more specifically in the humerus.62,109,211,245,284 Complicated osteoporotic cases may require a combination of implants to provide optimum stability that will allow an effective and uncomplicated rehabilitation program (Fig. 36-33A–D). Gardner et al.90 found no biomechanical differences in hybrid constructs (combining locking and nonlocking screws in the same plate) as compared with fully locked plates which may help to reduce the cost, bearing in mind that locking screws are more expensive than the traditional ones. 
Figure 36-33
 
A: Sixty-eight-year-old female patient with a proximal diaphyseal humeral fracture at the tip of a plate that was used for the fixation of a proximal humeral fracture 8 months ago. B: After the removal of the plate the new, grossly osteoporotic fracture, was treated with a combination of intramedullary nailing (to splint the whole humerus internally) and locking plating. The plate was taken from the distal tibia set, because it could provide locking screws that could go around the nail, as well as unicortical screws that could compress the nail against the endosteum and increase the stability of the fixation. C, D: Clinical result at 6 months post operation. The patient expressed her satisfaction from the treatment and did not attend the next follow-up appointment.
A: Sixty-eight-year-old female patient with a proximal diaphyseal humeral fracture at the tip of a plate that was used for the fixation of a proximal humeral fracture 8 months ago. B: After the removal of the plate the new, grossly osteoporotic fracture, was treated with a combination of intramedullary nailing (to splint the whole humerus internally) and locking plating. The plate was taken from the distal tibia set, because it could provide locking screws that could go around the nail, as well as unicortical screws that could compress the nail against the endosteum and increase the stability of the fixation. C, D: Clinical result at 6 months post operation. The patient expressed her satisfaction from the treatment and did not attend the next follow-up appointment.
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Figure 36-33
A: Sixty-eight-year-old female patient with a proximal diaphyseal humeral fracture at the tip of a plate that was used for the fixation of a proximal humeral fracture 8 months ago. B: After the removal of the plate the new, grossly osteoporotic fracture, was treated with a combination of intramedullary nailing (to splint the whole humerus internally) and locking plating. The plate was taken from the distal tibia set, because it could provide locking screws that could go around the nail, as well as unicortical screws that could compress the nail against the endosteum and increase the stability of the fixation. C, D: Clinical result at 6 months post operation. The patient expressed her satisfaction from the treatment and did not attend the next follow-up appointment.
A: Sixty-eight-year-old female patient with a proximal diaphyseal humeral fracture at the tip of a plate that was used for the fixation of a proximal humeral fracture 8 months ago. B: After the removal of the plate the new, grossly osteoporotic fracture, was treated with a combination of intramedullary nailing (to splint the whole humerus internally) and locking plating. The plate was taken from the distal tibia set, because it could provide locking screws that could go around the nail, as well as unicortical screws that could compress the nail against the endosteum and increase the stability of the fixation. C, D: Clinical result at 6 months post operation. The patient expressed her satisfaction from the treatment and did not attend the next follow-up appointment.
View Original | Slide (.ppt)
X

Pathological Fractures

Sarahrudi et al.262 proposed that patients in the advanced stage of metastatic disease are better treated with intramedullary nailing while ORIF should be kept for metaphyseal fractures and for those patients with a solitary metastasis in the humerus or those with a better prognosis. However, most studies propose intramedullary nailing as the treatment of choice in metatstatic fractures of the humeral diaphysis because this allows splintage wand protection of the whole humerus.11,176,228,234,283 As, in general fracture healing is not expected, nail augmentation and filling of the areas of bone loss with cement or other substances has been proposed.156,234,255 Taking advantage of the minimal invasiveness of the MIPO technique and the extensive coverage of the humeral shaft that such a plate provides, Choo et al.46 described the management of a metastatic lesion of the distal humerus with MIPO plating creating a new indication for this technique. 

Periprosthetic Fractures

Periprosthetic fractures of the humerus are rare but will become more frequent, as the number of shoulder and elbow arthroplasties increase and people live longer.12,13,260,286,319 Periprosthetic humeral fractures can occur perioperatively or postoperatively. Common risk factors include perioperative technical errors during primary or revision arthroplasty, over-reaming the humeral canal, and other general factors such as rheumatoid arthritis, osteoporosis, revision surgery, and osteolysis or loosening of the prosthesis. Wright and Cofield320 classified periprosthetic humeral fractures after a shoulder arthroplasty. Type A are those that start at the tip of the prosthesis and extend proximally; type B are around the tip of the prosthesis; and type C are located distal to the tip of the prosthesis. Likewise, O’Driscoll and Morrey classified periprosthetic humeral and ulna fractures that occur after elbow joint arthroplasty. Type I are periarticular/metaphyseal fractures at the level of the condyles/olecranon, type II fractures at the level of the stem of the prosthesis, and type III beyond the tip of the prosthesis in the diaphysis (Mayo classification).210 
Treatment options for periprosthetic humeral fractures depend on the stability of the prosthesis, the location of the fracture, and the bone quality.66 In general, nonoperative treatment can be attempted for undisplaced fractures in the presence of a stable prosthesis. Surgery can be reserved for failures of conservative treatment which is more frequent with types B and C for shoulder arthroplasty and type III for elbow arthroplasty. Nonoperative treatment can also be attempted in the case of displaced fracture but only with a stable prosthesis. If the prosthesis is loose or unstable it must be removed and replaced by a longer one, either cemented or not. The new stem must bypass the fracture by at least two cortical diameters and if cemented, care should be taken not to allow the cement to protrude at the fracture site and prevent bone healing. Augmentation of the revision prosthesis with a side plate and/or cerclage wire(s) is usually necessary for stabilization of the fracture. Complications that can occur during or after these procedures include infection, neurologic problems, loss of fixation, hardware failure, and delayed union or nonunion of the fracture.13,33,210 

Summary, Controversies, and Future Directions Related to Humeral Shaft Fractures

Nonoperative treatment, mainly in the form of functional bracing, remains the preferred treatment method for acute diaphyseal humeral fractures despite the progress of surgical techniques over the last decades because of the following: 
  •  
    The ease of nonoperative management (simple splinting, ambulatory patient, no hospitalization).
  •  
    The complex anatomy and unique biomechanical characteristics of the arm that make surgical intervention demanding.
  •  
    The lack of consensus about:
    •  
      indications for and timing of surgical intervention.
    •  
      nailing issues, such as the indications for antegrade or retrograde, reamed or unreamed, static or dynamic, “fixed” or “bio” techniques.
While surgical techniques and implants are emerging and improving (locking plates, MIPO, new nail designs, and less traumatic approaches), we witness an enduring and fascinating debate among the supporters of each treatment method.101 Research is ongoing and future directions are unclear but, in general, the trend is toward less invasive techniques that can provide high fracture union rates while minimizing complications, faster and better shoulder and elbow joint functional recovery, and prompt return to everyday activities. Future research may reveal that the treatment of diaphyseal humeral fractures depends more on fracture characteristics (pattern, location, timing of injury) and patient’s details (age, comorbidities, occupation, etc.) rather than the surgeon’s preference. 

Acknowledgment

The author would like to thank Dr. K. Doudoulakis MD, for his invaluable contribution with the drawings of the chapter. 

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