Appropriateness of fixation methods - Trauma Meeting 2019: humeral diaphysis
Humeral shaft fractures account for about 1-3% of all fractures in adults and are classified according their location, open or closed status and the pattern of fracture lines. Conservative treatment with functional bracing has been the most widely accepted treatment option in the last decades, however an increasing number of patients is treated surgically. This article overviews the indications, pros and cons of the most used fixation methods. Plates and nails are the most used devices, have widely overlapping indications, mostly depending on surgeon’s preference. Plate fixation can be used for almost all humeral fractures and represent the best option for transitional fractures (proximal or distal shaft), particularly those with intraarticular involvement. MIPO techniques combines the advantages of plates with less soft tissue impairment. Fractures associated with nervous lesions deserve special considerations: the need to explore the radial nerve can drive the choice of implant more than the fracture itself. Intramedullary implants are the best option for pathological fractures of the humeral shaft, and can appropriately replace plates fixation for middle third or proximal shaft even with intraarticular simple patterns. External fixation is rarely indicated, mainly for damage control and/or extensive soft tissue damage.
Humeral shaft fractures account for 1-3% of all fractures in adults. Although conservative treatment with functional bracing has been the most widely accepted treatment option 1,2, a growing number of cases are currently treated with surgery. The increasing widespread of surgical indications has, as usual, many factors. On one hand, young and high demanding patients looking for a restitutio ad integrum as soon as possible, on the other increasingly low demanding patients with poor bone stock (osteoporosis, pathologic fractures, geriatric patients…) with an even greater need for faster recovery and no immobilization 2,3.
All fixation methods have been described over the years for humeral shaft fractures, although the most used are plates and intramedullary nails; external fixators play a role in open fractures. This article overviews the indications, pros and cons of the most used fixation methods in traumatology.
Humeral diaphyseal fractures have a typical two-peak incidence: the first in the 2nd-3rd decades (usually following a fall, or high energy accidents) and the latter around the 7th-8th decades (usually a low energy trauma) 4. Young males with high energy trauma are typical in the first peak, and the M:F ratio is similar in the second peak. Smoking and female gender independently increase the healing time.
The commonest associated injury is transient radial nerve palsy (10-12% of all closed shaft fractures). In case of post -traumatic radial nerve deficit with closed injuries, the problem is almost always a transient neuropraxia; about 95% recover spontaneously and primary exploration is usually not indicated 5,6. On the contrary, when radial palsy is associated with open fractures, a higher frequency of nerve lesions imposes surgical exploration and repair 2.
Other commonly associated injuries are ipsilateral shoulder or forearm lesion; the coexistence of multiple injuries, either in the same limb or in the contralateral one, is normally an indication for surgical treatment.
The AO-OTA is the most common classification system 7, although recently Garnavos proposed a simpler classification 8. Basically, all classification systems consider the morphology of the fracture (simple, one/two additional fragments or comminution) and the location (proximal, middle or distal third). In addition, Garnavos leave an additional class for transitional fractures extended to the joint (Fig. 1) 8.
A variety of scores is available when in doubt for amputation, as MESS, LSI, NISSSA and the Hannover scale, although they were intended especially for lower limbs and, as is common knowledge, in the upper extremities every attempt should be made to save the limb. Therefore, scoring systems are mostly of limited value in clinical practice to manage an individual situation 2.
Indication for surgical treatment
Nonoperative treatment is still the method of choice for most humeral shaft fractures, using some form of fracture bracing 1,2,4. Humeral diaphyseal fractures have a good prognosis with conservative treatment 1, which is to be expected in both comminuted and simple fractures; indeed simple transverse fractures are a relative contraindication for conservative treatment 2,11. In adults, < 20° angulation anteriorly and 30° varus, < 40º rotation and < 30 mm shortening are considered adequate displacement at bone consolidation, reaching good to excellent outcomes and 95% union rates 1,2,11.
Typical indications for surgical treatment are open fractures, polytrauma, bilateral fractures, complex fracture patterns and/or combinations of the upper limb traumatic lesions, transverse fractures, associated neurovascular injuries and neurological diseases (e.g. Parkinson, ICP, etc.), obesity. However, a wide range of overlapping indications leave the choice to surgeons and patients 2-4.
Information gathered from the AO group are milestones regarding this topic. Careful planning and application of AO principles is paramount before approaching any fracture, but this is beyond the aim of this work.
The first problem to solve is how to reduce the fracture and this is largely independent from the fixing devices, although, the surgical approach needed for reduction influences the choice of the implant. Secondly, the same plate allows to obtain absolute or relative stability and can be used as compression, protection, or bridging tool, giving more options for different situations. Obviously, it should be decided before surgery, which is the best option for each case 12.
The upper limb is not weight bearing; however, it has a large rotational excursion and because of this, it is advisable to use long plates to cushion the torsional moment. For this reason, it is advisable to use 4.5 mm plates, with 8 cortexes on each side of the fracture. Dedicated 4.5/3.5 mm precontoured plates are available for transitional fractures. Plates may be implanted for every surgical approach; the choice is mostly a matter of soft tissue and reduction. In general, antero- or anterolateral approaches are more used in proximally extended fractures, posterior or lateral for distal ones (Fig. 2a-e) 4.
In poor quality bone and accounting for large rotational forces, locking screws are preferable and should be bicortical. When ORIF is required, plating enables to reduce and hold articular or periarticular fragments.
Although sometimes technically demanding, results are predictable. According to published reports of 600 humeral plating procedures, a 92-98% union rate could be obtained, the infection rate is less than 1% and iatrogenic radial nerve palsy is 3%. More than 97% of these patients achieve good functional results 13.
Minimally invasive plate osteosynthesis (MIPO)
In the last 20 years, MIPO of humeral shaft fractures using two or three small incisions became popular, similar to techniques described for lower limb 2,4. This method, however, has been considered with great caution because of neurovascular structures at risk, for the radial and musculocutaneous nerves. Many studies have dealt with this subject reporting good outcomes with few complications, with union rates around 95% 14-17.
As for traditional ORIF, generally for MIPO an anterior/anterolateral or lateral approach were chosen for proximal fractures, lateral or posterolateral approach was used to treat distal humeral shaft fractures 15.
The lateral approach has three windows: proximal, through the deltoid for the insertion of the plate, in the middle to allow the passage between the biceps and triceps muscles, and distally for visualization of the radial nerve and fix the plate 4. While it was concluded that MIPO is a safe and efficient procedure for humeral shaft fracture treatment, with high union and low complication rates, although in distal third elbow flexion contracture could be a problem and might indicate the need for a formal elbow rehabilitation protocol 14,15. Despite clinical evidence that MIPO is safe for diaphyseal humeral fractures, anatomical studies have pointed out the the risk for nerve injury (radial and musculocutaneous) is tangible and should not be underestimated 18,19.
MIPO or ORIF?
This is a reiterate question in traumatology. As usual, the problem is primarily a matter of reduction and secondly of fixing method. Thus, one should consider suitable for this question only fracture pattern liable of closed reduction. Once again, planning is paramount and a plan b (switching from MIPO to ORIF) must be considered. Given these premises and looking for EBM, two meta-analyses have described better results with MIPO, namely concerning complications 20,21.
Intramedullary nails (IMN)
IMN are the gold standard treatment option for pathological fractures of the humeral shaft 22. In addition, segmental fractures and obesity are considered relative indications for IMN, even if there is a large indication overlap between IMN and plates.
Pre-operative planning for intramedullary nailing is not different from other techniques. The peculiar condition is that IMN can be inserted either antegrade or retrograde, each one reamed or unreamed. In any case, IMN are more frequently inserted in an antegrade fashion, as retrograde nailing is technically more challenging and has a higher risk of iatrogenic distal humeral fracture (Fig. 3a-d).
Recent designs include smaller diameter nails, with more locking options (overall proximal), so that these designs allow the treatment of transitional fractures, extending into the proximal humerus. On the contrary, if such implants are not available, to use simpler IMN the fracture must be located between the surgical neck and the transition between shaft and distal metaphysis. Obviously, closed nailing does not allow intraoperative visualization of the radial nerve, for this reason in our centre we do not usually use IMN for closed fractures associated with radial palsy.
External fixation (EF) has a limited role for acute humeral diaphyseal fractures, and is used mainly during the damage control setting and/or open fractures with extensive soft tissue and bone loss. As plating and nailing have been advocated even in low grade open injuries, indications for EF are even more limited 4.
For external fixation, a unilateral, half-pin frame is enough for fracture stabilization and a “delta-shaped” frame can be used to achieve more stability. If any of the pins are close to neurovascular structures, limited open placement of the pins is recommended. Concerning the conversion to definitive treatment, plating after 2 weeks is a safe and effective time window for patients with multiple injuries or severe soft tissue 23.
Plating or nailing?
Plating and IMN have up to date widely overlapping indications.
In two prospective randomized trials comparing plating and locked IM nailing 20 years ago, similar union rates were reported, although there was a higher complication rate in the IMN group 24,25. In the last years, however, the trend has in favor of IMN 26-29; a good example of this orthopedic customs and traditions drift can be appreciated matching the 7th and 9th edition of the Rockwood and Green’s Fractures in Adults 4. New IMN designs and established surgical know-how, progressing from the first decades, could be the basis of this trend.
Concerning time to healing, both plates and IMN showed no differences, however intramedullary nailing was significantly associated with shoulder pain and stiffness and plating was significantly associated with elbow stiffness especially in distal third fractures, but not with elbow pain 26.
Shoulder joint impairment is also the main problem with antegrade nailing: in a study designed to compare the functional outcomes of the shoulder joint anterograde IMN and ORIF with DCP showed no statistically significant difference in shoulder pain, functional scores, or isometric strength parameters between the two groups 30. Exactly the opposite conclusions were described by Li et al., which showed that after IMN patients had lower shoulder functional scores, a decreased range of shoulder motion and a greater degree of malrotation 31. In a recent study, MIPO seemed overall better with respect to nonunion, functional outcomes and rate of complications 32, nevertheless, the available data concerning plating and IMN have not given conclusive results 20, therefore allowing for further considerations on the surgeon and case, taking into account their personal experience and patients’ needs.
Special consideration for osteoporosis
The choice of the implant in osteoporotic bone is always difficult. Bone weakness and potential fixation failure are the principal concerns, and in addition these patients often have many co-pathologies and need fast recovery for many reasons 4. IMN is a good option, because it is a long load-sharing implant. However, in osteoporotic bone the medullary canal is often so wide, that no IMN can provide adequate fit and the only fixed points are the few screws through the nail (Figs. 4-5). More recently, humeral nails have been designed with threaded screw holes in order to provide more stability. Locking plates are theoretically advantageous in osteoporotic fractures, supplying a wider fixing area 33-36.
Concerning surgical treatment of diaphyseal humeral fractures, both plates and nails are adequate options.
In our center, given the indication for surgical treatment, we prefer following options:
- for the proximal 2/3 of the humeral shaft IMN (MIPO only for selected patients), the same for transitional proximal humerus fractures, according to fracture pattern. IMN are always reamed and blocked. Relative contraindications concerning the rotator cuff are considered (e.g. the need to use crutches, wheelchair chronically…);
- the distal third is preferably approached with plates, in osteoporotic bone, as far as possible, with 4,5mm LCP plates and at least 4 bicortical locking screws on each side of the fracture. Precontoured 4.5/3.5 mm plates are used for distal transitional fractures. In case of nerve palsy, ORIF with plate is preferred.
Figures and tables
- Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977; 59:596-601.
- Buckley RE, Moran CG, Apivatthakakul T. AO principles of fracture management. Vol. 1: Principles, Vol. 2: Specific fractures. Thieme Publishing Group. 2018.
- Blauth M, Kates SL, Nicholas JA. Osteoporotic fracture care. Medical and surgical management. Thieme Publishing Group. 2018.
- Tornetta P, Ricci WM, Oatrum RF. Wolthers & Kluwers: Philadelphia; 2019.
- Ekholm R, Ponzer S, Tornkvist H. Primary radial nerve palsy in patients with acute humeral shaft fractures. J Orthop Trauma. 2008; 22:408-14. DOI
- Korompilias AV, Lykissas MG, Kostas-Agnantis IP. Approach to radial nerve palsy caused by humerus shaft fracture: is primary exploration. Injury. 2013; 44:323-6. DOI
- Marsh JL, Slongo TF, Agel J. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007; 21:S1-S133.
- Garnavos C, Kanakaris NK, Lasanianos NG. New classification system for longbone fractures supplementing the AO/OTA classification. Orthopedics. 2012; 35:e709-19. DOI
- Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58:453-8.
- Tscherne H, Gotzen L. Springer-Verlag: Berlin, Germany; 1984.
- Sarmiento A, Horowitch A, Aboulafia A. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br. 1990; 72:283-7.
- Van de Wall BJM, Theus C, Link BC. Absolute or relative stability in plate fixation for simple humeral shaft fractures. Injury. 2019; 50:1986-91. DOI
- Chen F, Wang Z, Bhattacharyya T. Outcomes of nails versus plates for humeral shaft fractures: a Medicare cohort study. J Orthop Trauma. 2013; 27:68-72. DOI
- Zhiquan A, Bingfang Z, Yeming W. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma. 2007; 21:628-33. DOI
- Ji F, Tong D, Tang H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach. Int Orthop. 2009; 33:543-7. DOI
- Concha JM, Sandoval A, Streubel PN. Minimally invasive plate osteosynthesis for humeral shaft fractures: are results reproducible?. Int Orthop. 2010; 34:1297-305. DOI
- Apivatthakakul T, Phornphutkul C, Laohapoonrungsee A. Less invasive plate osteosynthesis in humeral shaft fractures. Oper Orthop Traumatol. 2009; 21:602-13. DOI
- Apivatthakakul T, Patiyasikan S, Luevitoonvechkit S. Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: a cadaveric study. Injury. 2010; 41:169-72. DOI
- Livani B, Belangero WD. Bridging plate osteosynthesis of humeral shaft fractures. Injury. 2004; 35:587-95. DOI
- Tetsworth K, Hohmann E, Glatt V. Minimally invasive plate osteosynthesis of humeral shaft fractures: current state of the art. J Am Acad Orthop Surg. 2018; 26:652-61. DOI
- Hu X, Xu S, Lu H. Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis. J Orthop Surg Res. 2016; 11:59. DOI
- Pretell J, Rodriguez J, Blanco D. Treatment of pathological humeral shaft fractures with intramedullary nailing. A retrospective study. Int Orthop. 2010; 34:559-63. DOI
- Suzuki T, Hak DJ, Stahel PF. Safety and efficacy of conversion from external fixation to plate fixation in humeral shaft fractures. J Orthop Trauma. 2010; 24:414-9. DOI
- Chapman JR, Henley MB, Agel J. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000; 14:162-6. DOI
- McCormack RG, Brien D, Buckley RE. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg Br. 2000; 82:336-9. DOI
- Fan Y, Li YW, Zhang HB. Management of humeral shaft fractures with intramedullary interlocking nail versus locking compression plate. Orthopedics. 2015; 38:e825-9. DOI
- Putnam JG, Nowak L, Sanders D. Early post-operative outcomes of plate versus nail fixation for humeral shaft fractures. Injury. 2019; 50:1460-3. DOI
- Bisaccia M, Meccariello L, Rinonapoli G. Comparison of plate, nail and external fixation in the management of diaphyseal fractures of the humerus. Med Arch. 2017; 71:97-102. DOI
- Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev. 2011;CD005959. DOI
- Flinkkila T, Hyvonen P, Siira P. Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation. Arch Orthop Trauma Surg. 2004; 124:537-41. DOI
- Li Y, Wang C, Wang M. Post-operative malrotation of humeral shaft fracture after plating compared with intramedullary nailing. J Shoulder Elbow Surg. 2011; 20:947-54. DOI
- Kulkarni VS, Kulkarni MS, Kulkarni GS. Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures. Injury. 2017; 48:S8-13. DOI
- Rathi P, Paknikar KP, Malve SP. Role of locking compression plate in management of metaphyseal fractures in osteoporotic bones: an experimental study from rural Maharashtra. Int J Res Orthop. 2019; 5:388-92. DOI
- O’Toole RV, Andersen RC, Vesnovsky O. Are locking screws advantageous with plate fixation of humeral shaft fractures? A biomechanical analysis of synthetic and cadaveric bone. J Orthop Trauma. 2008; 22:709-15. DOI
- Hak DJ, Althausen P, Hazelwood SJ. Locked plate fixation of osteoporotic humeral shaft fractures: are two locking screws per segment enough?. J Orthop Trauma. 2010; 24:207-11. DOI
- Davis C, Stall A, Knutsen E. Locking plates in osteoporosis: a biomechanical cadaveric study of diaphyseal humerus fractures. J Orthop Trauma. 2012; 26:216-21. DOI
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