Updated: Jul 22 2024
Humeral Shaft Fractures
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Summary
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Humeral shaft fractures are common fractures of the diaphysis of the humerus, which may be associated with radial nerve injury.
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Diagnosis is made with orthogonal radiographs of the humerus.
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Treatment can be nonoperative or operative depending on location of fracture, fracture morphology, and association with other ipsilateral injuries.
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Epidemiology
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Incidence
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3-5% of all fractures
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20% of humeral fractures involve shaft
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7 to 11.3 per 100,000
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Demographics
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age
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60% occur in patients olderthan 50 years
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bimodal age distribution
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young
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high-energy trauma
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peak incidence in third decade of life
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elderly patients
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low energy falls
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osteopenic patients
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sex
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70% occur in men when ageless than 50
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70% occur in women when agegreater than 50
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Location
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30% occur in the proximalthird of the humeral shaft
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60% occur in the middlethird of the humeral shaft
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Most common location
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10% occur in the distalthird of the humeral shaft
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Risk factors
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previous fracturehistory
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smoking in men
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elderly age
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osteoporosis
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Etiology
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Pathophysiology
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mechanism of injury
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ground level fall (60%)
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most common mechanism
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motor vehicle accident (~30%)
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2nd most common mechanism
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pathologic fractures (4.3%)
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open fractures (3%)
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proximalthird humeral shaft fractures
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commonin older individuals
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oftenresults from fall onto an outstretched hand resulting in impaction fracture atthe surgical neck
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middlethird humeral shaft fractures
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transversefracture
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resultof a direct blow to the arm
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spiralfracture
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resultsfrom a fall onto an outstretched hand or from torsional force
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distalthird humeral shaft fractures
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resultfrom fall onto a flexed elbow
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Associatedconditions
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floating elbow
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fracture of the humeral shaft and the proximal to middle radius and ulna
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often occurs as a result of a high-energy trauma
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morecommon in pediatric patients than in adults
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ipsilateralshoulder dislocation
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uncommoninjury pattern
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dislocationis most likely to be a posterior dislocation rather than an anteriordislocation
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Anatomy
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Osteology
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humeral shaft extends fromthe surgical neck of the humerus to the supracondylar ridge and is cylindricalin shape
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distally humerus becomestriangular with the formation of the medial and lateral supracondylar ridges
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intramedullary canalterminates 2 to 3 cm proximal to the olecranon fossa
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radial groove is adepression along the posterolateral aspect of the humerus where the radialnerve and profunda brachii artery traverse
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Arthrology
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articulates with scapulaproximally and distally with the radius and ulna
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Muscles
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insertion for
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pectoralis major
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deltoid
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will abduct proximal fragment in fracturesoccurring proximal to the insertion of the pectoralis major
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coracobrachialis
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origin for
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brachialis
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triceps
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brachioradialis
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Nerve
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radial nerve
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exits axilla posterior tothe brachial artery
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enters the posteriorcompartment of the arm through the triangular interval
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runs between the medial andlong head of the triceps
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radial nerve is found medial to the long and lateral heads and 2cm proximal to the deep head of the triceps
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courses along the spiral groovethen become anterior to the humerus
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~7.5cm from the articularsurface
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radial nerve exits the posterior compartment through the lateral intramuscular septum 10 cm proximal to radiocapitellar joint
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20cm proximal to the medial epicondyle
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14cm proximal to the lateral epicondyle
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ulnar nerve
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Enters the posterior compartmentat the arcade of Struthers and runs medially towards cubital tunnel
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~8cmfrom the medial epicondyle
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axillary nerve
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runs posterior to anterior around the proximal humerus 4 to 7cm from the tipof the acromion
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Compartments
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anterior compartment
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muscles
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biceps brachii, brachialis, and coracobrachialis
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vasculature
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brachial artery and vein
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nerves
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musculocutaneous, median, and ulnar nerve
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posterior compartment
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muscles
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triceps
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nerves
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radial nerve
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Classification
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OTA
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bone number: 1
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fracture location: 2
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fracture pattern: simple:A, wedge:B, complex:C
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Garnavos classification
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location
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P: proximal
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M: middle
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D: distal
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j: extension into the joint
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morphology
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S: simple
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T: transverse or oblique
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S: spiral
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I: intermediate
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one or two sizable butterfly fragments
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C: complex
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three or more butterfly fragments, or significant comminution
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Descriptive
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fracture location: proximal, middle or distal third
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fracture pattern: spiral, transverse, comminuted
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Holstein-Lewis fracture
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a spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (7-22% incidence)
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increases risk of radialnerve entrapment with the fracture
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Presentation
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Symptoms
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pain
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extremity weakness
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Physical exam
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swelling
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tenderness over the fracture site
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skin tenting
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examinination of overall limb alignment for deformity
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will often present with shortening and in varus
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preoperative or pre-reduction neurovascular exam is critical
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examine and document status of radial nerve pre and post-reduction
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wrist and thumb interphalangeal joint extension
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sensation over the dorsum of the hand
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Imaging
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Radiographs
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views
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AP and lateral
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be sure to include joint above and below the site of injury
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transthoracic lateral
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may give better appreciation of sagittal plane deformity
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rotating the patient prevents rotation of the distal fragment avoiding further nerve or soft tissue injury
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traction views
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may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated
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CT scan
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may be utilized if there is concern for intra-articular extension
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CTA
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may be indicated if there is concern for vascular injury
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Electromyography (EMG)
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indicated in the setting of nerve palsy to assess for nerve recovery,but is not indicated acutely as it will not dictate fracture management
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Treatment
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Nonoperative
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immobilization (coaptation splintor hanging arm cast for 7 to 10 daysfollowed by a functional brace)
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indications
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indicated in vast majority of humeral shaft fractures
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criteria for acceptable alignment include:
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< 20° anterior angulation
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< 30° varus/valgus angulation
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< 30° of rotational malalignment
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< 3 cm shortening
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relative indications
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community ambulator
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noncompliant patients
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contraindications
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absolute
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severe soft tissue injury or bone loss
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vascular injury requiring repair
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brachial plexus injury
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relative
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see relative operative indications section
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worsening nerve dysfunction
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radial nerve palsy is NOT a contraindication to functional bracing
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outcomes
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averageunion rate of 93.5% (77-100%)
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increased risk withproximal third (54%), and oblique or spiral fracturepatterns (23%)
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average time to union of 10.7 weeks (6.5-22 weeks)
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average malunion rate of 12%
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range of motion
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38-45% of patients lose externalrange of motion (5-45 degrees)
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88.6% of patients lose lessthan 10 degrees of shoulder motion
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92% lose less than 10degrees of elbow motion
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varus angulation is common but rarely has functional or cosmetic sequelae
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damage control orthopaedics (DCO)
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closed humerus fractures, including low velocity GSW, should be initially managed with a splint or sling
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type of fixation after trauma should be directed by acceptable fracture alignment parameters, fracture pattern and associated injuries
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Operative
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external fixation (Exfix)
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indications
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high energy complex or comminuted fracture
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open fracture
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significant soft tissue or bony defect
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floating elbow
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hemodynamically unstable polytrauma
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concomitant vascular injury
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typically utilized asprovisional fixation until definitive treatment can be performed, but may beused definitely if needed
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outcomes
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average operative time of30 minutes (18 to 50 minutes)
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80% achieve good to excellentoutcomes
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superficial pin track infectionrate of 12%
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open reduction and internal fixation (ORIF) and minimally invasive plate osteosynthesis
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indications
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absolute
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open fracture
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vascular injury requiring repair
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brachial plexus injury
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ipsilateral forearm fracture (floating elbow)
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compartment syndrome
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periprosthetic humeral shaft fractures at the tip of the stem
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inability to maintain satisfactory reduction closed
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progressive nerve deficit after closed manipulation
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relative
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bilateral humerus fracture
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polytrauma or associated lower extremity fracture
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allows early weight bearing through humerus
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pathologic fractures
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typically indicated if life expectancy is greater than 6 months
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burns or soft tissue injury that precludes bracing
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fracture characteristics
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distraction at fracture site
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segmental fractures
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short oblique or transverse fracture pattern
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OTA type A
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intraarticular extension
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long oblique proximal humeral shaft fracture
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large body habitus, obesity, or large breasts
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radial nerve palsy
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outcomes
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significantly lower rates of nonunion and malunion versus nonoperativemanagement
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average malunion rate of 1%
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average union rate of 90-92%
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average time to union of 11.9 weeks
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improved DASH scores at 6 weeks and 3 months with no significantdifference at 12 months compared to nonoperative management
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intramedullary nailing (IMN)
See AlsoDistal Humeral fractures-
indications
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relative
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pathologic fractures
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segmental fractures
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severe osteoporotic bone
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overlying skin compromise limits open approach
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polytrauma
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outcomes
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lower risk of infection(1.2%) than ORIF (5.4%)
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no significant risk ofreoperation (average 11.6%) versus ORIF (average 7.6%)
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no difference in rates ofnonunion with faster time to union (average 10 weeks) than ORIF (average 11.9weeks)
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significantly fasteroperative time (average 61 minutes) than ORIF (average 88 minutes)
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increased rate whencompared to plating (16-37%)
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greater risk of shoulderimpingement postoperatively
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functional shoulder outcomescores (ASES scores) not shown to be different between IMN and ORIF
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Techniques
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Coaptation Splint & Functional Bracing
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coaptation splint or hanging arm cast
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applied until swelling resolves
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adequately applied splint will extend up to axilla and over shoulder
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common deformities include varus and extension
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valgus mold to counter varus displacement
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functional bracing
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extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles
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sling should not be used to allow for gravity-assisted fracture reduction
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shoulder extension used for more proximal fractures
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weekly radiographs for first 3 weeks to ensure maintenance of reduction
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every 3-4 weeks after that
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External Fixation
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approaches
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proximal pins
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anterolateral surface of proximal humerus
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mini-open approach with dissection down to bone to mitigate axillary nerve injury
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distal pins
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lateral aspect of distal fragment
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requires mini-open approach with dissection down to bone to mitigate radial nerve injury
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most distal pin is just proximal to olecranon fossa
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visualize cortical surface prior to inserting pins
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Open Reduction and Internal Fixation (ORIF)
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approaches
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anterior (brachialis split) approach to humerus
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used for middle third shaft fractures
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deep dissection through internervous plane of brachialis muscle
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lateral fibers (radial n.) and medial fibers (musculocutaneous n.) in majority of patients (~80%)
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anterolateral approach to humerus
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used for proximal third to middle third shaft fractures
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distal extension of the deltopectoral approach
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performed in a supine orbeach chair position with arm abducted 45° to 60°
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radial nerve identified between the brachialis and brachioradialis distally
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protected proximally anddistally by the brachialis
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brachioradialis willprotect the musculocutaneous nerve distally
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cephalic vein and anterior humeral circumflex arteries may be encountered during the surgical approach
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posterior approach to humerus
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maybe performed eitherprone or in a lateral position
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usedfor distal to middle third shaft fractures
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can be extensile
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allows for exposure from the olecranon fossa to the junction of the proximal and middle third of the humerus
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triceps may either be split or elevated with a lateral paratricipital exposure
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triceps split
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incision through the commontendon of the triceps
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allows for retraction ofthe lateral head of the triceps laterally and long head of the triceps medially
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allows exposure to theradial nerve and profunda brachii artery within the spiral groove
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lateral brachialcutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmarkleading to the radial nerve
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benefits
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avoids the need for ulnar nervedissection and mobilization
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can allow for adequate exposureof the humeral shaft fracture
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limitations
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55% of the humeral shaftcan be exposed without radial nerve mobilization
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76% of the humeral shaftcan be exposed with radial nerve mobilization
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does not utilize a trueinter-nervous plane
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limited proximal extensionof the incision
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triceps sparing or “paratricipital”
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utilizes lateral and medial windows without disrupting the extensormechanism
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lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach
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lateral window
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lateral head of the tricep and intermuscular septum
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allows for identification of the radial nerve, and posteriorantebrachial cutaneous nerve
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medial window
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mobilization of the ulnar nerve followed by dissection to the medialintermuscular septum border posteriorly
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benefits
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minimizes injury to the triceps
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improved postoperative functional measures
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decreased risk of denervation of the triceps and anconeus
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allows for exposure of ~94% of the humeral shaft through the lateralwindow
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limitations
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requires dissection and mobilization of the ulnar nerve for the medialwindow
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lateral approach
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extends from the insertion of the deltoid to the lateral epicondyle
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allows for exposure of the distal two-thirds of the humerus
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the interval is between the lateral intermuscular septum and the triceps
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radial nerve identified proximal to the deep head of the triceps andmobilized by releasing the lateral intermuscular septum
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higher risk of iatrogenic radial nerve injury
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medial approach
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primarily used to access the brachial artery, median nerve, and ulnarnerve
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rarely used for fracture fixation
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incision extends from the proximal medial margin of the biceps distally tothe medial epicondyle
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ulnar nerve is retracted posteromedially
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median nerve and brachial artery retracted anterolaterally
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minimally invasive plate osteosynthesis
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proximal and distal incisions performed through an anterolateralapproach followed by the creation of an extraperiosteal tunnel
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theplate is tunneled and positioned under fluoroscopic guidance
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Minimizes surgical dissection, but increases the risk of radial nerve injurydue to lack of direct visualization
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techniques
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plate osteosynthesiscommonly with narrow or broad, 3.5mm or 4.5mm dynamic compression plate orlimited contact dynamic compression plate
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dynamic compression plateallows for staggered screws
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narrow dynamic compressionplate better accommodates patients with a more narrow humerus
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limited contact dynamiccompression plate provide benefit of being easier to contour, decreased stressshielding, and preservation of periosteal blood supply
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relationship of plate and radial nerve must be respected to preventinadvertent nerve injury
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absolute stability with lag screw or compression plating in simple patterns
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apply plate in bridging mode in the presence of significant comminution
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may require the incorporation of condyles or dual plating in distalfractures
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bony defects up to 3cm can be dealt with via shortening, but larger defects(>3cm) may require grafting
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postoperative
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full crutch weight bearing shown to have no effect on union
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Intramedullary Nailing (IMN)
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techniques
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can be done antegrade or retrograde
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antegrade
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performed supine
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3cm incision over theanterolateral edge of the acromion down the deltoid, which is then split toidentify the rotator cuff
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entry site for the nailthrough the supraspinatus fibers as medial as possible to apex of the humeralhead
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retrograde
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performed prone or lateral through a posteriorincision over the posterior supracondylar cortex
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avoid reaming across thefracture site to prevent radial nerve injury
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complication
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nonunion
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nonunion rates not shown to be different between IMN and plating in recent meta-analyses
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IM nailing associated with higher total complication rates
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nerve injury
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radial nerve
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at risk with a lateral to medial distal locking screw
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while controversial, a recent meta-analysis showed no difference between the incidence of radial nerve palsy between IMN and plating
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musculocutaneous nerve
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at risk with an anterior-posterior locking screw
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axillary nerve
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at risk with proximal locking screws in antegrade nails
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anterior and posterior humeral circumflex vessels are also at risk
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shoulder pain
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increased rate when compared to plating (16-37%)
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functional shoulder outcome scores (ASES scores) not shown to be different between IMN and ORIF
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supraspinatus at risk with antegrade nails
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due to the avascular nature of the supraspinatus tendon atit* insertion site near the greater tuberosity
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entry portal should be created near the musculotendinous junction
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entry portal should not be greater than 1cm
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postoperative
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full weight bearing allowed and had no effect on union
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Complications
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Nonunion
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no callous on radiograph and gross motion at the fracture site at 6 weeks from injury has a 90-100% PPV of going on to nonunion in closed humeral shaft fractures
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82% sensitivity and 99% specificity
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radiographic union score for humeral fracture (RUSHU)
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1 score per cortex on radiographs obtained 6-weeks from injury
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1: absent callus
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2: present, nonbridging callus
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3: present, bridging callus
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score ≥8 - 86% NPV for nonunion
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score <8 - 65% PPV
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risk factors
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humeral shaft fractures treated nonoperatively dependent on fracture pattern
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OTA type A (15.4 to 29%) > type B (4%) >type C (0%) fractures
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No significant difference in the rate of nonunion following open reductionwith internal fixation versus intramedullary nailing
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treatment
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higher rates of union with plate fixation and autologous bone grafting than with exchange intramedullary nailing
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management predicated by type of nonunion (atrophic, hypertrophic, infected)
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atrophic nonunion
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debridement and curretage of non-viable fragment and fibrous scar at fracture site
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intramedullary nail revision with reaming and exchange to larger nail
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ream up by at least 1mm to improve biomechanical stability
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compression plating with bone grafting
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iliac crest graft, femoral autograft from REA (reamer/irrigator/aspirator)
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bone graft subsititue
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hypertrophic nonunion
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intramedullary nailing with exchange for larger nail
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locked angle plating
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Malunion
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varus angulation is common but rarely has functional or cosmetic sequelae
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risk factors
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transverse fracture patterns
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Radial nerve palsy
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incidence
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overall incidence of 12.3% ( 8-15%)
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increased incidence distal one-third fractures (22%)
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neuropraxia most common injury in closed fractures and neurotomesis in open fractures
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iatrogenic radial nerve palsy is most common following ORIF via a lateral approach (20%) or posterior approach (11%)
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spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months
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risk factors
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fracture location
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distal third (56.9%) > middle third (41.5%) > proximal third (1.5%)
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fracture type
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transverse (21.2%) > spiral (19.8%) > oblique (8.4%) > comminuted (6.8%)
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open fracture
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treatment
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observation
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indicated as initial treatment in closed humerus fractures
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approximately 77.2% with spontaneous radial nerve recovery
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85-90% of these will recovery within the first 3 months
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obtain NCS/EMG at ~2 months
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useful to determine the extent of nerve damage, baseline of function, and to monitor recovery
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wrist extension in radial deviation is expected to be regained first
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brachioradialis first to recover, extensor indicis is the last
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surgical exploration
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indications
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open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve)
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closed fracture that fails to improve over ~4-6 months
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fibrillations (denervation) seen on EMG
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may require debridement or removal or incarcerated fragments, nerve grafting, or nerve transfers at the time of exploration
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outcomes
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radial nerve appearance at the time of exploration
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nerve in continuity (62.7%)
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lacerated (26.8%)
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incarcerated within the fracture site (10.5%)
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timing of exploration
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early exploration (within three weeks of injury)
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recovery rate ~90%
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late exploration (eight weeks or more out from injury)
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recovery rate ~68%
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tendon transfers
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indications
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persistent radial nerve palsy - optimal timing debated
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wrist extension: PT to ECRB
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finger extension: FCR/FCU to EDC
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thumb extension: PL to EPL
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outcomes
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overall recovery rate of 88.6%
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primary nerve palsy recovery rate - 88.2%
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iatrogenic/secondary nerve palsy recovery rate - 93.9%
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predictable recovery pattern
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brachioradialisand extensor carpi radialis longus are first to recover
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extensorpollicus longus and extensor indicis proprus are last to recover
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