Midshaft Humerus Fracture: Operate or Treat Conservatively

Today, we will talk about when to Midshaft Humerus Fractures- when & how you decide to operate or not!

Clinical Presentation

• 44 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over right arm
• Paresthesia in distribution of radial nerve; no motor loss
• Co-morbidities – post traumatic neurogenic bladder (Old trauma)

Conservative treatment- When/How/Where to avoid?

Indications

Criteria for acceptable alignment include: 

< 20° anterior angulation

< 30° varus/valgus angulation

< 3 cm shortening

Resulting shortening and varus angulation is well adjusted in upper limb and without cosmetic issues.

Method- reduction in GA and cast application/ Coaptation splints

Absolute contraindications

• Brachial plexus injury
• Vascular injury requiring repair
• Severe soft tissue injury or bone loss

Relative contraindications

• Associated ipsilateral forearm fracture/lower extremity fracture 
• Pathologic fractures
• Soft tissue injury that hinders bracing
• Iatrogenic nerve injury while attempted reduction
• Bilateral humeral fracture
• Obese patient- difficult to reduce and maintain reduction; compliance issue with brace
• Fracture characteristics
  • Distraction at fracture site
  • Transverse or short oblique fracture pattern
  • Intraarticular extension of fracture line
  • Fracture characteristics not in acceptable criteria

Radial nerve palsy alone is not an absolute indication for operative intervention

Absolute indications for fracture fixation

• Open fracture (Compound fractures) 
• Vascular injury requiring surgical intervention
• Brachial plexus injury    
• Floating elbow   
• Compartment syndrome
• Periprosthetic humeral shaft fractures
• Failed Conservative treatment

Approach for fixation

• Anterolateral Approach-
  • Open with wide dissection
  • MIPPO technique
  • Proximal third to middle third shaft fractures

• Posterior Approach-
  • Distal to middle third shaft fractures
  • Cases requiring visualization of radial nerve