1. Midshaft humerus fractures
Abel David, MS-III
University of Virginia
School of Medicine
August 4, 2016

2. Epidemiology Accounts for approximately:
3% of all fractures
20% of humeral fractures
Primary mechanisms of humerus fractures include:
Motor vehicle crashes
Violent injury
Accidental falls
In 3-year epidemiological study, with n=249 consecutive humeral shaft fractures, demonstrated a bimodal distribution:
A peak in the 3rd decade, majority males, high energy
A larger peak in the 7th decade, majority females, low energy

3. Relevant Anatomy Muscles: Nerves: Artery:
Insertion of: pectoralis major, deltoid, and coracobrachialis
Origin of: brachialis, triceps, and brachioradialis
Nerves:
Radial nerve
Courses along spinal groove
14 cm proximal to lateral epicondyle
20 cm proximal to medial epicondyle
Artery:
Brachial artery

4. Deforming forces
Major deforming forces include the deltoid m. and pectoralis major m.
Different displacement of the fracture segments based on the location of the fracture relative to the insertion of deltoid and pectoralis major

5. Case Report: M.B. 19 y/o F
M.B. is a 19-year-old female who presented to the UVA ED as a trauma alert, she was the restrained occupant of a high-speed, rollover MVC. Her orthopedic injuries included: right radial shaft fracture, left humeral shaft fracture, and right forearm laceration with exposed FDS muscle/tendon.
No PMHx or PSHx

6. Case Report: M.B. 19 y/o F Right Forearm Left Arm
Right forearm tender to palpation, mild deformity, 6cm laceration with exposed muscle belly
Intact motor to AIN/PIN/U nerves
SILT M/R/U nerve distributions
Compartments soft and compressible
2+ radial pulse
Left Arm
No deformities noted, no open wounds
Motor intact to wrist flexion/extension, finger flexion/extension/intrinsics
Intact motor to AIN/PIN/U nerve
SILT M/R/U distributions

7. Injury Imaging AP
Lateral

8. Case Report: M.B. 19 y/o F
Then, an anterolateral approach to the humerus was made and interval between the biceps and brachialis was carefully dissected. Biceps was retracted medially and brachialis was split along the lateral 2/3 of the muscle down to bone. We immediately encountered fracture hematoma. Dissection was carried more proximally and part of the deltoid insertion was reflected for plate placement. We palpated and visualized the fracture fragments and the radial nerve, which was not in the fracture site. We then irrigated and delineated the fracture edges and reduced the fracture using reduction forceps. We then reduced the proximal shaft fragment to distal shaft fragment using reduction forceps. We then placed a synthes narrow 4.5mm 7-hole LCP plate and secured it provisionally with a k wire. We confirmed location and position with fluoro. We then placed two proximal cortical screws, then 3 distal cortical screws, then 2 more proximal cortical screws. Fluoro was then taken again and we confirmed satisfactory reduction of fracture fragments and adequate plate positioning.

9. Post-ORIF Imaging

10. Follow-up 2 weeks later
Remained NWB in bilateral UE with a splint on her right forearm and a sling on her left arm
Pain was well controlled, no signs or symptoms concerning for site infection, no constitutional symptoms,
ROM, strength, neurovascular status continue to remain stable
Imaging confirmed no hardware issues or fracture displacement

11. Clinic Follow Up ImagingAP
Lateral

12. Classification No classification scheme of humeral shaft fractures
Traditionally described by:
Location: proximal, middle, or distal
Type of fracture line: transverse, oblique, spiral, comminuted, or segmental
Open vs. closed
AO/OTA fracture descriptions

13. Classification Bone 1, Fracture Location 2
Simple transverse humeral shaft fracture, OTA Classification: 12-A3

14. Holstein-Lewis Fracture
Named fracture of the humerus
Spiral fracture of the distal 1/3 of the humeral shaft, associated with neuropraxia of the radial nerve

15. Management Non-operative management Operative management
Coaptation splint followed by functional brace
Operative management
Closed reduction, intramedullary nailing
Open reduction internal fixation

16. Non-operative Management
Indicated in majority of humeral shaft fractures
Criteria for acceptable alignment:
< 20˚ of anterior angulation
< 30˚ of varus/valgus angulation
< 3 cm of shortening
Absolutely contraindicated in brachial plexus injury, vascular injury requiring repair, and severe tissue/bone loss

17. Operative management, ORIF
Indications:
Open fracture
Vascular injury requiring repair
Brachial plexus injury
Compartment syndrome
Ipsilateral forearm fracture (floating elbow)
Relative: polytrauma

18. Operative management, IMN
Relative indications
Pathologic fractures
Segmental fractures
Severe osteoporotic bone

19. Non-operative v. operative
Plate fixation vs. functional bracing in 51 consecutive patients (19 with plate and 21 with functional bracing) – Jawa et al.
Demonstrated that operative treatment achieved more predictable alignment and quicker return of function
There was a higher risk of iatrogenic radial nerve injury, infection, and increased reoperation rates
Functional bracing was associated with skin problems, and angular deformity but function and ROM were usually acceptable

20. ORIF v. IMN
Similar numbers of patients had nonunion, infection, and iatrogenic nerve injury Mean hospital stay, blood loss, and operation time were not significantly different
In two RCTs, the reoperation risk for IMN was three times that for plates (Changulani et al. Chapman et al.)
In one RCT, patients who received IMN had more shoulder pain and decreased shoulder ROM (Changulani et al.)

21. Complications Malunion Non-union Radial nerve palsy
Brachial artery injury

22. Prognosis of Humeral Fractures
Non-union is associated with:
Long oblique fracture pattern
Alcohol abuse
Obesity
Comminuted fractures
Open fractures
Fractures in the middle third of the humeral shaft
Transverse fractures

23. Summary
Relatively common fracture seen in 3rd decade males with high energy mechanisms and in 7th decade females with low energy mechanisms
Neurovascular assessment is important, especially the evaluation of radial nerve function and for brachial artery injury
Majority are managed non-operatively with good outcomes with a coaptation splint and functional brace
Operative management has a more predictable alignment and quicker return of function, but higher rates of iatrogenic nerve injury/infection
Additional RCTs are still needed to further validate

24. References
Tytherleigh-Strong G, Walls N, McQueen MM (1998) The epidemiology of humeral shaft fractures. J Bone Joint Surg Br; 80:
Houwelingen AV, McKee MD (2004) Management and Complications of Humeral Shaft
Fractures. University of Toronto Medical Journal; 81:96102.
Jawa A, McCarty P, Doornberg J, et al (2006) Extraarticular distal third diaphysealfractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am; 88:23437.
Changulani M, Jain UK, Keswani T (2006) Comparison of the use of the humerusintramedullary nail and dynamic compression plate for the management of diaphysealfractures of the humerus. A randomised controlled study. Int Orthop.
McCormack RG, Brien D, Buckley RE, et al (2000) Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br; 82:3369.
Chapman JR, Henley MB, Agel J, et al (2000) Randomized prospective study of humeralshaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma; 14:1626.