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There is general agreement that operative treatments of fractures of the mid-shaft of the humerus have a high complication rate.
Non-union, nerve injuries and infection are often seen.
Management of these fractures with a functional brace gives a high rate of union and the functional result is good, especially in older people.
The open treatment of fractures of the distal third of the humerus is advocated.
There is a belief that an open treatment is necessary to obtain an acceptable e.g. an anatomical alignment.
The most common problem in the conservative treatment is the difficulty in controlling angulation.
In distal humeral fractures good results are described with a functional brace.
There are several advantages when a humeral brace is made of Soft Cast.
In older people the skin looses some of its elasticity which may cause some problems when a rigid brace is applied.
However, the function of the brace is only then optimal when the brace is tightly closed, to compress the surrounding tissues.
The rigidity of the traditional materials might also cause pressure problems on prominent humeral condyles.
The result of both the problems described is that the patient loosens the brace which results in a decreased functionality.
A humeral brace with an overlap made of Soft Cast solves these problems.
The softness of Soft Cast is barely noticed on the humeral condyles.
More important is the possibility of applying the brace tightly in a comfortable way.
This gives the brace optimal function.
The fracture is supported by the surrounding soft tissue and this support is increased during activities.
There is no need for a splint reinforcement in a humeral brace.
In some cases, e.g. when the fracture is located in the proximal third of the humerus, a proximal prolonged version of the brace can be used.
The short and long humeral braces are described.
Also a humeral brace is described which can be used in the initial treatment or in the treatment of fractures in the distal third of the humerus.
This brace is similar to the hinged long arm cast as described in that chapter with the only difference that a full range of motion is allowed in the wrist.
Humeral shaft fractures
In 1977, Sarmiento et al. presented the results of fifty-one humeral shaft fractures treated with a functional brace and conclude that the early introduction of functional activity to the entire extremity appears to provide a desirable physiological environment conducive to rapid healing.
Apart from the difficulties encountered in carrying out long-term follow-up studies, reported in Sarmiento et al.'s long-term follow-up review of 620 of 922 patients with humerus fractures, the authors conclude that functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union, particularly when used for closed fractures.
The residual angular deformities are usually functionally and aesthetically acceptable.
McCormack et al. suggest that open reduction and internal fixation with a dynamic compression plate remains the best treatment for unstable fractures of the shaft of the humerus.
Fixation by intramedullary nailing may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.
Farragos et al. reviewed the literature and conclude that the attractive theoretical advantages of locking humeral nails have not been borne out in clinical studies.
Complications such as shoulder pain, delayed union or nonunion, fracture about the implant, iatrogenic fracture comminution, and the difficulty in the reconstruction of failures have diminished their usefulness.
The precise role of locking nails in the treatment of humeral shaft fractures has yet to be defined.
At present, open reduction and compression plating remain the treatment of choice for humeral shaft fractures that require operative intervention.
Wallny et al. treated 87 patients with a functional brace and performed a review to determine the effectiveness of the treatment. Eighty-six percent of the follow-up group showed no restrictions in the movement of their shoulder and elbow joints.
On the basis of subjective criteria, 95% of the patients were content with the functional treatment, 65% claimed to be pain free in their daily activities and at work, and 35% felt pain only when doing vigorous activities or heavy physical work.
Although malposition with an angulation greater than 10 degrees was observed in ten patients (12.6%), functional outcome was good or excellent in two thirds of the cases followed up.
Klestil et al. evaluated sixty-three patients with humeral shaft fractures clinically and radiographically 18 months after injury; 27 patients were treated surgically and 36 patients conservatively.
They concluded that the results of these two comparable groups suggest that conservative treatment of humeral shaft fractures is superior regarding mobility of the shoulder and elbow, strength, the incidence of neurological complications, pain, subjective rating and cosmesis and found no differences on roentgenograms between the two groups.
The same authors treated a group of 8 bedridden, mentally incompetent or non-compliant patients with functional fracture bracing immediately following the initial insult with good results.
Soft Cast was used to fabricate these braces.
Also Hreckovski achieved fracture stabilisation primarily by a humeral brace, custom made from Soft Cast.
Clinically it was observed, that already within the first week of the brace treatment the pain reduced equally to the reduction of the swelling; this pain reduction motivated most of the patients to increase functional activities.
95% of the patients did not have limitation in the joint movements at the moment that the X-ray showed fracture union, and were satisfied with this treatment.
At time of union 5 patient had a limitation of 15° abduction in the shoulder compared to the unaffected shoulder.
There were no non-unions and 22 fractures healed clinically long before an union was identified on the x-rays.
During heavy physical exercises (push ups) most of the patients had no pain.
All patients in this study were treated in the out patients clinic.
When looking at cost effectiveness and patient outcome, this functional therapy showed significant benefits compared to operative interventions.
= Humeral shaft fractures.
= Extra-articular fractures of the distal third of the humerus.
= 75 cm x stockinette 7.5 cm.
= 1 roll x Soft Cast 10 cm.
= 1 roll x Soft Cast 5 cm (only for the long humeral brace).
= Straps, rivets, sports tape.
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