Humeral Shaft Fracture


Non operative Mangement




< 20o sagittal

< 30o coronal

< 3 cm of shortening


Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral




1.  Vietnam Cast / hanging cast

2.  Functional bracing 3/52


Functional Humerus Brace




United Humeral Fracture LateralUnited Humeral Fracture


Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative group nonunion 20% and 12% malunion

- operative group nonunion 8% v 1%

- no increased time to union or radial nerve palsy in operative group


Operative Managment





- compound fracture

- radial nerve palsy post reduction

- failure to obtain / maintain acceptable reduction

- displaced Holstein Lewis with radial nerve palsy



- multi-trauma

- floating elbow

- obese (very difficult to splint)

- pathological fracture - won't heal

- segmental fracture

- bilateral humeral fractures

- brachial plexus injury - allows early rehab


Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral



- antegrade IM Nail

- retrograde IM Nail

- ORIF with plate


Indications Plate vs Nail


Chapman et al J Orthop Trauma

- RCT antegrade nail v plate 84 patients

- union rates similar in each - 90%

- shoulder discomfort and decreased ROM with nail

- decreased elbow ROM with plate especially distal third


1.  Antegrade Humeral Nail


Humeral Nail APHumeral Nail Lateral


Relative indications

- segmental fracture - need very long plate

- impending pathological fracture




Set up

- lazy beach chair

- need to get II of shoulder and distal forearm

- patient relatively supine to ensure ease of AP distal locking


Anterolateral approach shoulder

- longitudinal split SS

- entry point at medial aspect GT

- entry with K wire or awl

- check down IM canal of humerus with II

- most nails have mild valgus proximal angulation

- increase diameter proximally with hand reamers


Pass guide wire

- can do closed

- can perform mini open to blunt dissect and protect radial nerve


Minimal reaming


Pass nail

- bury enough to protect cuff

- need to consider hardware removal


Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon


Distal AP locking screw


Careful repair of rotator cuff




Cox et al J Orthop Trauma 2000

- 37 patients treated with antegrade nail

- 4 non unions and 4 delayed unions (>4 months)

- 6 patients had poor shoulder function (4 due to stiffness, 2 due to pain)




Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

- still incidence of shoulder pain


Humerus Prominent IM Nail


2.  Retrograde IM Nail


Relative indication

- distal 1/3 humeral fracture

- avoids shoulder pain




Set up

- Patient prone

- arm on table, need to flex elbow


Entry dorsal

- 3cm above Olecranon fossae

- gentle reaming to prevent blow-out


Distal locking with butterfly construct and screws


Proximal locking

- some have extendable hook




Distal blow out

- difficult problem


Nail removal

- not easy procedure




Cheng et al J Trauma 2008

- RCT of antegrade v retrograde IMN

- similar union rates (>90%)

- longer time to perform retrograde IMN

- longer time to recover shoulder function in antegrade group


3.  Plate Osteosynthesis


Humeral Plate LateralHumeral Plate Long AP



- nerve injury requiring exploratation



1.  Proximal 2/3

- anterior or anterolateral

2.  Distal 1/3

- posterior




A.  Anterior Approach Humerus


Sterile tourniquet


Incision lateral aspect of biceps

- incise deep fascia



- retract deltoid laterally and biceps medially


Identify plane between biceps and brachialis

- protect MCN between the two

- identify and split brachialis in midline


Internervous plane

- radial nerve lateral brachialis

- MCN medial brachialis


Distal extension

- between brachialis and BR in distal 1/4

- find and protect radial nerve


4.5 mm DCP

- minimum 6 cortices above and below


B.  Anterolateral approach


Allows more distal plating


Utilise interval between triceps and brachialis

- identify and protect radial nerve distally between brachialis and BR

- extend proximally into deltopectoral groove


C.  Posterior Approach


Humerus ORIF Posterior Approach



- lateral approach

- arm over bolster


Sterile tourniquet if needed


Midline incision

- interval between long and lateral heads

- Split medial head of triceps

- identify radial nerve proximally 


Radial Nerve Injury




4% incidence of radial nerve injury


Associated with Holstein Lewis fracture


Holstein - Lewis JBJS Am  1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach


Holstein Lewis


Incidence of laceration / entrapment


Noaman et al Microsurgery 2008

- operative exploration of 36 patients with radial nerve palsy

- entrapped in fracture site in 9 and lacerated in 8

- 9 epineural repairs and 5 nerve grafts

- neurolyis in remainder




Average time to see recovery is 7 weeks

Average time to full recovery 15 weeks

Longest time to see recovery 7 months to 1 year




Sarmiento JBJS Am 2000

- 922 fractures managed in brace, 620 followed, no MUA

- radial nerve palsy in 11% / 101

- 1 radial nerve didn't recover


Pollock & Drake et al JBJS Am 1963

- 24 humeral shaft fractures with radial palsy (14/24 distal third)

- 9 of these were complete motor and sensory (8/9 distal third)

- treatment immobilisation or traction

- all had complete recovery




1.  Explore + ORIF

- easy to make this decision if fracture requires operative management


2.  Manage non operative

- if no recovery tendon transfer