Chapter 36: Humeral Shaft Fractures

Associated Injuries
- Nerve Injury - radial nerve in 10-12% of closed fxs
- No need for urgent decompression, with good prognosis for recovery
- Holstein and Lewis proposed spiral lateral to medial fxs had high rate of nerve
entrapment (but usually recovered spontaneously)

- Ipsilateral Humeral Head Fx

- Definitely operative, usually with nail
- Technically challenging but satisfactory results

- Concomitant Dislocation of Shoulder

- Reduce the shoulder ASAP, usually under anesthetic

- Soft Tissue Injuries - 63.6% of abnormal findings on MRI such as RCT or bursitis

- Floating Elbow
- More common in peds
- Need surgery, outcomes still not awesome

- Signs/Symptoms
- Swelling
- Beware hidden injuries elsewhere in the arm

- Imaging
- AP and lateral, joint above and below
- Doppler, CT or ultrasound, nerve conduction studies

Classification
- Bone Injury
- Three parts: proximal (11), diaphyseal (12), and distal (13)
- Diaphyseal - simple (A), wedge (B), complex ©
- Benign (1) to difficult (3)

- Garnavos Classification
- Proximal (P), Middle (M), Distal (D), extension into joint (j)
- Simple (S)
- Transverse (t) or spiral (s)
- Intermediate (I)
- Complex ©

- Soft Tissue Injury

- GA classification
 - OTA/OFS
- Skin
- Can be approximated
- Cannot be approximated
- Extensive degloving
- Muscle
- No muscle in area, no appreciable necrosis
- Muscle loss, but remains functional
- Dead muscle or complete disruption of muscle tendon unit
- Arterial
- No injury
- Artery injury without ischemia
- Artery injury with distal ischemia
- Contamination
- None or minimal
- Surface
- Bone or soft tissues
- High risk environmental (barnyard, fecal, dirty water, etc)
- Bone loss
- None
- Missing or devascularized but still some contact
- Segmental bone loss

- Tscherne and Gotzen

- Grade 0 - minimal soft tissue damage, simple pattern
- Grade 1 - superficial abrasion or contusion, mild/moderate fx pattern
- Grade 2 - deep contaminated abrasions, impending compartment syndrome,
severe fx
- Grade 3 - crush, decompensated compartment syndrome, major vascular injury,
severe fx

Outcome Measures
- Constant-Murley Score
- 100 point functional shoulder assessment tool (worst to best)
- Pain (15 pts), functional assessment (20 pts), ROM (40 pts), strength (25 pts)
- DASH
- 30 items vs 11 on quickDASH
- 0-100 where higher score = greater disability
- American Shoulder and Elbow Surgeons Self-Report Form for the Shoulder
- There is also one for the elbow
- Mayo Elbow Performance Index (MEPI)
- Pain, motion, stability, function
Pathoanatomy and Applied Anatomy
- Shaft = area below surgical neck/tuberosities; above supracondylar ridge at elbow
- Changes gradually from cylindrical to triangular as it courses distally
- Important bony landmarks
- Deltoid tuberosity at junction of proximal and middle 1/3s
- Spiral groove in middle/posterior aspect housing radial nerve and profunda brachii
artery
- Radial nerve enters posterior compartment and runs between long and lateral heads of triceps,
entering spiral groove and exiting 10-15 cm proximal to lateral epicondyle
- Axillary nerve runs 4-7 cm from tip of acromion about proximal humerus, running posterior to
anterior

Treatment Options
- Nonop
- Acute, closed, isolated fx in cooperative and ambulatory patient
- Type A fxs, proximal ⅓, long oblique fxs, segmental fxs
- Contraindicated for bilateral fxs, polytrauma patients, or periprosthetic fxs
- Union rate of 94.5% for closed treatment with functional bracing
- Sling/Swathe and Velpeau Bandage
- Velpeau is more restrictive with elbow more flexed and forearm pressed to chest
- U-Slab/Coaptation Splint
- Get it as high laterally as possible, replace soon with functional brace
- Hanging Cast - full arm cast left gravity dependent to pull fragments into place
- Functional Bracing
- Sarmiento 1977
- Two plastic sleeves tightened with velcro to apply hydrostatic pressure
- Patients encouraged to employ pendulum movements
- Outcomes - average healing 93.5%, time to union between 6.5 and 22 weeks
- Expect loss of ROM of shoulder - 5-45 deg ER
- Average nonunion rate 15.4% in type A fractures
- Higher risk in proximal fractures, larger fracture gaps, and lack of
bridging callus at 6 weeks
- Operative Tx
- Plate Osteosynthesis
- ORIF
- Supine, prone, or lateral depending on approach and fx location
- Drill, graft instruments, large bone reduction tools, large and small frag
sets and K wires
- Anterolateral approach more common for proximal and middle fxs thus
supine position
- Anterolateral approach - tip of coracoid process in line with deltopectoral
groove to lateral aspect of humerus at deltoid insertion, continued
distally until 5 cm proximal to flexion crease of elbow joint
 - Cephalic vein proximally, retract deltoid laterally and pec major
medially
- Anterior circumflex artery encountered deep and should be
ligated
- In middle third, must mobilize biceps medially, exposing
brachialis which is split in midline to protect innervation
(musculocutaneous and radial)
- Posterior approach - midline incision from tip of olecranon to about 5-10
cm distal to acromion, interval between long and lateral heads of triceps,
sharply incising common tendon of triceps in midline distally
- Will encounter radial nerve and profunda proximally
- May opt for triceps sparing approach which is laterally directed,
though must mobilize radial nerve
- Lateral approach - deltoid insertion to lateral epicondyle, interval
between lateral intermuscular septum and triceps
- Anteromedial approach - medial margin of biceps directed toward medial
epicondyle, more so used for neurovascular surgery than fracture fixation
- Implant of choice for fixation is 4.5 mm narrow dynamic compression
plate (DCP) or 4.5 mm low contact plate
- Minimum 3-4 holes both proximal and distal to fx
- Ideally 4 screws each side if lagging is not possible
- Postop - collar and cuff for support, PT 2-3 days after and simple ROM
at 3-4 weeks
- No bad outcomes with immediate weight bearing
- Can accept up to 2-3 cm of shortening
- Minimally Invasive Plate Osteosynthesis (MIPO)
- Most proximal extent of fx must be distal to bicipital groove and most
distal extent of fx must be proximal to olecranon fossa
- Supine or lateral, anterior approach requires 30-60 deg abduction and full
supination of forearm
- Two incisions, 3-5 cm proximally and 3-5 cm distally
- Split brachialis carefully to avoid damage to musculocutaneous
nerve
- Lateral and posterior approach also feasible with 2-3 incisions
- Tunneling instrument used to position plate (4.5mm narrow DCP) with
suture tied to end of plate and through hole in instrument
- Provisionally fix with one screw, reduce fx, secure into other
fragment
- Overall strong outcomes, though residual elbow motion deficits were
prevalent
- Intramedullary Nailing
- Antegrade
- Supine position, drill, guidewires, humeral reamers, distal targeting
device (optional)
 - 2-3 cm incision from anterolateral edge of acromion obliquely forward,
identify entry point on sulcus toward its medial border
- Long head of biceps can be palpated and protected, can use small bone
hook to avoid acromion by pulling humeral head laterally
- Awl to enter canal, pass guidewire, ream (pause when passing fx site to
minimize risk to radial nerve), wash reaming debris from under rotator
cuff
- Ream 0.5 to 1 mm more than width of nail
- Targeting device to lock nail proximally, distally would go perfect
circles
- Expandable nail is an option to avoid risks of distal interlocks
- Mobilize shoulder and elbow early and often, may use axillary crutches
within 2 weeks of surgery
- Retrograde
- Lateral or prone position, nail sets and wires etc
- C arm on same side as injury
- 4-5 cm incision from tip of olecranon, triceps tendon split until olecranon
fossa is visualized
- Two drill holes connected by osteotome, pass guidewire, hand ream after
fracture reduction, introduce nail, lock distally with targeting device and
then proximally with perfect circles
- Beware iatrogenic fx of supracondylar area as canal is smaller
here than proximally
- External Fixation
- Monolateral vs hybrid
- “Sarmiento” rings
- Pin tract infections are most likely bad outcome
- Comparison Studies
- Plating or Nailing
- IMN higher rate of shoulder impingement, plating more ideal for
unstable fxs
- Consider nails for pathologic fxs, obese patients, osteopenic pts, and
large segmental humeral fxs
- Antegrade or Retrograde Nailing
- Only real difference is longer op time for retrograde
- Shoulder functional recovery may lag behind for antegrade group
- ORIF or MIPO?
- Greater postop malrotation for MIPO, though lower incidence of
iatrogenic radial nerve injury
- MIPO does perform better than antegrade nailing or open plating with
respect to nonunion, functional outcome, and complications
Author’s Preferred Tx
- Functional bracing for uncomplicated fxs, U-slab for dc from ED w/ 1 wk f/u
- IMN preferred when surgical management is indicated
 - Unlocked nailing to be considered as humerus is non weight bearing bone, can tolerate wide
degrees of axial and rotational malalignment, tolerates shortening of a few CM, and given risks
associated with freehand interlocking screw placement
- Also called “bio” nailing, though use is declining
- Nailing ideally performed for acute fractures while fracture hematoma remains present
- Nonunion typically atrophic and managed with surgical debridement, autologous
corticocancellous bone grafting, and rigid fixation w/ compression plating
Adverse Outcomes and Unexpected Complications
- Generals
- Nonunion - 1-10% in nonsurgical tx, 10-15% in surgical tx
- Infection
- Secondary Neurologic Injury
- Permanent in 2-3% of patients
- Consider exploration and repair vs tendon transfers if function does not return
within 4-6 months
- Implant Specific
- Plating
- Loss of Fixation
- Nailing
- Injury to vulnerable soft tissues by locking screws
- Nail protrusion and impingement (antegrade nailing)
- Shoulder dysfunction (antegrade nailing)
- Backing out of proximal locking screws (antegrade nailing)
- Fracture at supracondylar area during insertion (retrograde nailing)
- Risk reduced by flexing elbow beyond 100 deg during nail insertion,
opening a wide entry portal, de-roofing the entry portal, reaming the
distal humeral canal, and the use of a nonrigid nail
- Complications attributed to specific nail design
- External Fixation
- Pin track infection
- Refracture after removal
Special Considerations for Humeral Shaft Fxs
- Open Fractures
- Dependent on severity, though many can be debrided and then treated without internal
fixation
- External fixation for severely contaminated or very open fractures
- Osteoporotic Fractures
- IMN reliable for these injuries as well as for nonunions
- Locking plates that produce a fixed angle implant also of use
- Pathologic Lesions and Fractures
- Fracture healing not expected, thus nail augmentation and filling of areas of bone loss
with cement is ideal
- Systemic complications and need for reoperation higher in this population
- Periprosthetic Fractures
 - Wright and Cofield classification
- Type A - tip of prosthesis and extend proximally
- Type B - tip of prosthesis
- Type C - distal to tip of prosthesis
- O’Driscoll and Morrey
- Type I - periarticular/metaphyseal at level of condyles/olecranon
- Type II - level of stem of prosthesis
- Type III - beyond tip of prosthesis in diaphysis
- Replace implant, bypass fracture by at least two cortical diameters, do not allow cement
to protrude from fracture site as this will prevent bone healing
Summary
- Nonop remains king
- MIPO won’t cover them all
- Nails carry very specific risks and should be used with care and good judgment

Chapter 14: Gunshot and Wartime Injuries

Wartime Injuries
- Intro
- 70% of combat deaths from explosive injury
- 60% of all combat wounds are extremity injuries, of which ⅓ are fractures
- Physics of Explosion
- Hot, high pressure gas expands outward at 3-4 km/sec, and a layer of compressed air
(blast wave) forms in front of gas volume containing most of the energy released
- Pressure wave disperses at inverse proportion to the third power of the spherical
explosive’s radius
- Classical waveform: Friedlander wave, describes pressure changes from a fixed location
relative to the explosive event
- Blast injuries classified by mechanism
- Blast shockwave (primary effects) - lung, GI, soft tissue deformation, possible
traumatic amputation
- Fragments from explosive device and energized debris (secondary effects) -
penetrating wounds to extremities resulting in significant ST injuries and fxs
- Combination effects - massive soft tissue injury and traumatic amputation
(occurs when victim is near seat of the explosion)
- Acceleration and deceleration injuries, flail injuries, axial loading, crush
phenomenon (tertiary effects) - lower limbs and spine bear the brunt, fractures
from impact with solid objects, ST crush injuries → compartment syndrome,
nerve injury
- Thermal injuries (quaternary effects) - burns
- Effect of Blast on the Musculoskeletal System
- Primary
- Hollow, air containing organs see worst effects from blast wave
- If close enough, blast wave alone can enact bending moment to fracture long
bone
 - Soft tissue injury usually occurs several levels proximal to the level of the bone
injury
- One level = ⅓ of bone segment
- Many traumatic amps in Afghanistan had no fracture, and were straight
through knee or ankle, suggesting force of blast wave were predominant
injury mechanism
- Secondary
- Permanent cavity formed when second cortex struck by penetrating projectile,
causing widespread destruction of cancellous bone and fragmentation of cortical
bone on exit
- “Drill hole fractures” are produced by lower velocity projectiles and often do not
require surgery
- Combined
- Brisance (shattering effect) of antipersonnel mines are classic example
- Total or subtotal amputation of limb with zone of ST injury extending more
proximally to the damaged bone
- Zone I - area closest to seat of explosion, traumatic amp
- Zone II - focal areas of microlaceration of the muscle fascicles with
small and large blood vessel injury as well, producing focal hemorrhage
- Critical zone of tissue injury
- Zone III - avulsion of small arterioles from main vessels, impaired
venous return and reactive changes in axons of peripheral nerves
- Border of Zone II and III is optimal area for amputation
- Tertiary
- Similar to blunt trauma seen in civilian population, particularly relevant for IEDs
detonating under vehicles and causing severe axial loading of extremities
- “Deck slap injury”
- Quaternary - burns, less often orthopaedic
- Special Effects of Explosions
- Closed vs Free Field
- Primary lung injury more common in closed, causing highest number of severe
injuries and casualties and needing the most surgery
- Orthopaedic injuries in closed spaces typically tertiary in nature
- Suicide Bombings
- 8.9 times more fatalities and 7 times more injuries than non-suicide attacks with
statistically higher kill:wounded ratio
- More devastating injuries attributed to metallic fragments in explosive packaging
- Management of Blast Injury
- Cornerstone of treatment is to rapidly correct triad of hypothermia, coagulopathy, and
acidosis - best achieved by stemming blood loss
- <C>ABC rather than ATLS ABC where <C> is catastrophic hemorrhage
- Prehospital Care
- Pressure dressings, tourniquets, topical hemostatics
- 67% drop in fatality rate in Iraq with use of tourniquets
 - Rapid infusion of IV fluids, IO access effective in a pinch
- Just get em to the hospital as fast as you can (MERT teams)
- Hospital Care
- Hemostatic Resuscitation
- TXA if within 3 hours from injury
- Blocks plasminogen, inhibiting fibrinolysis
- Early delivery of blood products (1:1:1 platelets, FFP, PRBC)
- Q30min lactates
- Can use TEG to evaluate coagulopathy
- Damage Control Surgery
- Principles: hemorrhage control, limiting contamination, and temporary
closure or coverage for onward evacuation or more definitive sx at later
date
- Proximal vessel control w/ ligation, suture, or shunting
- Duration determined by physiologic state of patient
- Acute Management of the Injured Extremity
- Address hemorrhage, perform full NV exam, assess ST and skin, reduce any noted
fractures and apply splint
- Antibiotics
- Prophylactic benzylpenicillin IM within 1 hour of wounding, not effective past 6
hours
- 1.2g on arrival
- Add cefuroxime and metronidazole if hollow viscous has been perforated
- Be cautious administering pre-hospital IV abx as MDR bugs have been an issue
for military casualties
- Immunization
- Foreign bone implantation is a significant concern in suicide bombings, thus
conferring possible blood borne infection (HBV in particular)
- Tetanus is a must, consider testing for HCV, intervene for HBV for penetrating
exposures
- Debridement - remove foreign material and nonviable tissue
- Other ST Structures
- Leave damaged nerves and tendons alone initially and until wound is free of
infection
- Pack lightly with sterile dressing and cover with bulky dressing to absorb
drainage
- Management of Small Fragment Injuries
- Leave em be, give oral PCN and Flucloxacillin 4x/day for a week
- Over 80% can be safely treated nonoperatively
- Compartment Syndrome
- High rates of revisions for casualties who underwent fasciotomy
- Most commonly inadequately opened compartments were anterior and deep
posterior
- May opt to perform prophylactically in high risk individuals
 - Management of Skeletal Injury
- Traction and plaster immobilization entirely suitable for initial tx
- Acute external fixation becoming more commonplace as part of damage control
orthopaedics
- High rates of instability, pin site infections, or pin loosening, however
- Indicated for unstable fxs, severe soft tissue injury, fxs with associated
vascular injury, multiply injured patient, pts requiring evacuation
- Amputations
- Factors pushing toward amp: irreparable vascular injury, warm ischemia >8
hours, severe crush, severe limb damage threatening to patient’s life
- MESS score >7 predicts amputation (sensitivity 63%)
- LEAP study - plantar sensation should NOT be used to predict limb viability
- Ongoing Care and Reconstruction
- Need clean, non-contaminated wound, all dead tissue removed, fractures
stabilized, and timely coverage of exposed tendon and bone
- Provision of robust, well vascularized coverage over nerve grafts and
musculotendinous units also crucial
- Definitive Fx Stabilization
- Unreamed, narrow devices favored using existing wounds if possible
- Maintains bony blood supply as much as possible and reduces op
time/reaming burden on patient physiology
- Plate within zone of potential future amp if one is anticipated
- Soft Tissue Reconstruction
- Not until two consecutive washouts yield macroscopically clean tissue beds
- Angio prior to all free tissue transfers
- Skin substitutes may be used such as Integra to minimize wound retraction seen
with STSG
Gunshot Wounds
- Intro
- 85,000 nonfatal injuries in the US in 2015
- 2nd most common mechanism of extremity injury on battlefield
- Wounding effects determined by:
- Physical properties of missile (mass, velocity, shape, construction)
- Flight characteristics (velocity, stability in flight, tumbling characteristics)
- Interaction of projectile with differing types of tissue (bone vs ST)
- Types of Guns
- Shotguns
- Smooth bore, fire either multiple pellets or single large projectile
- Birdshot vs buckshot
- Shot charge and wad leave muzzle, after which shot expands and lengthens
- Distribution of pellets determined by the choke (constriction of the bore at the
muzzle end of the barrel)
- Handguns/Rifles
- Rifled barrels (spiral parallel grooves cut into bore)
 - Handgun barrels typically <30 cm
- Ammunition
- Case, primer, propellant, and bullet
- Jacketed - core of lead covered by coating of harder metal like cupronickel or steel
- Exposed (soft-point) or hollowed (hollow-point) tips for partially jacketed bullets
- Wound Ballistics
- Wounding potential of a bullet is related to the amount of kinetic energy a bullet
possesses when striking its target
- Function of muzzle velocity
- Low velocity = <2000 ft/sec (600 m/sec)
- High velocity = >2000 ft/sec
- Amount of energy transferred relates to viscoelastic properties of the various tissues the
bullet encounters
- Drag = ½ drag coefficient x density of medium x cross sectional area of projectile in
frontal plane x velocity^2
- Bullet begins to tumble once it encounters flesh
- Bullet-Tissue Interface
- Temporary cavity formed, leaving behind permanent cavity after tissue retracts from
initial expansion
- Temporary cavity can be as much as 10-40 times the size of permanent cavity
- Cavity formation most important when bullet impact velocities exceed 400 m/sec
- Amount of recoil from cavitation dependent on tissue properties (muscle much more
elastic than the liver, for example)
- Small vessels and capillaries take most of the heat, though larger vessels may experience
thrombosis and intimal injury when not directly severed
- Neuropraxia from peripheral nerve stretch
Evaluation and Management of Gunshot Wounds
- Initial Eval
- Full exposure, ATLS guidelines
- Limb inspection, NV exam, ABIs
- Reduce and splint fractures if present
- Management of Low-Velocity Gunshot Wounds
- Can treat fractures as closed (ulna and tibia are potential exceptions given their proximity
to subcutaneous border)
- Management of High-Velocity Gunshot Wounds
- Antibiotics - 1st gen cephalosporin asap and continued for 48-72 hours
- PMMA beads with antibiotic within may be considered for heavily contaminated
wounds
- Wound Debridement
- Remove devitalized tissue, excise or “floss” wound track
- Second look often required
- Retained Fragments
- Can usually be left in place if they are in areas that will not cause pain or in a
joint
 - May be prudent to assess lead levels
- Exception: wadding in shotgun shells are often comprised of organic material
and thus pose higher infection risk – best to debride
- Intra-Articular Injuries
- Nonop if bullet lands in soft tissues and nothing is retained in joint
- Scope debridement of low energy GSWs to knee
- Fix any large osteochondral fragments encountered
- Transabdominal GSWs
- Debride intra-articular contamination if present
- Vascular Injuries - proximal control as soon as possible, coupled with repair vs shunting
- Prophylactic fasciotomies recommended if repair is performed
- Nerve Injuries - direct nerve transection unlikely unless directly encountered by projectile
- Strain >12% likely to sustain axonotmesis, thus rapid radial expansion of
temporary cavity can cause significant intraneural damage
- EMG 3 weeks after injury to assess Wallerian degeneration
- Scarring around nerve can cause entrapment and adhesion, thus extensive
neurolysis may be indicated at a later date
- Initial Skeletal Fixation
- Tug test - gentle pressure applied with forceps to bone fragment. If easily removed, it is
nonviable
- Ideally ex fix out of zone of injury and away from planned internal fixation
- Definitive ideally within 2 weeks to minimize complications
Summary
- As above lol