Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures.Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management.Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture.Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing.There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy. Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033.

Humeral shaft fractures.

Conventional plate osteosynthesis is a valuable treatment option in displaced proximal and/or middle one-third humeral shaft fractures. Nonetheless, this procedure can be complicated by a radial nerve palsy. To date, many surgical techniques have been developed in an attempt to minimize this high-impact complication. A helical plate has the potential to avoid an iatrogenic radial nerve palsy due to its design. This article aims to evaluate safety and functional outcomes of patients treated with a helical plate compared to conventional plate osteosynthesis. In particular healing rates, complications and functional outcome measures. We retrospectively included all patients with displaced proximal and/or middle one-third humeral shaft fractures who were treated with a helical plate from October 2016 until August 2018 at a single level-1 trauma center (AZ Groeninge, Kortrijk, Belgium). A self-molded long PHILOS plate (DePuy Synthes®) or a pre-contoured A.L.P.S proximal humeral plating system (Zimmer Biomet®) were used. Patient baseline characteristics and standard radiographs were obtained pre- and postoperatively. We retrospectively searched for complications. Patients were reassessed using the Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley (CMS) and EQ-5D-5L scores with a minimal follow-up of 1 year. The humeral shaft fractures of all sixteen patients consolidated within 3 months and no iatrogenic radial nerve palsies were observed. One plate had to be removed after 1 year due to a late deep infection. With a minimum follow up of 1 year, the mean DASH score was 22 ± 19 and the mean normalized CMS was 80 ± 19. Operative treatment of proximal and/or middle one-third humeral shaft fractures with a helical plate is a safe procedure with good to excellent shoulder function at one-year follow-up. Contrary to conventional plate osteosynthesis, a helical plate has the potential to completely avoid a radial nerve palsy, while maintaining similar healing rates and functional outcomes. Retrospective cohort study. B396201939564
 . Registered on 10 MAY 2019.

/pdf/one-year-follow-up-after-treatment-of-proximal-and-or-middle-42xeiuvana.pdf

One-year follow-up after treatment of proximal and/or middle one-third humeral shaft fractures with a helical plate: healing rates, complications and functional outcome measures.

The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures. A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes. Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P  = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P  = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P  = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P  < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P  = 0.997), or approaches (two studies; RR: 0.36; P  = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P  = 0.004) but not different between approaches (2 studies; RR: 0.95; P  = 0.960). Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

/pdf/complications-in-humeral-shaft-fractures-non-union-3o5bufvn.pdf

Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

Identification of the radial nerve is important during the posterior approach to a humerus fracture. During this procedure, the patient can be placed in the prone or lateral decubitus position depending on the surgeon's preference. The distance from the radial nerve to the osseous structures will be different in each position. The purpose of this study was to identify the safety zones in various patient and elbow flexion positions. The distances from the olecranon to the center of the radial groove and intermuscular septum and lateral epicondyle to the lateral intermuscular septum were measured using a digital Vernier caliper. The measurements were performed with cadavers in the lateral decubitus and prone positions at different elbow flexion angles. The distance from where the radial nerve crossed the posterior aspect of the humerus measured from the upper part of the olecranon to the center of the radial nerve in both positions at different elbow flexion angles varied from a mean maximum distance of 130.00 mm with the elbow in full extension in the prone position to a minimum distance of 121.01 mm with the elbow in flexion at 120° in the lateral decubitus position. The mean distance of the radial nerve from the upper olecranon to the lateral intermuscular septum varied from 107.13 to 102.22 mm. The distance from the lateral epicondyle to the lateral edge of the radial nerve varied from 119.92 to 125.38 mm. There was not significant contrast in the position of the radial nerve with osseous landmarks concerning different degrees of flexion, except for 120°, which is not significant, as this flexion angle is rarely used.

Location of the radial nerve along the humeral shaft between the prone and lateral decubitus positions at different elbow positions.

OBJECTIVE Compare anterior minimally invasive plate osteosynthesis (MIPO) to open reduction/internal fixation (ORIF) for humeral shaft fractures, assessing complications and clinical outcomes. DESIGN Retrospective matched case-controlled cohort. SETTING Tertiary referral trauma centre. PATIENTS/PARTICIPANTS Humeral shaft fractures identified retrospectively over 5 years; 31 were treated by MIPO and 54 by ORIF. Matched-case cohort assembled according to fracture pattern, sex, age, and comorbidities, with 56 total patients (28 per group). INTERVENTIONS MIPO and ORIF. MAIN OUTCOME MEASURES Complication rate was the primary outcome (radial nerve injury, nonunion, infection, and reoperation). Radiographic alignment and the Disabilities of the Arm, Shoulder and Hand Score were secondary outcomes. RESULTS Cumulative complication rates were 3.6% after anterior MIPO and 35.7% after ORIF (P = 0.0004). The only complication after anterior MIPO was a nonunion, managed with revision ORIF and bone graft. The ORIF group had 10 complications, including 5 superficial infections, 4 iatrogenic radial nerve injuries, and 1 nonunion. The mean Disabilities of the Arm, Shoulder and Hand score after MIPO was 17.0 ± 18.0 and after ORIF was 24.9 ± 19.5. The mean coronal plane angulation after MIPO was 1.8 ± 1.3 degrees and after ORIF was 1.0 ± 1.2 degrees. The mean sagittal plane angulation after MIPO was 3.0 ± 2.9 degrees and after ORIF was 1.0 ± 1.2 degrees. CONCLUSIONS The cumulative complication rate was 10 times higher after ORIF of humeral shaft fractures compared with the MIPO technique. MIPO achieved nearly equivalent radiographic alignment, with no clinically meaningful differences observed. MIPO is the safer option and should be considered for patients with humeral shaft fractures that would benefit from surgical intervention. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures Is Safer Than Open Reduction Internal Fixation: A Matched Case-Controlled Comparison.

Objective To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy. Design Retrospective. Setting Two trauma centers. Patients Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation. Intervention Plate fixation of humerus shaft fractures, from 2008 to 2016. Main outcome measurement Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics. Results Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006). Conclusion Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation.

Purpose: Thrower’s Elbow (TE) is an overuse injury of the medial elbow in pediatric, throwing athletes. The purpose of this study is to report the outcomes of TE in pediatric, throwing athletes. Methods: Between 1996 and 2018, 30 athletes at an average of 12.2 years old (range: 7.9 to 15.4 years old) were treated for TE. Demographic, radiographic, and treatment variables were recorded. Outcome measures included return to original position, inability to return to sport, surgery, premature physeal arrest, and recurrence of elbow pain. Results: Prior to their initial presentation, 25 athletes (25/30, 86%) stated they continued to throw despite arm fatigue/pain. At an average follow-up of 26 months (range: 6 months to 122 months), 22 athletes (22/30, 73%) returned to their original position at an average five months from their initial presentation. Recurrence of elbow pain occurred in 27 athletes (27/30, 90%). No athletes had premature physeal arrest of the medial epicondyle. Conclusions: The majority of athletes with TE returned to their original position or sport after initial treatment, but 90% of those athletes developed recurrent pain. It is important to educate athletes about overuse throwing injuries and prevention by adhering to established guidelines. 

Thrower's Elbow: Outcomes and Recurrence of Elbow Pain in Pediatric Athletes

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Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation.

Thrower's Elbow: Outcomes and Recurrence of Elbow Pain in Pediatric Athletes