Humeral Shaft Fractures - comparative Management

John Geoghan, 2007

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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?