humeral shaft fracture

A 68-year-old, right-hand-dominant female fell onto her left arm while walking her dog. An injury radiograph is shown in Figure 6–8.

 

 

 

Figure 6–8

 

What is her best treatment option?

1. Closed reduction followed by 4 weeks of immobilization

2. Sling for comfort followed by early range of motion

3. Closed reduction with percutaneous pinning of the humeral head

4. Early total shoulder arthroplasty

 

Discussion

The correct answer is (B). This is a two-part fracture in an elderly patient, and clinical outcomes with nonoperative treatment are overall good. Long-term immobilization is not ideal because of the significant decrease in functional range of motion. Instead, early passive ROM should be initiated with early physical therapy follow-up (within 2 weeks from injury). A closed reduction with percutaneous pinning carries risks of axillary nerve injury and pin migration, especially in osteoporotic bone, without significant benefit over nonoperative treatment. This patient will most likely have a rotator cuff injury and possible deltoid atony after her injury and would not be a good surgical candidate for a total shoulder arthroplasty in the acute setting.

The patient heals her fracture as shown in Figure 6–9.

 

 

 

Figure 6–9

 

In another 6 months, she returns with radiographic signs of avascular necrosis of the humeral head, Cruess stage III, although she does not have any clinical complaints at this time.

How does this affect your treatment plan?

1. Discuss diagnosis and reassure the patient as she is currently asymptomatic.

2. Recommend a core decompression of the humeral head now with physical therapy and weight-bearing restrictions.

3. Order an MRI to assess whether patient is a better candidate for a hemiarthroplasty or reverse shoulder arthroplasty.

4. Recommend she proceed with a total shoulder arthroplasty.

 

Discussion

The correct answer is (A). Although avascular necrosis of the humeral head is more common in four-part fractures, it can occur in any proximal humerus fracture. It is unclear in the shoulder that radiographic signs correlate with clinical deficits. In the case of this patient, since her pain is gone, and she has no complaints, the osteonecrosis can be treated conservatively with reassurance and an explanation of possible future symptoms. If symptoms arise and lead to life-style changes, surgical options can be discussed at that time.

 

Objectives: Did you learn...?

 

 

Nonoperative management of proximal humerus fractures? Management of osteonecrosis of the humeral head?

CASE                               10                               

Dr. Christina M. Hylden

A 42-year-old, right-hand-dominant, male, government contractor sustains blunt trauma to his right arm while using a jackhammer. He has immediate pain and deformity to his right upper extremity and presents immediately to the emergency department with this isolated injury. Physical examination shows skin to be intact, and patient has wrist extensor weakness. Plain radiographs reveal a spiral fracture of the right humerus mid-diaphysis with 30 degrees of anterior and 30 degrees of varus angulation.

Which of the following is NOT a contraindication to nonoperative treatment with a coaptation splint?

1. 20 degrees of varus angulation

2. Vascular injury

3. Radial nerve injury

4. Brachial plexus injury

 

Discussion

The correct answer is (C). Acceptable alignment for nonoperative management of a humeral shaft fracture is less than 20 degrees in the sagittal plane, less than 30 degrees in the coronal plane, or less than 3 cm of shortening. Radial nerve palsy in a closed fracture is most likely a neuropraxia, and it is not a contraindication to closed treatment. Vascular injuries that require repair and a brachial plexus injury are both considered absolute indications for surgery and repair or exploration. Another absolute indication is an open fracture.

Which of the following about the radial nerve is true?

1. It courses across the posterior humerus from lateral to medial.

2. It can be found 5 cm proximal to the lateral epicondyle of the humerus.

3. It can be found 10 cm proximal to the medial epicondyle.

4. It has an increased incidence of injury with a distal one-third humeral shaft fracture.

Discussion

The correct answer is (D). A spiral fracture of the distal one-third of the humeral shaft (eponym Holstein–Lewis fracture) has a 22% incidence of radial nerve

neuropraxia. The radial nerve travels from the medial humerus proximally, crossing posteriorly to the lateral side. On average it is 14 cm proximal to the lateral epicondyle and 20 cm proximal to the medial epicondyle.

The above patient is treated with an intramedullary nail and is later lost to follow-up. He presents to clinic 9 months later with a complaint of persistent right arm pain. Radiographs and advanced imaging reveal that he has a hypertrophic nonunion.

What is the most appropriate definitive treatment?

1. Nail removal and open reduction with internal fixation with autologous bone grafting

2. Revision intramedullary nailing

3. Nail removal and functional bracing

4. Continued observation

 

Discussion

The correct answer is (A). In this case, the patient is more than 6 months out from his procedure but does not show cortical healing. The question defines that his nonunion is hypertrophic, which means that he has poor stability of the fracture fragments from the intramedullary nail. The best option is to create a more stable fixation with open reduction and plating. Adding a bone graft will augment this fixation and give him the best chance of healing with one procedure. Exchanging the nail, functional bracing, and observation will not obtain the stability that he needs.

 

Objectives: Did you learn...?

 

 

Indications for nonoperative management of a humeral shaft fracture? Anatomic location of the radial nerve?

 

Treatment of humeral shaft nonunion?