Surgical Management of Humeral Shaft

Fractures: Plate vs Nail

E. Mark Hammerberg, MD
Denver Health Medical Center
University of Colorado

Acknowledgements
OTA and AO lecture archives

Gold Standard:
Functional Bracing
97.4% Union Rate
Good Functional Outcomes
Minimal Complications

Sarmiento et al., JBJS Am 1977

Indications for ORIF

Failed closed treatment

Open fracture
Vascular injury
Brachial plexus injury
Segmental fractures
Associated articular injuries
Floating elbow
Bilateral humerus fractures
Polytrauma
Radial nerve injury?

Indications for ORIF Injury Factors

Absolute
indications for
surgery: open
fracture, vascular
injury

Radial Nerve Injury

Incidence varies from 1.8% to 24% of shaft
fractures
Primary - occurs @ injury
Secondary - occurs later during closed or
open management
Mangement controversial

Radial Nerve Injury

Transverse fractures of
middle 1/3
neuropraxia

Spiral fractures of the

distal 1/3 (HolsteinLewis)
laceration/ entrapment

Radial nerve palsies

Most resolve
with time
Only strong
indication for
exploration is
open fracture

AO Meta-analysis, 1991
50% of humeral shaft fractures
are treated operatively
???
Nast-Kolb et al., Unfallchirurg 1991, 94:447-54.

Plate or nail?

McCormack et al., JBJS (Br) 2000, 82:336339.

Nail vs. plate:

randomized trial
Complications:

nail
n=21

plate
n=23

Iatrogenic radial nerve palsy: 14% 0%

Iatrogenic fracture:
5% 0%
Nonunion:
10% 4%
McCormack et al., JBJS (Br) 2000, 82:336-339.

ORIF Advantages
Allows for direct visualization and
protection of radial nerve.
Provides for direct anatomic reduction
Allows early physiologic range of motion
Allows early weight-bearing
Avoids unnecessary injury to rotator cuff

Anterior Approach

BEWARE: radial nerve emerges through

intermuscular septum laterally and distally!

Posterior Approach

Allows for direct exposure of radial nerve

Lateral Approach
Allows for exposure of entire
length of humerus
Can be performed with
patient in supine position
Can be modified to allow
prone or lateral positioning

Mills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996.

Plate Osteosynthesis
Avoid excessive
dissection
Preserve soft tissue
attachments of
butterfly fragments
Employ sound plating
principles

Plate Osteosynthesis
Transverse: Dynamic
Compression
Oblique:
Lag
Screw and Neutralization

Plate Osteosynthesis
Comminution:
Bridge Plate

Zhiquan et al., J. Orthop. Trauma 2007

MIPO?

Intramedually Nails: Should they

ever be used?

Intramedullary Nail:
Disadvantages
Rotator cuff
injury
Radial nerve at risk
Iatrogenic fracture (retrograde)

2 cm

Main
Disadvantage
Nonunion!

Intramedually nail: Advantages

Fast, minimally invasive
Load-sharing implant

Intramedullary Nail:
Potential Indications

Segmental fractures
Osteopenic bone
Pathologic fractures
Highly comminuted
fractures

IM Nail Relative Indications

Obese patients
Poly-traumatized patients
Soft tissue injury precluding
open approach

IM Nail Technique

Deltoid split
Formal incision in rotator cuff, must be repaired
Small diameter nail, with or without reaming
Avoid portrusion proximally
Interlock screws
Proximal: lateral to medial
Distal: anterior to posterior

Starting Point

Potential Advantages of Reaming

Decreases the risk of nail incarceration
Decreases the risk of fracture diastasis
Permits placement of a larger diameter,
stronger nail

Potential Disadvantages of Reaming

Disrupts endosteal blood supply
May result in fracture
comminution in setting of
relatively thin cortices

IM Nail: Pitfalls
Shoulder pain
Iatrogenic fracture
Retrograde insertion creates a stress riser
Over-reaming may threaten bone stock

Radial nerve at risk during insertion of nail

Axillary nerve at risk during insertion of proximal
interlock screw
Delayed/ Nonunion rates remain higher than for plate
fixation.

Humeral Shaft Fracture

Summary
Most can (should) be treated without
surgery
When surgery is required, ORIF with plate
osteosynthesis has best results.
Intramedullary nails should be used less
frequently for rare indications.

 One of the best

methods to
avoid surgical
complications
is to avoid
surgery.

Thank You

Case Example: 44 year old male

MIPO Bridge Plate

Postop.

6 weeks

3 months

Revision Plate with Autograft

Postoperative infection

9 months, 3 Revision
rd

16 months, atrophic nonunion

Revision Bone Graft: RIA,

Cancellous Allograft, BMP-2

2 years, persistant nonunion,

treated with vascularized fibula

2 years
(July 2011)

4 years
(Jan. 2013)

6th revision
(Masquelet)

The Saga Continues