5 Humeral Shaft Fractures: Open Reduction Internal Fixation

5.Humeral Shaft Fractures: Open Reduction Internal Fixation

Indications/Contraindications

Numerous studies have shown that the majority of humeral shaft fractures can be treated nonoperatively with high rates of union and excellent functional results. However, in specific clinical settings, open reduction and internal fixation (ORIF) are favored over closed functional methods. Good results can be expected (1,2,3) and outcomes are superior to comparable fractures treated with intramedullary nailing (4,5,6). Although there are no absolute indications for plate fixation, we favor its use in some patients and consider the fracture characteristics and the presence of concomitant injuries in our decision (Table 5.1).

Fracture Considerations

Internal fixation is indicated in patients with closed fractures in which a satisfactory reduction cannot be achieved or maintained. The most common cause of a poor reduction in an otherwise healthy individual is interposition of soft tissue. Failure to maintain an acceptable closed reduction sometimes occurs in obese patients or women with large breasts. Other indications include segmental and peri-articular fractures. The latter can be difficult to control, and the prolonged immobilization of the adjacent joint can lead to loss of motion.

Open fractures require surgical debridement and bony stabilization to allow optimal soft-tissue management. After thorough debridement, ORIF of the humerus is a good method of fracture stabilization for most grade I, II, and IIIA injuries with limited bony defects. It produces a stable limb, improving postoperative wound management. With extreme comminution or bone loss, acute shortening of up to 5 cm is usually well tolerated.

Experience has taught us that nonoperative treatment of pathologic humeral fractures frequently results in nonunion and persistent pain. There is widespread agreement that patients with a pathologic humeral fracture as a result of metastatic disease benefit from

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surgical stabilization. Usually these fractures are best managed with a locked intramedullary nail, but occasionally, a fracture is not amenable to intramedullary nailing and is better managed with a long spanning plate (7).

Table 5.1. Indications for Surgical Stabilization of Humeral Shaft Fractures

Early Late
Failure of closed treatment
Multiple injuries, patient
Multiple injuries, limb
Open fracture
Pathologic fracture
Associated arthrodesis
Periprosthetic fracture
Nonunion
Malunion

Periprosthetic fractures around elbow or shoulder arthroplasty frequently require internal fixation. Fractures that occur around the stem of an implant occasionally require revision of the prosthesis.

Delayed unions and nonunions are additional indications for ORIF of a humeral fracture. Delayed union is generally accepted to mean that the fracture has failed to show progressive signs of healing within 3 to 4 months, whereas nonunion is defined when the healing is delayed or arrested beyond 6 months. Nonunions can occur because of fracture instability, poor bone vascularity, or marked displacement. Infection must be ruled out for nonunions of open fractures that have been surgically repaired. Union is usually obtained following revision ORIF and autogenous bone grafting (8), and in osteoporotic bone this may be done successfully with locking compression plates (9).

Malunion is rarely an indication for surgical intervention because angular deformity is often well tolerated after closed treatment. The amount of mal-alignment that can be accepted varies between patients and is influenced by level of activity and cosmesis. Most patients tolerate up to 20 degrees of varus, 15 degrees of anterior angulation, and 5 cm of shortening.

Concomitant Injuries

Internal fixation of humeral shaft fractures is also indicated in a variety of circumstances due to concomitant injuries. The patient with multiple injuries is the most common candidate for operative treatment of humeral shaft fractures (10,11,12). When patients sustain injuries to multiple body systems, early surgical stabilization of long bone fractures may be life-saving. Fixation should be undertaken early to reduce analgesic needs, allow early mobilization, and facilitate nursing care.

Patients with ipsilateral injuries to the shoulder, elbow, or forearm often require operative treatment of their humeral fracture. In bilateral humeral fractures or any contralateral upper-extremity injury, fixation may be necessary to allow activities of daily living and self-care. Humeral shaft fractures associated with a fracture of both forearm bones require fixation of both the forearm and the humerus to allow early range of motion. Finally, rehabilitation of injuries to the lower extremities can be accelerated by fixation of the humerus, which allows for the use of crutches through the stabilized humerus.

If an axillary or brachial artery injury is associated with a closed fracture, then this should be stabilized at the time of vascular repair. Internal fixation of the humerus through the vascular approach is recommended to protect the vascular repair, to facilitate ongoing assessment, and allow rehabilitation of the limb. Brachial plexus or peripheral nerve injuries in the ipsilateral limb are often an indication for internal fixation of a humeral fracture because concomitant brachial plexus injuries may be associated with high rates of delayed union, nonunion, and malunion of the humeral shaft when treated closed (13). To prevent these complications and to facilitate rehabilitation, operative treatment should be considered with this combination of injuries.

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The management of humeral fractures with associated radial nerve injury remains controversial (14,15,16). The incidence of radial nerve injury in humeral fractures is approximately 10%, with a range reported between 2% and 26%. Humeral shaft fractures seen with a primary radial-nerve injury do not usually require nerve exploration. If the fracture reduction can be maintained, closed treatment will result in fracture healing and a good outcome with a greater than 80% chance of spontaneous nerve recovery. The majority of cases are neurapraxias, which should show signs of recovery by 3 to 4 months, with improvements in muscle grade up to 2 years after injury (11).

Some studies have shown that with modern microsurgical techniques and late exploration of radial nerve palsies, better than 90% recover (14,15). Therefore, we recommend initial observation and late exploration for nerve injuries that do not resolve. The injury should be documented clinically and electrophysiologically with electromyogram/nerve conduction studies (EMG/NCS) in the early stages. The hand should be splinted, and an intensive physiotherapy program should be initiated to maintain mobility at the elbow, wrist, and fingers. Patients are evaluated monthly and have a follow-up EMG/NCS at 6 and 12 weeks. If after 4 to 6 months there is no sign of radial nerve recovery, then we explore the nerve.

More controversial is the management of secondary radial-nerve palsy. Most commonly this occurs after closed reduction of a humeral fracture. Traditionally, a nerve palsy occurring in such a circumstance was considered an indication for nerve exploration and internal fixation. Although some have shown that the nerve can be trapped between the fracture fragments (17), and while it seems reasonable to explore the nerve and free it from any ongoing compression, there is no scientific evidence that the outcome is improved by early surgery. Secondary radial-nerve palsy, however, continues to be an accepted indication for early exploration.

Relative contraindications to plate fixation of humeral shaft fractures include grade IIIB open fractures with massive soft-tissue injury or extensive bone loss, soft-tissue or bone infection, as well as severe osteoporosis, that would preclude fixation.

Preoperative Planning

With all injured patients, a careful history and physical examination are mandatory. Associated injuries should be identified and carefully assessed. Physical examination should include the chest, neck, shoulder, arm, elbow, forearm, wrist, and hand. The physical signs of fracture are usually obvious after humeral shaft fractures with pain, swelling, crepitus, and motion at the fracture site. The neurologic examination of the limb must be meticulous. Radial nerve injury is the most commonly associated neurological injury, but any peripheral nerve, including the brachial plexus, can be injured in association with a humeral diaphyseal fracture. The vascular assessment includes palpation of the axillary, brachial, and radial pulses and an assessment of hand-tissue perfusion. The soft-tissue compartments of the arm and forearm should be evaluated for compartment syndrome.

Good quality radiographs of the humerus are essential. Anteroposterior (AP) and lateral views of the humerus should be obtained that include the shoulder and elbow joints. The anatomic location of the fracture, the fracture pattern, and the expected bone quality are critical when developing a preoperative plan.

Once a decision is made to operate on a humeral fracture, a surgical tactic should be developed that includes the patient position, the surgical approach, the steps necessary for fracture reduction, temporary fixation, and the implant to be used for final fixation.

There are four basic approaches to the shaft of the humerus: the anterolateral, straight lateral, posterior, and anteromedial. However, the anteromedial approach is rarely used in humeral-shaft fracture treatment and will not be discussed further. The decision about which surgical approach to use is based on the fracture level and configuration, the need for radial nerve exploration, and the patient's general condition. The most common approach is the anterolateral. Fractures located anywhere in the proximal two thirds of the humerus can be successfully managed through this approach, but it does not allow adequate exposure of the distal one third of the humerus; therefore, it cannot be used if the fixation

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must be extended into the distal third. In fractures involving the distal two thirds of the humerus, with an associated radial-nerve injury that requires surgery, we prefer the straight lateral approach. This approach can be extended into the anterolateral approach and thereby give access to the entire humerus if necessary. It may also be extended proximally by utilizing the same muscular interval but passing posteriorly to the deltoid, the proximal limit being the axillary nerve (18). The posterior approach can be used for fractures that involve the distal half of the humeral shaft.

The steps necessary for fracture reduction and temporary fixation before final fixation must be carefully considered. In most cases, direct reduction techniques are appropriate. The fracture hematoma is evacuated, and the fracture surfaces are anatomically reduced. For spiral or oblique fracture patterns, temporary fixation can usually be accomplished with Weber pointed reduction forceps. Transverse fractures can usually be stabilized temporarily with Kirschner (K) wires or by drilling a hole in each fragment and using pointed reduction forceps away from the site of anticipated plate application. Some comminuted fractures that still have cortical contact between the main proximal and distal pieces cannot be temporarily stabilized satisfactorily. In those cases, the appropriate plate is secured to one fragment, the fracture is then reduced under the plate, and fixation is completed.

Severely comminuted fractures may be amenable to indirect reduction techniques. The femoral distractor is used to secure the reduction, which is confirmed under image intensification. The appropriate plate is then secured to the main proximal and distal fragments. The soft-tissue attachments to the comminuted intercalary fragments are left intact. Bone grafting is not added when the indirect reduction technique is used.

When planning plate fixation in oblique or spiral fractures, surgeons strive to achieve interfragmentary compression, which can be done by using interfragmentary lag screws inserted either outside (Fig. 5.1) or through the plate (Fig. 5.2). Interfragmentary screws alone are insufficient fixation for humeral shaft fractures and must be supplemented with a neutralization plate. In transverse fracture patterns, interfragmentary compression is

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achieved by using a limited-contact dynamic-compression (LCDC) plate, and the plate must be prestressed (prebent) to avoid a gap in the far cortex (Fig. 5.3). In general, the plate of choice is a broad 4.5-mm LCDC. This is a strong plate with a wide surface contact and offset screw holes to prevent longitudinal splitting of the shaft from collinear screws. In addressing acute fractures, we aim for at least six cortices of fixation above and below the fracture. When dealing with osteoporotic bone, we either use more cortices of fixation or locking compression plates. Bone grafting should be planned with comminuted fractures. If more than one third of the circumference of the humeral shaft is comminuted, we generally use an autogenous iliac-crest bone graft.

 Initial fixation is accomplished with an interfragmentary screw. This is supplemented by a neutralization plate

Figure 5.1. Initial fixation is accomplished with an interfragmentary screw. This is supplemented by a neutralization plate.

Interfragmentary fixation through the plate.

Figure 5.2. Interfragmentary fixation through the plate.

Transverse fracture pattern in which interfragmentary compression is achieved by using a prebent dynamic-compression plate

Figure 5.3. Transverse fracture pattern in which interfragmentary compression is achieved by using a prebent dynamic-compression plate.

In many cases, the humerus is small, and the broad LCDC plate cannot be used. In such a situation, a narrow 4.5-mm LCDC plate can be used. Likewise, in the distal shaft, where extensive contouring of the plate is necessary, a 3.5-mm pelvic reconstruction plate is occasionally used for neutralization. However, this type of plate should be used only when there is excellent interfragmentary compression with multiple lag screws. It is important to avoid encroachment of the hardware in the olecranon or coronoid fossae when fixing the distal humerus.

Surgery

All trauma patients are prescrubbed with a chlorhexidine nail brush: The area is washed off with saline and then chlorhexidine is poured over the limb prior to formal prepping and draping. However, for open fractures, iodine is preferred. A sterile tourniquet is used if the fracture is in the middle or distal one third. If it is used, the tourniquet is deflated prior to closure and hemostasis achieved; therefore, a drain is rarely necessary.

The anterolateral approach is performed with the patient supine and a pad beneath the scapula. The arm is free draped allowing access to the neck (subclavian vasculature) and placed on a radiolucent arm board. Surface landmarks, coracoid process, deltopectoral groove, lateral bicipital sulcus, and the lateral epicondyle, are marked with a sterile pen (Fig. 5.4). Depending on the fracture, the incision may extend from the coracoid process down to approximately 6 cm from the lateral epicondyle (Fig. 5.5). The deltopectoral groove is developed proximally. The belly of the biceps is identified and its lateral border mobilized, exposing the brachialis muscle (Fig. 5.6). Care is taken to avoid injury to the proximal cephalic vein and the lateral cutaneous nerve of the forearm in the medial aspect of the distal wound area. The biceps is retracted medially, and the brachialis is divided

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longitudinally, lateral to its midline and down to bone, aiming for the middle of the humeral shaft (Fig. 5.7). Through this approach, the radial nerve, which is lateral to the brachialis, is protected and the innervation of the lateral portion of the brachialis (radial nerve) is preserved. Flexion of the elbow, along with partial (anterior) detachment of the deltoid insertion and of the medial brachialis origin, is done to allow reduction and plating of the anterolateral surface of the humerus (Fig. 5.8).

 Incision for the anterolateral approach

Figure 5.4. A,B. Incision for the anterolateral approach.

The straight lateral approach requires careful dissection but allows excellent visualization of the radial nerve and adjacent structures. It is ideal for exploration of the radial nerve and fixation of the distal humerus in a multiply injured patient. With the patient supine, the arm is free draped and kept adducted along the patient's body. The surface landmarks are the lateral epicondyle, deltoid tuberosity, and the coracoid process as necessary (Fig. 5.9).

The incision extends longitudinally from the lateral epicondyle proximally to the deltoid tuberosity. After incision of the investing fascia of the arm, the intervals between the triceps and brachialis proximally and the brachioradialis and brachialis distally are identified. The distal interval is first developed bluntly as described by Henry (19): 鈥溾€lace well-gloved

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thumbs, lengthwise and parallel, on each belly (brachialis and brachioradialis), and open the plane like a book on your knee. The nerve marks the place鈥� (Fig. 5.10). The radial nerve is isolated, looped with a rubber sling, and protected. The nerve is retracted laterally while the proximal dissection is completed. The periosteum anterior to the intermuscular septum is split longitudinally, and subperiosteal elevation progresses medially and proximally with direct visualization and protection of the nerve at all times. This can be gently elevated if further access is required. As the nerve courses posteriorly and proximally, one might need to incise the intermuscular septum to mobilize the nerve and visualize its relation to the fracture. The nerve is retracted anteriorly, and the distal dissection is completed. The distal plane between the brachioradialis and the triceps is identified (Fig. 5.11). This plane is incised sharply, and the brachioradialis is reflected anteriorly, protecting the distal portion of the nerve. The entire distal humerus is exposed laterally and anterolaterally (Fig. 5.12). A narrow, 4.5-mm LCDC plate positioned laterally is often the best implant with this exposure. The plate is often quite distal and screw placement in the coronoid/olecranon fossae must be avoided (Fig. 5.13).

Initial muscular exposure: (1) biceps; (2) pectoralis major; (3) deltoid; and (4) cephalic vein

Figure 5.5. A,B. Initial muscular exposure: (1) biceps; (2) pectoralis major; (3) deltoid; and (4) cephalic vein.

 Splitting of the brachialis in the line of its fibers: (1) biceps; (2) pectoralis major; (3) deltoid; (4) brachialis; (5) humerus; (6) anterior, circumflex, humeral vessels; (7) cephalic vein; and (8) lateral cutaneous nerve of the forearm

Figure 5.6. Splitting of the brachialis in the line of its fibers: (1) biceps; (2) pectoralis major; (3) deltoid; (4) brachialis; (5) humerus; (6) anterior, circumflex, humeral vessels; (7) cephalic vein; and (8) lateral cutaneous nerve of the forearm.



The posterior approach is used in cases of isolated fractures in the distal half of the humerus. The patient is placed prone and brought to the edge of the operating table. The arm is free draped to allow access to the whole arm and the elbow. The shoulder is abducted 90 degrees in neutral flexion and supported distally at the elbow by a modified Mayo stand (Fig. 5.14). The stand can be altered by cutting a hole at the edge of the tray and padding the exposed rim of the stand. During the procedure, the forearm and hand are dropped into the hole, which is lined by a sterile c-arm pack protecting the forearm and hand from contamination that is possible due to their low-lying position. An additional advantage of using the Mayo stand is the ability to place instruments on it. An alternative is to place the patient in a lateral position with a bolster under the arm.

 Completed exposure of the proximal two thirds of the humeral shaft: (1) pectoralis major; (2) biceps; (3) brachialis; (4) deltoid; (5) humerus; (6) anterior, circumflex, humeral vessels; (7) cephalic vein; and (8) lateral cutaneous nerve of the forearm.

Figure 5.7. Completed exposure of the proximal two thirds of the humeral shaft: (1) pectoralis major; (2) biceps; (3) brachialis; (4) deltoid; (5) humerus; (6) anterior, circumflex, humeral vessels; (7) cephalic vein; and (8) lateral cutaneous nerve of the forearm.

Figure 5.8. Prebent, broad, 4.5-mm, dynamic-compression plate applied to a transverse fracture via an anterolateral approach.

Positioning and skin incision for the straight lateral approach to the distal humerus

Figures 5.9. Positioning and skin incision for the straight lateral approach to the distal humerus.

Surface markings are the posterolateral corner of the acromion and the olecranon. The straight incision extends from the distal border of the posterior deltoid, along the lateral edge of the long head of triceps, to the tip of the olecranon (Fig. 5.15). The long head can



be identified as a mobile mass on the posteromedial aspect of the arm. Skin, subcutaneous tissue, and fascia are incised and the distal, thick, white triceps tendon is identified. Proximally, the interval between the long and the lateral heads of the triceps is identified and dissected bluntly. Distally, these two superficial heads are sharply dissected by division of the triceps tendon (Fig. 5.16). Careful blunt dissection is carried out to identify the radial nerve on the proximal aspect of the deep head of triceps (Fig. 5.17). A rubber sling is placed around the radial nerve, which is protected throughout the case. The deep triceps is split longitudinally in its midline, and its medial and lateral portions are elevated, exposing the humerus (Fig. 5.18). Reduction and fixation can now proceed. The closure includes reapproximation of the triceps aponeurosis with absorbable suture and superficial layer closure.

 The radial nerve is identified in the interval between the brachialis and the brachioradialis: (1) triceps; (2) brachialis; (3) brachioradialis; and (4) radial nerve.

Figure 5.10. The radial nerve is identified in the interval between the brachialis and the brachioradialis: (1) triceps; (2) brachialis; (3) brachioradialis; and (4) radial nerve.

The intervals between brachialis and triceps proximally and between brachioradialis and triceps distally are developed: (1) biceps brachii muscle; (2) radial nerve; and (3) triceps brachii muscle.

Figure 5.11. The intervals between brachialis and triceps proximally and between brachioradialis and triceps distally are developed: (1) biceps brachii muscle; (2) radial nerve; and (3) triceps brachii muscle.

The brachialis and brachioradialis are retracted anteriorly and the triceps posteriorly exposing the distal humeral shaft: (1) humerus; (2) radial nerve; (3) brachialis muscle; (4) brachioradialis muscle; and (5) triceps brachii muscle.

Figure 5.12. The brachialis and brachioradialis are retracted anteriorly and the triceps posteriorly exposing the distal humeral shaft: (1) humerus; (2) radial nerve; (3) brachialis muscle; (4) brachioradialis muscle; and (5) triceps brachii muscle.

Reduction and internal fixation of a distal humeral fracture through the straight lateral approach

Figures 5.13. Reduction and internal fixation of a distal humeral fracture through the straight lateral approach.

 Positioning for the posterior approach with modified Mayo stand and sterile tourniquet.

Figure 5.14. Positioning for the posterior approach with modified Mayo stand and sterile tourniquet.

Skin incision for posterior approach.

Figure 5.15. Skin incision for posterior approach.

Postoperative Management

Postoperatively, a compression bandage is applied and patients are placed in a sling, which is removed to permit active range-of-motion exercises of the shoulder and elbow within 1 or 2 days of surgery. Full elbow and shoulder motion should be obtained within 6 weeks of surgery. Patients are seen on a monthly basis until the fracture is united and they have returned to normal activity. Radiographs are obtained at each visit. The patient is carefully assessed for shoulder, elbow, wrist, and hand function. The radiographs are studied for signs of fracture healing and any evidence of implant failure. With stable fixation, fracture union is often difficult to assess. If follow-up radiographs show maintenance of the reduction, light weights are usually allowed at 6 weeks and regular weights at 12 weeks. At 12 weeks, patients can begin returning to normal activities. Heavy work can be started at 16 weeks. Sporting activities, such as tennis and golf, can also be started about 4 months after surgery.

The posterior approach. Identification of the long and lateral heads of triceps: (1) long head of triceps and (2) lateral head of triceps.

Figure 5.16. The posterior approach. Identification of the long and lateral heads of triceps: (1) long head of triceps and (2) lateral head of triceps.

Exposure of the deep head of the triceps and radial nerve: (1) long head of triceps; (2) lateral head of triceps; (3) deep (medial) head of triceps; (4) deltoid; (5) deep brachial artery; and (6) radial nerve.

Figure 5.17. Exposure of the deep head of the triceps and radial nerve: (1) long head of triceps; (2) lateral head of triceps; (3) deep (medial) head of triceps; (4) deltoid; (5) deep brachial artery; and (6) radial nerve.

 Exposure of the distal half of the humeral shaft: (1) long head of triceps; (2) lateral head; (3) medial head; (4) deltoid; (5) humerus; (6) deep brachial artery; and (7) radial nerve. B. By using the posterior approach, reduction and lag screw fixation is achieved

Figure 5.18. A. Exposure of the distal half of the humeral shaft: (1) long head of triceps; (2) lateral head; (3) medial head; (4) deltoid; (5) humerus; (6) deep brachial artery; and (7) radial nerve. B. By using the posterior approach, reduction and lag screw fixation is achieved. C. This is followed by placement of a neutralization plate positioned laterally to avoid encroachment on the olecranon fossa.



Complications

Most complications can be avoided by adhering to basic principles. Failure of fixation occurs in up to 4% of patients and can be avoided by careful preoperative planning and implant selection as well as limited soft-tissue dissection. When using a plate, interfragmentary compression, either with lag screws and a neutralization plate or with a compression plate alone, is essential. At least 6 points of cortical fixation on each side of the fracture must be obtained. If the fixation fails, revision ORIF is necessary, usually with a longer locking plate and bone graft because nonoperative management is rarely successful.

Nonunion after plate osteosynthesis occurs in 3% to 5% of cases. Factors thought to contribute to nonunion include open fractures, middle-third transverse fractures, pathologic fractures, patient alcohol abuse, or a technical error in the primary procedure. Factors that can be controlled by the surgeon include accurate fracture reduction, stability of fixation, and minimization of soft-tissue stripping and bone grafting. Nonunion is treated by revision ORIF and autogenous cancellous bone grafting. A longer plate must be used at the revision procedure. Nonunion after intramedullary nailing is also best treated by ORIF rather than exchange nailing (20).

With few studies assessing function in detail, loss of motion of the shoulder or elbow is probably underreported. Several studies report that 15% to 20% of patients have decreased shoulder and elbow motion after ORIF. Etiologic factors include fractures with extensive soft-tissue injuries or with ipsilateral bone or joint injury. Stable fixation and early motion are recommended. If significant stiffness is identified, a more vigorous physiotherapy program is initiated. We have not needed to use any surgical modalities to deal with joint stiffness after ORIF of humeral shaft fractures.

Infection is an uncommon complication of ORIF. The routine use of perioperative antibiotics, limited soft-tissue dissection, careful hemostasis, and thorough debridement of open fractures may reduce the rate of infection after ORIF. If infection develops, then the

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microorganism must be isolated. This is followed by assessing and correcting problems with stability, fragment approximation, vascularity, and soft-tissue coverage. The infected site should be incised, drained, and thoroughly debrided. The area is packed with antibiotic-loaded, acrylic, cement beads and systemic parenteral antibiotics are given. The choice of local and systemic antibiotic depends on the Gram stain findings and the final culture and sensitivities. Parenteral antibiotics are generally continued for 6 weeks. The local antibiotic depot is usually removed at 7 to 10 days during repeated debridement and irrigation. If the fixation is rigid, it is left in place, but if it is loose, it is revised and rigid fixation is obtained.

Radial nerve palsy most frequently occurs at the time of injury. Iatrogenic radial-nerve palsy occurs in about 5% of surgical cases. An intraoperative laceration should never occur, but if it does, it should be repaired immediately by a trained microsurgeon. A postoperative nerve palsy after identification and protection of the nerve should be observed, and full functional recovery anticipated.

Recommended Readings

1. Meekers FS, Broos PL. Operative treatment of humeral shaft fractures: the Leuven experience. Acta Orthop Belg 2002;68:462鈥�470.

2. Niall DM, O'Mahoney J, McElwain JP. Plating of humeral shaft fractures has the pendulum swung back? Injury 2004;35:580鈥�586.

3. Sarmiento A, Waddell JP, Latta LL. Diaphyseal humeral fractures: treatment options. Instr Course Lect 2002;51:257鈥�269.

4. Chapman JR, Henley MB, Agel J, et al. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma 2000;14:162鈥�166.

5. McCormack RG, Brien D, Buckley RE, et al. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg Br 2000;82:336鈥�339.

6. Modabber MR, Jupiter JB. Operative management of diaphyseal fractures of the humerus: plate versus nail. Clin Orthop 1998;347:93鈥�104.

7. Dijkstra S, Stapert J, Boxma H, et al. Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement. Eur J Surg Oncol 1996;22:621鈥�626.

8. Marti RK, Verheyen CCPM, Besselaar PP. Humeral shaft nonunion: evaluation of uniform surgical repair in fifty-one patients. J Orthop Trauma2002;16(2):108鈥�115.

9. Ring D, Kloen P, Kadzielski J, et al. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop 2004;425:50鈥�54.

10. Bell MJ, Beauchamp CG, Kellam JK, et al. The results of plating humeral shaft fractures in patients with multiple injuries: the Sunnybrook experience. J Bone Joint Surg Br 1985;67:293鈥�296.

11. Bleeker WA, Nisten MW, Duis H-J, et al. Treatment of humeral shaft fractures related to associated injuries: a retrospective study of 237 patients. Acta Orthop Scand 1991;62:148鈥�153.

12. Heim D, Herkert F, Hess P, et al. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma 1993:35:226鈥�232.

13. Brien WW, Gellman H, Becker V, et al. Management of fractures of the humerus in patients who have an injury of the ipsilateral brachial plexus. J Bone Joint Surg Am 1990;72:1208鈥�1210.

14. Amillo S, Barrios RH, Martinez-Peric R, et al. Surgical treatment of the radial nerve lesions associated with fractures of the humerus. J Orthop Trauma 1993;7:211鈥�215.

15. Samardzic M, Grujicic D, Milinkovic ZB. Radial nerve lesions associated with fractures of the humeral shaft. Injury 1990;21:220鈥�222.

16. Sarmiento A, Horowitch A, Aboulafia A, et al. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br 1990;72:283鈥�287.

17. Holstein A, Lewis GB. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am 1963;45:1382鈥�1388.

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19. Henry AK. Extensile exposures. 1st ed. Edinburgh: E. S. Livingstone; 1945.

20. McKee MD, Miranda MA, Reimer BL, et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma1996;10:492鈥�499.