Humeral Shaft Fractures

Question 1

What is the relationship of the radial nerve and the elbow?

Answer 1

Courses in the spiral groove 20cm above the medial epicondyle and 14cm above the lateral epicondyle

Question 2

What is a spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve?

Answer 2

Holstein-Lewis fragment; 22% incidence of neuropraxia

Question 3

What are criteria for acceptable alignment for humeral shaft fractures that are treated non-operatively?

Answer 3

30° Varus/valgus angulation
20° AP angulation
3cm bayonet apposition

90% union rate with functional bracing

Question 4

What are contraindications for non-operative management with functional bracing of humeral shaft fractures?

Answer 4

1) Vascular injury
2) Brachial plexus injury
3) Large soft tissue injury or bone loss

Radial nerve palsy is NOT a contraindication

Question 5

What are absolute and relative indications for ORIF of humeral shaft fractures?

Answer 5

Absolute:

1) open fracture
2) vascular injury requiring repair
3) brachial plexus injury
4) ipsilateral forearm fracture (floating elbow)
5) compartment syndrome

Relative:
1) bilateral humerus fracture
2) polytrauma or associated lower extremity fracture
allows early weight bearing through humerus
3) pathologic fractures
4) burns or soft tissue injury that precludes bracing
5) distraction at fracture site, short oblique or transverse fracture pattern, intraarticular extension

Question 6

Where is the radial nerve found during the anterolateral (extended deltopectoral) approach to humeral shaft fractures?

Answer 6

Between brachioradialis and brachialis

Approach is used for proximal and middle third fractures

Question 7

What are landmarks that can be used during the posterior approach to the humerus to find the radial nerve?

Answer 7

1) Exits the lateral intermuscular septum 10cm above the capitellum
2) Medial to the long and lateral heads of the triceps, 2cm proximal to the deep head of the triceps

Question 8

How do IM nails and plating of the humerus compare in regards to union rate and complications?

Answer 8

Recent meta-analysis shows equal union rates but higher complications with IM nails (16-37% increased shoulder pain)

Question 9

With placement of locking screws in an IM nail of a humerus what structures are at risk?

Answer 9

The proximal AP- musculocutaneous n.

The distal lateral-medial- radial n.

Question 10

What is the best treatment for non-union of humeral shaft fractures?

Answer 10

Compression plating with bone grafting

Question 11

How is radial nerve palsy managed in humeral shaft fractures?

Answer 11

1) Observation in closed
2) Exploration in open fxs
seen in 8-15% of closed fractures
neuropraxia most common injury in closed fractures and neurotomesis in open fractures
85-90% of improve with observation over 3 months
spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months
treatment
3) EMG at 3-4 months
4) Open exploration if no improvement in 6 months

Question 12

In the polytrauma patient that is being managed with DCO, what is the preferred management of the humerus?

Answer 12

Closed reduction and splinting; even in GSW

Question 13

What are risk factors for non-union of humeral shaft fractures?

Answer 13

Risk factors include

1) vitamin D deficiency (most common)
2) open fractures
3) segmental injuries
4) smoking and obesity.

Question 14

What are the “three sisters” in regards to the deltopectoral or anterolateral approach to the humerus?

Answer 14

the anterior circumflex humeral artery and its two venous commincantes