Prof. Lennard Funk’s Education Portal

Call: 01625 545071
Email: [email protected]
For treatment enquires visit The Arm Clinic

Humeral Shaft Fractures - comparative Management

John Geoghan, 2007


  Click Here for Presentation


  Click Here for Presentation


Epidemiology:


Epidemiology:
  • 3% of all fractures
  • Incidence of 15 per 100,000
  • Bimodal age distribution  - 3rd decade males
         - 7th decade women
  • 8% incidence of radial nerve palsy
  • 8% pathological#
  • 2% open fractures

Acceptable displacement:

  • < 3cm shortening
  •  < 20° AP angulation
  •  < 30° varus - valgus angulation

John Charnley:
"A fracture of the shaft of the humerus is perhaps the easiest of major long bone fractures to treat by conservative means. 
 "If some shortening results it is of no significance. If some angular deformity persists it is usually concealed by muscle covering.... 
 "These are facts which must be remembered when any elaborate or operative method for treating this bone is under consideration"
 The Closed Treatment of Common Fractures - John Charnley (1950).

Non-operative Treatment

Hanging Cast (Caldwell, 1933):

  • Remain upright to maintain traction
  • Shortening, rotational deformities, angulation (POP fulcrum)
  • Concerns of over distraction & non-union.
  • Union 93-96%
  • Significant elbow stiffness

U-Slab:

  • Temporary splint acute setting
  • Immobilises shoulder and elbow
  • Axilla hygiene and skin problems
  • Over distraction

Functional Bracing (Sarmiento, 1999):

  • Temporary coaptation splint / POP approx 12 days
  • Functional brace
  • Pendulum exercises day 1
  • Active elevation & abduction avoided
  • Reported
    • Good alignment
    • Rapid healing
    • No non-union cases in non pathological fractures
  • Non-union 1.8 to 3.9%
  • Union 8 to 11 weeks
  • Limitation of motion
    • Shoulder =  0-15°
    • Elbow = 0-10°

Ekholm et al JOT 2006 20(9):591-6:

  • Non-union 10%
  • Non-unions more frequent in type A fractures
  • Concluded that seemed reasonable to explore use of plate fixation in this group.

Comparative studies

Brace  vs U slab Camden P,  1992

  • No difference time to union or alignment
  • Significantly decreased ROM elbow at union - u slab
  • 11-126° brace compared to 50-119° U slab

Brace vs nail  Wallny T, 1997

  • Brace superior to nailing
  • FROM shoulder 86% brace & 46% im nailing

Brace vs plating Bleeker WA, 1991

  • Bracing superior results
  • Operative Management
    • Plating
    • Intramedullary Nailing
  • Operative Indications
    • Absolute
      • Open fracture
      • Floating shoulder / elbow
      • Bilateral humeral fractures
      • Vascular injury
      • Neurological Injury
      • Brachial Plexus
      • Holstein-Lewis
      • Secondary radial nerve injury
    • Relative
      • Inability to obtain reduction
      • Long spiral : muscle interposed
      • Transverse : over distraction
      • Segmental
      • Inability to maintain reduction
      • Obesity (large breasts)
      • Neurological deficit, Parkinson's
      • Non-compliance (alcohol / drug abuse)
      • Pathological
      • Non-union

Plating

"Effective and predictable" - Rockwood & Green, 5th Ed

Concerns:

  • Significant dissection
  • Operative time
  • Radial nerve injury
  • Osteopenic bone
  • Union 93-100%
  • Infection 0-6%  (open fractures)
  • Iatrogenic radial nerve palsy 0-5%
  • ROM shoulder & elbow returns predictably

Intramedullary Nailing

  • Minimally invasive
  • Low morbidity
  • Rapid fixation and return to function
  • Principles and designs extrapolated from experience in femur and tibia

The Problems:

  • Complicated anatomy & unique biomechanics arm
  • Poor studies due to numerous principles, implants, designs and techniques - difficult to analyses
  • Varied results
  • Shoulder function
  • Non-union
  • Controversial
  • On Going Research

Interlocking Nail Results

  • Non-union     8-33%
  • Poor shoulder function   16-50%
  • Impingement    37%
  • Metalwork removal   25%
  • Re-op rate     70%
  • Complication rate   87%
  • Infection / radial nerve palsy comparable to plating

Amount of stability required for humeral union remains to be defined

Compare and contrast with the lack of significant rotational / axial stability with bracing.

Retrograde nailing

  • Excellent shoulder function  90%
  •  Excellent elbow function   88%
  •  Migration     5%
  •  Fracture on insertion and extraction 5%

Plating - theoretically better biomechanics in humerus


Prospective Randomised Studies

Searching Medline
Two studies - plate vs nail
Prospective Randomised Plating with antegrade & retrograde nailing

McCormack RG 2000, JBJS-Br 82(3):336-9

  • Prospective Randomised Plating with antegrade nailing
  • Union @ 16 weeks   87% nails: 93% plating
  • Shoulder pain &? ROM  significant assoc nails
  • ? ROM elbow    significant assoc plating
  • Other Complications  equal prevalence

Summary

  • Literature limited & poor
  • Gold standard - functional bracing
  • Operative gold standard - compression plating
  • Define role of humeral nailing: 
    •  pathological fractures
    •  long spiral
    •  segmental fractures 
    •  osteopenic fractures

What's your choice?



  Click Here for Presentation

Search ShoulderDoc.co.uk

Find a Shoulder Professional

+ Add Your Clinic Advanced Search

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.

ShoulderDoc.co.uk satisfies the INTUTE criteria for quality and has been awarded 'editor's choice'.

The material on this website is designed to support, not replace, the relationship that exists between ourselves and our patients. Full Disclaimer