Dr. Ebraheim’s educational animated video describes humeral shaft fractures, signs and symptoms, imaging and diagnostic tests, and treatment options.
There are several important points involving humeral shaft fractures:
1-Humeral shaft fractures are treated without surgery in the majority of cases. Nonoperative treatment gives a satisfactory outcome. A perfect alignment of the humerus is not important for an acceptable functional result.
2-Radial nerve palsy in not uncommon: check for neurovascular deficit before and after reduction (Especially wrist and finger extension). Holstein-Lewis fracture is commonly associated with neuropraxia of the radial nerve (Approximately 22% of cases).
3-Platting of the humerus is better with an IM rod.
Treatment
•Nonoperative is used in the majority of cases.
•Acceptable alignment
•Hanging arm cast occasionally used
•Humeral fracture brace: 7-10 days when the swelling and the pain is less.
•Functional bracing
Indications for surgery
•Open fractures •Vascular injury •Floating elbow •Loss of reduction
•Polytrauma patient •Brachial plexus injury
Surgery
•Plate fixation, more stable, less reoperation or complications. plate fixation is better than a rod
•Rod fixation: less stable, more reoperation
•External fixation: not commonly used.
Complex fracture:
types of fixation :
•plate •rod •external fixator (near fracture, away from fracture).
Anterolateral approach: in the proximal 2/3 the nerve lies posterior to the intermuscular septum, so its difficult to see the nerve. In order to see the nerve, you need to search for it between the brachialis and brachioradialis distally.
Posterior approach: is used for the distal 1/3 of the humerus.
Plating technique
•Pre-bend the plate: allows compression on the near and far cortex. Usually use 4.5 mm plate and screws. The humerus is subject to larger rotational forces. Staggered hole screw placement is ideal.
•Lag screw and neutralization plate for oblique fracture.
•Use bridge plate for comminuted fracture.
•Posterior approach for plating of fractures in the distal third of the humerus. The posterior surface is flat. Anatomically easier approach. Biomechanically better.
In general, plating of the humerus allows for immediate weight bearing with crutches or walker use.
•Locking plate •Used for osteoporotic patients •Sometimes 3.5 mm locking plate is used instead of 4.5 mm plate.
IM rod indications:
•Segmental fracture •Osteoporotic fracture •Pathological fracture
•Comminuted fracture
There is higher complication rate and shoulder pain with IM rod fixation. IM rodding will give you callus endochondral ossification. More callus than with plating.
Distal screws may have complications with plating. If you go from anterior to posterior, you risk injury to the musculocutaneous nerve.
External fixation is used in
•infected or contaminated cases with bad soft tissue injury
•Sometimes used temporarily
•Watch the position of the radial nerve when you insert the screws.
Usually three complications with humeral shaft fractures
1-Varus: common, especially after conservative treatment (does not affect function).
2-Nonunion: check 25-hydroxy vitamin D. usually plate and bone graft. If a rod has been used, remove the rod and then do plate and bone graft. If the nonunion is hypertrophic, use a compression plate alone.
3-Radial nerve palsy
Splint the wrist and obtain EMG studies in about 6 weeks. Fibrillation is bad, polyphasic is good. Monitor the brachioradialis muscle since it is the first muscle to recover. Extensor indices muscle is the last muscle to recover. Wrist extension radial deviation recovers first. Explore the nerve f the nerve fails to recover within 4-6 months.

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