Chapter 91 - Fractures of the Humeral Shaft and the Distal Humerus

Question 1

relationships of the radial nerve as you move along the humerus

Answer 1

14cm proximal to the lateral distal articular surface
20 cm proximal to the medial distal articular surface
DIRECTLY posterior to the deltoid tuberosity

Question 2

anterolateral approach to the humerus

Answer 2

best for proximal to middle 1/3 humeral fractures
radial nerve located distally in incision between brachioradialis and brachialis mm
Brachialis has dual innervation (radial and musculocutaneous n. split it to preserve this innervation and to protect the radial n)

Question 3

posterior approach to the humeral shaft

Answer 3

• between lateral and long heads of the triceps
• radial nerve in spiral groove
• ulnar n runs deep to. medial head of triceps

Question 4

associated nerve injuries with their fracture patterns

Answer 4

distal 1/3 humerus - radial n
articular injuries - ulnar nerve

Question 5

most common fracture deformity

Answer 5

apex anterior
varus (deltoid)

Question 6

at what time point do you need to convert from coaptation splint to sarmiento?

Answer 6

7-10 days

Question 7

at what point can you do pendulums/codmans, isometric biceps/triceps/deltoid?

Answer 7

as soon as you transition to a fracture brace

Question 8

what screw orientation improved bending strength when plating a humeral shaft fracture?

Answer 8

Long plate - near near (aka right next to fracture) then far far (ie the last holes in the plate)

Question 9

plating a humerus fracture in a poly trauma patient has what benefit?

Answer 9

ability to be immediately WBAT

Question 10

biomechanical outcomes of nail vs plate

Answer 10

nails can withstand higher axial and bending loads than plates although plates allow full weightbearing, so there is no clinical benefit potentially

Question 11

outcomes of plate v nail in humeral shaft fracture

Answer 11

increased incidence of shoulder pain, increased revision risk, and higher non-union rate in humeral nail

Question 12

to minimize shoulder pain in humeral nailing what should you do?

Answer 12

more medial start point
split the interval between the anterior and middle thirds of the deltoid
split the cuff in line with muscle fibers

Question 13

radial nerve recovery outcomes

Answer 13

incomplete&raquo_space; complete (97 v 78% recovery)
closed fx&raquo_space; open fx (97 v 86%)

Question 14

what nerve is at risk with anterior to posterior distal interlock screws?

Answer 14

musculocutaneous -> LABC

if the nail is torated a little such that the screw aimed anteromedial to posterolateral the median n and brachial a are at risk

Question 15

what nerve is at risk with a lateral to medial distal interlock screw?

Answer 15

radial n

Question 16

what nerve is at risk with the proximal interlocks?

Answer 16

axillary n

Question 17

biomechanical difference between 90-90 plating and locked plating?

Answer 17

parallel plating biomechanically superior to 90-90 both are more than clinically adequate

Question 18

how to treat capitellar fractures surgically

Answer 18

I: big bony piece of capitellum- headless compression screws
II: cartilge shear injuries - excise fragment
III: severely comminuted - excise fragments

Question 19

what exposure should you avoid in elderly distal humerus fractures with a chance of total elbow?

Answer 19

olecranon osteotomy