Humeral shaft fracture fixation method dependent on a number of factors

The options are many, but ultimately the method of fixation should hinge upon the situation.

There are numerous treatment options available for fractures of the humeral shaft, as well as various indications for surgical treatment. As technology and techniques evolve, it is important to remember that which is most effective on a case-by-case basis, according to a Minneapolis orthopedist.

These techniques and options were outlined by David C. Templeman, MD, in a presentation at Orthopedics Today Hawaii 2009.

Templeman’s presentation covered various bone fixation materials, situations and techniques, as well as comparisons between many of the available options.

Plating or nails?

Cases that are most often predisposed to non-union are transverse, displaced, diaphyseal fractures, Templeman, who is also a member of the Orthopedics Today Editorial Board, said.

“The big indication for fixation in humerus fractures is for the mobilization of the multiply injured patient,” he said. “If you take somebody with good bone and you do a good plating job, you can get that patient get up weight-bearing the arm with crutches.”

David C. Templeman, MD, said the main indication for fixing humeral fractures is mobilizing the multiply injured patient. Image: Beadling L, Orthopaedics Today

Still, Templeman warned, such mobilization has not been documented in comminuted fractures where nails are used for fixation.

“I’d be nervous about a locked nail with an unstable fracture problem,” he said.

Studies comparing the efficacy of nailing and plating in bone fixation report that antegrade and retrograde nailing techniques have a higher nonunion rate than plating. The major causes of non-union are primarily surgical, Templeman said, and though infection rates in plating are slightly higher than what most would like to consider for elective surgeries, the lower non-union rate makes it a strong option.

Causes of failure

Failures in fixation tend to come from lack of cortical purchase and osteoporosis, as well as damages sustained in falls that occur after the procedure.

Templeman also expressed difficulties in operating on and plating upper-extremity injuries in alcoholics.

“They miss clinic appointments, they go on drinking binges to alleviate their pain once their arm hurts and they fall repeatedly,” he said. “We have had many, many fixation failures in this group. At least for me, if it is an isolated injury I really try to push nonoperative treatment for 3 to 4 months, prior to operating.”

Hybrid plating

Newer technology, which makes use of locking plates, still does not solve all fixation problems in the humerus, Templeman said.

“I’ll have you consider that for many of these locking constructs, the screws are unicortical,” he said. “If you put a unicortical screw in osteoporotic bone, you are not going to get good fixation.”

Instead, Templeman pointed out that recent studies and trends have noted the use of “hybrid” constructs as being effective in the treatment of diaphyseal fractures. Standard plate fixation, he said, relies on the friction generated between the screws and the plate compressed to the bone. Hybrid fixation secures the plate to the bone with standard techniques and then locking screws.

“Exactly where the locking screws go and how many of them are there remains a bit of a debate,” Templeman added.

The point of vivo fixation

Templeman also questioned whether or not percutaneous fixation was plausible; ultimately saying that it was possible but not very sensible.

“It is doable,” he said. “We are seeing more of it, and the fractures will unite … but I am not sure what it solves, because you don’t get good, solid reconstructions, so the patient can’t really weight-bear on that limb.”

“If the indication for fixation is to use the arm for weight-bearing with crutches and stable fixation is not achieved, which usually occurs with minimally invasive plating of the humerus, this becomes a bit of technology over reason,” he added. “I think the patient will do just as well with a functional orthosis.”

For more information:

• David C. Templeman, MD, is the director of pelvic trauma at the Department of Orthopedic Surgery at the Hennepin County Medical Center, and can be reached at Hennepin County Medical Center, Department of Orthopaedic Surgery, 701 Park Ave. 862B, Minneapolis, MN 55415; e-mail: templ015@umn.edu. He receives royalties from Zimmer, and is a consultant for Stryker.

Reference:

• Templeman DC. Humeral shaft fractures: indications and options. Presented at Orthopedics Today Hawaii 2009. Jan. 11-13, 2009.