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Surgical treatment of humeral stem fractures and technical points

Views: 3     Author: Site Editor     Publish Time: 2022-10-14      Origin: Site


Postoperative weight restriction should be maintained at a maximum of one kilogram until significant fracture healing is achieved (usually three months).Humeral stem fractures (HSF) are relatively common, accounting for approximately 1% to 5% of all fractures. The annual incidence is 13 to 20 per 100,000 people and has been found to increase with age.HSF has a bimodal age distribution, with the first peak occurring in men between 21 and 30 years of age following high-energy trauma, usually resulting in comminuted fractures and associated soft tissue injuries. The second peak occurs in women between 60 and 80 years of age, usually following low-energy trauma.

Surgical treatment

一. Internal fixation with incisional repositioning plate

Indications:

  • Radial nerve palsy (RNP) in HSF is not an indication for surgery because it is associated with a high rate of spontaneous recovery (see also - Complications/Radial Nerve below).

  • Alternatively, any vascular injury requiring repair or bypass is an absolute indication for surgical treatment of the fracture, as rigid fixation protects the vascular anastomosis.

  • In this particular case, internal fixation with a plate is faster and more reliable than IMN because the vascular repair is performed through a direct approach (usually a medial approach).

  • HSF with proximal or distal intra-articular extension is another situation in which ORIF with plates is a better option.

Surgical exposure:

  • Fractures located in the proximal and/or middle third are treated using the classic anterolateral approach.

  • When needed, this approach is extended distally to expose the entire humerus.

  • However, this approach is not recommended for distal intra-articular fractures.

  • Fractures of the distal third are usually exposed by a triceps split approach.

  • For distal and middle third fractures, the modified posterior approach described by Gerwin et al30 can expose 76-94% of the humerus (depending on radial nerve release and septal release).

Surgical techniques:

  • The patient is placed in a beach chair position for the anterolateral approach. The use of an arm brace helps to maintain humeral stem alignment. For posterior exposure, the lateral position is the preferred position.

  • Optimal plate construction consists of a 4.5 mm steel plate or equivalent and should cover at least 6 cortices above and below the fracture site, but 8 cortices are preferred.

  • When needed, a combination of a small and a large fragment plate is recommended, such as a short third tubular plate to maintain repositioning (transverse fracture or butterfly fragment), which is then supplemented with a narrow 4.5 mm plate for final fixation of the fracture.

  • For distal third fractures, a posterior lateral column preformed plate (3.5/4.5) is recommended to allow strong epiphyseal fixation.

The use of locking screws in HSF remains controversial:

  • When comparing locking plates with non-locking plates for comminuted fractures with good bone quality, there is no biomechanical advantage in torsion, bending or axial stiffness for both structures.

  • On the other hand, when faced with poor bone quality, the use of locking plates may be advantageous.

  • In a biomechanical study conducted by Gardner et al. specifically for osteoporotic fracture models, 34 non-locking structures were significantly less stable than locking or hybrid structures.


Minimally invasive plate splicing is a surgical option that appears to offer a high success rate and low complication rate. However, in a retrospective study involving 76 patients, van de Wall et al. demonstrated that absolute stability of humeral stem fractures alone significantly shortens radiographic healing time compared to relative stability.

Postoperative management:

  • Usually, stable fixation is obtained with the use of a plate. Thus, the patient is allowed to perform active and active-assisted activities without being limited by the range of motion of the shoulder or elbow.

  • The sling can be used for several days for pain management.

  • Postoperative weight restriction should be maintained at a maximum of one kilogram until significant fracture healing is achieved (usually three months).

  • Younger patients are allowed to bear weight where permitted (e.g., requiring crutches to walk), but in older patients this should be discussed on a case-by-case basis.

Reported results

  • Healing rates after plating ranged from 87% to 96%, with a mean healing time of 12 weeks.

  • Complication rates range from 5% to 25%, with the most common nonspecific complications such as infection, osteonecrosis, and malunion.

  • Medically derived RNP is a risk for most humeral stem approaches. Streufert et al50 reviewed 261 cases of HSF treated with ORIF and found that medically derived RNP occurred in 7.1% of anterolateral approaches, 11.7% of separated triceps approaches, and 17.9% of preserved triceps approaches.

  • Therefore, it is critical to identify and protect the radial nerve in all open dissections.

二. Intramedullary nail

Indications:

  • Theoretically, IMN can provide biomechanical and surgical benefits superior to plating

  • From a biomechanical standpoint, the device's intramedullary positioning is aligned with the mechanical axis of the humeral stem.

  • For this reason, the implant is subjected to lower bending forces and allows for better load sharing. The surgical indications for intramedullary nailing are the same as for plating.

  • However, as mentioned earlier, some fractures are better suited for plating than nailing.

  • Fracture characteristics and patterns that have been found to be superior to IMN are pathologic and impending fractures, segmental lesions, and osteoporotic fractures.

  • Simple mid-third transverse fractures are also good indications for IMN.

  • In addition, the nail can be inserted through a smaller incision, which reduces soft tissue stripping compared with the plating technique.

  • This is particularly true for fractures of the middle third of the humerus.

Surgical technique:

  • The optimal patient position for this procedure is on a beach chair. The use of an arm brace is very useful in maintaining shaft alignment as well as performing distal freehand locking screws.

  • The point of entry does depend on the design of the nail, but usually it is located at the junction of the greater tuberosity and the articular surface of the humeral head, which means that the rotator cuff muscles must be penetrated.

  • For this procedure, it is recommended to perform a deltoid division approach to visualize the supraspinatus tendon.

  • In fact, when entering the humeral head in the middle of the supraspinatus tendon, one will find oneself in the center of the head in the sagittal plane.

  • It is important to use the keratomile under fluoroscopy to ensure that the entry point is in an acceptable position in both the sagittal and coronal planes.

  • After this, the guide wire should be advanced further before opening the supraspinatus tendon longitudinally under direct vision.

  • The next step consists of opening the canal over the Kirschner needle, ensuring that the fracture is aligned with traction and/or external manipulation, and then advancing the guide in the intramedullary canal down to the elbow.

  • Reaming has been found to be advantageous in younger patients and not always necessary in older patients.

  • For distal bolt placement, AP locking is safer and requires a small 2-3 cm approach to reduce the risk of myocutaneous nerve injury.

  • Finally, paralleling IMN is superior to retrograde IMN because of the specific complications of the latter including medically induced supracondylar fractures, loss of elbow extension, and heterotopic ossification.


Special attention needs to be paid to the length of the nail chosen, as nails that are too long can lead to two technical errors:

  • Distraction at the fracture site during impact nail

  • and/or nails protruding into the subacromial space


For proximal third helix or long oblique fractures, the authors recommend a miniature open approach to reduce the fracture followed by fixation with a ring tie wire. In fact, for this fracture subtype, the deltoid muscle tends to abduct the proximal fracture fragment while the pectoralis major pulls the distal fracture fragment medially, which increases the risk of osseous nonunion or delayed healing.

Postoperative management

  • Patients are encouraged to perform active and active-assisted movements of the shoulder and elbow as tolerated.

  • Slings can be used for a few days for pain control.

  • Postoperative weight lifting restrictions are maintained at a maximum of one kilogram until fracture healing is evident (usually three months).

  • In most cases, weight bearing is allowed

Reported findings:

  • The literature on the use of locking nail devices for the management of HSF is inconsistent. On the one hand, the reported rate of bone nonunion is highly variable (between 0% and 14%), with the highest incidence in older generations of nails. On the other hand, the incidence of shoulder complications (including pain, impingement, loss of motion or strength) (ranging from 6% to 100%) has been reported in the previous literature.

  • Part of the problem can be explained by subacromial trauma due to chronic tendon dysfunction caused by protruding nails, scar tissue and/or rotator cuff injury in this critical area of isovascularity.

  • Several authors have described different approaches to avoid this hypovascular region and repair the tendon in a discreet manner, which have shown lower rates of shoulder dysfunction.


Conservative treatment of HSF has provided good functional outcomes and high healing rates in at least 80% of patients. For this reason, it remains the treatment of choice for most HSF. If alignment is unacceptable, surgery should be considered. This is particularly true for patients over 55 years of age presenting with a proximal third oblique fracture (lower healing rate). Regarding surgical treatment, the literature does not show any significant differences between plates and IMN in terms of healing rates or radial nerve complications, but shoulder complications (impingement and reduced range of motion) are more likely with IMN. Therefore, the cuff must be managed very carefully both at the point of entry and during closure.

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