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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