dr anglen humeral shaft fracture

7/29/2019 Dr Anglen Humeral Shaft Fracture

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Humeral Shaft

Fractures

J eff Anglen, MD FACS

Indiana University

Ortho aedic Trauma Association

AAOT


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Orthopaedic Trauma AssociationOrthopaedic Trauma Association

26th Annual Meeting26th Annual Meeting

October 14October 14 -- 16, 201016, 2010

Baltimore, MarylandBaltimore, Maryland

www.ota.org


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Plate or Nail?

Why are arms different than legs?


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Proconsul a miocene ape

A. Afarensis


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Brachiation


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Bipedal Brachiator

Lower Extremity

Compression during WB

Primarily bending stresses

Upper Extremity

Tension

Rotation


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Anatomy

Axillary nerve

Humeral circumflexartery

Radial Nerve

Profunda Brachii

artery


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Fracture


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Treatment options

Closed - Functional Brace

Plate

Nail

External fixation


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Closed treatment

Initially - splint or sling/swathe

Hanging ArmCast Historical treatment

2-3 weeks - functional brace

active ROM of elbow


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Functional Fracture Bracing

Sarmiento A. Zagorski JB. Zych GA. Latta LL. Capps CA.

Functional bracing for the treatment of fractures of the humeral

diaphysis.

Journal of Bone & Joint Surgery. 82(4):478-86, 2000 Apr.

620 fractures followed -155 open

16 Nonunions 2.5%87% healed with


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400


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Indications for Surgery

Open fracture

Segmental or floating elbow, ipsi shoulder fx Bilateral

Multitrauma

Penetrating trauma with neurologic deficit orvascular compromise

Uncontrollable

Pathological Not healing

Radial Nerve palsy is not anoperative indication in closed

fractures


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Plate or Nail?

Plate

Reliable, 96%union

Goodshoulder/elbow

function

Soft tissue scars, radialnerve, bleeding

Nail

Less incisionrequired

Successful in LE

Higher incidenceof complications?

Lower union rate?


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Plate or nail?

Chapman et a. J. Ortho. Trauma 14(3):162-6,2000

McCormack et al. JBJS 82B:336-9, 2000

Chiu et al. J. Trauma 43(6):947-951, 1997

Zatti et al. J. Trauma 45(6): 1046-50, 1998 Lin, J . J. Trauma 44(5): 859-64,1998

Comparisons


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Plate or nail?

Chapman et a. J. Ortho. Trauma 14(3):162-6,2000

McCormack et al. JBJS 82B:336-9, 2000

Chiu et al. J. Trauma 43(6):947-951, 1997

Randomized, Prospective, Comparisons


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Time to Union

Chapman, Chiu, Zatti, Lin Nail: 8.6 11.3 weeks

Plate 9.2 10.4 weeks

Similar in all 3 studiesNo difference between groups


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Incidence of Nonunion

Low overall

No statistically significant difference between groups

0

1

2

3

4

5

6

7

89

10

Chapman McCormack Zatti Lin Chiu

Nail

Plate

Selection Effect?

Technique?


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Overall complications

0

10

20

30

40

50

60

70

Chapman McCormack Chiu Zetti Lin

Nail

Plate


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Reoperation

0

5

10

15

20

2530

35

40

45

Chapman McCormack Chiu Zetti Lin

Nail

Plate


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Functional Outcome

No study has good patient oriented outcome

measures McCormack found no difference in pain or

ASES functional score (small numbers)

Both Chapman and McCormack:more problems with shoulder impingement,pain and restriction of motion after nailing


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What is the role for nailing?

Segmental fractures

Particularly with a very proximal fracture line

Pathologic fractures

? Cosmesis


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Humeral plates - Technique

Position

supine lateral

prone


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Supine - anterolateral


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Modified Posterior Approach

Gerwin, Hotchkiss and Weiland

J BJ S Am, 76-A, 1996 Identify nerve at lateral intermuscular septum

Retract medial and lateral heads of the tricepsmedially


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Lag Screws


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Cases


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Segmental

fracture

Shaft+Distal


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Segmental

Fracture

Shaft

+Proximal


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18 weeks


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35 yo RHD farmer falls from a

hayloft suffering a midshafthumerus fracture

Initial treatment is an IM Nail

9 months later - pain,

instability, NU


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Initial Treatment

Plate, Screws,

Implantable stimulator

Pain and instability

recurs within a week


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Nonunion treatment

Hardware

Removal, replatingwith bone graft


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40 yo physicians wife


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3 months


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Thanks

J eff Anglen

dr anglen humeral shaft fracture

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