HUMERUS EXTERNAL FIXATION:

Avoiding Neurovascular Injury

Melesse Gardie, Orthopaedics Resident

Duane Anderson, MD
Soddo Christian Hospital
Soddo, Ethiopia
June 2016
 Goals of External fixation of the Humerus

• Create the greatest stability possible with 4

pins and one bar if possible
• Avoid NV injury in the process
• Recreate normal anatomy of the bone, nl
length, rotation, angulation
• Allow wound care with ease
• Allow painless ROM of the shoulder and
elbow if possible
 Outline of Presentation
1.Anatomy (Bony and Soft tissues)
2.External Fixation principles as applied to the
humerus
3. Techniques to avoid NV injury
4. Case examples
 Ex Fix Goals explained
• Pin 1 and 4 should be as far apart as possible and
pins 2 and 3 should be as close as possible to
create greatest stability
• The bulk of the muscles of the humerus are
flexors(anterior) and extensors(posterior) of the
elbow, the pins should try to avoid entrapping
these muscles
• The radial nerve is the most important structure
at risk
• The axillary nerve is at risk proximally
 ANATOMY kkkkkkkkkkkkkkkkk
1. Bony Anatomy:
-proximal
-Shaft
-Distal Humerus
 Shaft (Upper Border Pec
maj insertion to supra
condylar ridge
 is nearly cylinderical prox &
triangular distally
 3 surfaces separated with 2
borders
 Radial groove
 Deltoid Tuberosity
 Nutrient foramen
 Antero superior view.

Position of inter tubercular groove,

glenoid cavity, prox humers, distal
humerus
Torsion of Humerus
Humerus Muscle insertions/origins
2. Soft tissue Anatomy
Vasculature
Axillary Nerve
Axillary nerve posterior view
 Radial/axillary nerves posterior view

right left
• Crosses the intermuscular
septum 8-12 cm proximal to
the elbow
 Radial Nerve Greatest risk of injury is
in the distal third of the humerus

Laterel I/M
Septum
TTriangular Interval:
Radial Nerve
Profonda Brachial Artery
 Indications for external fixation
• Open fractures with or without extensive soft
tissue loss
• Infected open fractures
• Burn patients with fractures
• Highly comminuted fractures
• Segmental bone loss
• Vascular injuries
• As an element of salvage procedure in cases of
major complications after nailing or plating
• As primary treatment in polytrauma patients
 Open fractures
• All open fractures do not need External
fixation
• Low energy open fractures that are relatively
stable and need 1 or 2 debridements don’t
need an ex fix, plating, or rodding
• Higher energy injuries that will require
repeated debridement are the biggest
indication
• Infected open fractures are a major indication
 External Fixation Technique
• placement of the pins
depends on the location
of the fracture
• generally a single frame
with two pins each
proximal and distal to
the fracture gives
enough stability
 External Fixation Technique
• Far distally straight lateral
pin placement avoids
entrapment of flexors and
extensors of the elbow
• The radial nerve is at risk
• The nerve crosses the
intermuscular septum 8-
12 cm from the elbow in
the adult patient
• The nerve then sits on top
of the brachialis and
under the radiobrachialis
 Distally
• Distally straight lateral
pin placement allows
avoidance of the radial
nerve and entrapment
of flexors and extensors
of the elbow if careful
surgical technique is
followed
 External Fixation Technique
• Distally straight lateral pin placement allows
avoidance of the radial nerve and entrapment
of flexors and extensors of the elbow if
carefully done
 Dangerous
• Skin Incision long enough (>1.5cm) to avoid
strain of skin margins after pin placement and
to allow easy blunt dissection, distally very
careful dissection and retraction and
placement of soft tissue protectors are
essential in prevention of nerve injury
• The more nervous you are the bigger the
incision, expose the nerve if you are afraid..
 Safe areas
• In safe areas of the humerus small incisions
with placement of drills through soft tissue
protectors is enough
 Pin placement
• Place drill sleeve with trocar in the prepared
soft tissue channel position in correct place,
predrill both cortices
• Pin placement should also be done with
sleeves, and feeling of the pin thread itself
into the opposite cortex confirms correct
insertion depth
 Proximally/Axillary nerve
• In an adult the axillary
nerve is 7 cm from the
acromion
• Is is just below the surgical
neck
• It corresponds to the largest
bulk of the deltoid
• Go just below this point for
most fracture patterns
• Make an incision and
bluntly dissect down to the
bone and place a drill in the
soft tissue protector and
use as a trocar
 The logical sequence of fixeters
• The most proximal and
distal pins should be
placed first #1, #4
• Then a bar should
interconnect them
 Rotation and length! Pin #1, #4
• With the first two pins
and the bar get the
Rotation and length
correct! IMPORTANT!
• If you don’t have
rotational markers at the
fx assume the proximal
fragment is in neutral
rotation, ie put the
forearm straight up in the
supine position(the
rotator cuff is balanced in
neutral rotation
 Pins #2, #3
• Your assistant needs to
hold the fx anatomically
while the middle pins
are placed
• I do NOT feel that the
pins have to avoid
fracture hematoma
 Fine tuning the fx site with the middle pins, #2, #3

• USE the bar/pin clamp

as a drill guide while the
fx is held anatomically
by your assistant
 How to avoid the radial nerve in the
middle/distal thirds of the humerus
• In some fractures the
nerve is visible, this is an
obvious advantage
• The nerve in the middle-
distal third is going from
posterior to anterior as it
goes distally
• Use what you can see to
your advantage, if you
need to follow its course
surgically do so
 How to avoid the radial nerve in the
middle third of the humerus
• If you know where the
nerve is, pull it out of the
way
• If you know it just went prox
posterior on its way
Distal
proximally, then go
further proximally and
direct your pin away from
the nerve by directing the
angle of the drill
anteriorly carefully hold
the drill to avoid a plunge
posteriorly
 Make an incision if you have to to find the nerve!

• Injuring the nerve

because you want to
make a small incision in
the middle-distal third
of the humerus is NOT
wise
Elbow motion in the hospital
Shoulder motion in the hospital
 Ex fix and ORIF
• Open elbow injuries to allow motion
• Spanning the elbow for very unstable open
injuries
Open 3A, fx’s on both sides of the joint
Limited ORIF on the humerus (major
bone loss), spanning ex fix
 Ex fix removed at 3 months
• at 4 months a capsulotomy was done to allow
elbow motion
6 months later
6 months post injury
Gustilo 3 B open fx
After ex fix and minimal ORIF
Move it!
Local Flap and coverage, move!
Other fixeter configurations
A Humerus Ex fix is invaluable!