Nonoperative Management

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The biomechanics of the humerus and its surrounding tissues make it readily reducible. The free movement of the scapulohumeral joint minimizes torsional stresses through the bone, making rigid immobilization unnecessary for proper healing (3). In addition, the humerus acts mostly as a lever, with little or no weight-bearing function or compressive forces. The influence of gravity places the fracture fragments in a physiologically dependent position, which facilitates reduction (3).

Many techniques have been attempted in the past. Initially, thoracoacromial immobilization with the use of a cast or a sling and swath was used to splint the fractured extremity against the thorax. The rationale for these techniques was to provide stability to the fracture site. The cast or swath was applied for 3 to 4 weeks, after which the patient was switched to a lighter sling. Beside the obvious problem of prolonged immobilization of the shoulder and elbow, this technique did not make use of gravity to help place the fracture in a dependent position. As a result, it was rarely been used since the advent of function bracing (3).

Caldwell in 1933 introduced the hanging cast as a method of providing stability to the fracture while also placing traction on the fracture fragments by the use of gravity. The technique involved placing a cast from the axilla to the hand, with the elbow held at 90 degrees of flexion and the forearm in midprona-tion. The upper portion of the cast was adjusted to account for the location of the fracture and its surrounding biomechanics. Further investigation led to slight modification in the cast, including changing the length of the sling aids to adjust for posterior versus anterior bowing and changing the position of the suspension hook so as to correct for medial versus lateral bowing as well as to change the amount of traction on the fracture fragments. Although good results were achieved with this method, the cast was generally uncomfortable and had to be maintained in a dependent position. In addition, an improperly applied or heavy cast could lead to distraction of the fracture site (2).

The short brachial splint, also known as a coaptation or U splint, is a modification on the hanging cast method while still using gravity to provide traction on the fracture fragments. A molded plaster slab is placed around the elbow and extended over the elbow. It is then held in place by an elastic bandage with the forearm suspended by use of a felt wrist cuff. This splinting method is still used today in emergency rooms as a method of temporary splinting. When used as the definitive form of treatment, however, results have not been superior to functional bracing (3,12).

The functional brace (Fig. 5A to C) introduced by Sarmiento in the late 1970s has become the treatment of choice for closed treatment of humeral shaft fractures. This method uses both gravity to align the fractured segments as well as physiologically induced motion to promote osteogenesis. The brace acts to stiffen the soft tissue, providing a splinting effect to the fracture fragment. It does not, however, immobilize the fracture site. As a result, fractures of the humerus treated with functional bracing tend to have some degree of varus angulation, but they are still acceptable both cosmetically and functionally (4).

Unlike the hanging cast or the U splint, the functional brace does not immobilize either the shoulder or the elbow joint. The adjustable brace is tightened around the soft tissues surrounding the fracture site and the arm is allowed to hang freely to the side in a normal position. The brace does not actually have to cover every one of the fracture fragments as long as the soft tissues are compressed. This creates an ideal environment for fracture healing.

The functional brace may be used for almost all closed fractures, with union rates of greater than 90% (4,13-15). The fracture geometry and location have little effect on healing as long as the soft tissue envelope is intact. Even open fractures with little surrounding soft tissue injury (Gustillo II and lower) may be treated successfully as long as thorough irrigation and antibiotic treatment are undertaken. Obesity in and of itself is not a contraindication to functional bracing, although these fractures do tend to have a higher level of angular deformity (14).

Some humeral shaft fractures may not be good candidates for functional bracing. These include closed or open fractures with significant soft tissue dam-

Treatment Fractured Humerus

Figure 5 Fracture bracing of humeral shaft fractures. 17-year-old male s/p football injury with a humeral shaft fracture treated with fracture bracing. A. AP x-ray taken in emergency room. B. AP x-ray after treatment with a functional brace for 8 weeks. C. AP x-ray of the same fracture after functional bracing for 3 months. (X-rays provided by Heather A. Vallier, MD, Metrohealth Medical Center, Cleveland, Ohio, U.S.A.)

Figure 5 Fracture bracing of humeral shaft fractures. 17-year-old male s/p football injury with a humeral shaft fracture treated with fracture bracing. A. AP x-ray taken in emergency room. B. AP x-ray after treatment with a functional brace for 8 weeks. C. AP x-ray of the same fracture after functional bracing for 3 months. (X-rays provided by Heather A. Vallier, MD, Metrohealth Medical Center, Cleveland, Ohio, U.S.A.)

age. As the soft tissue envelope is crucial for splinting of the fracture fragments, these fractures will tend to have a higher rate of nonunion or unacceptable angular deformity. In addition, patients with polytrauma or bilateral fractures will also tend to have a higher level of angular deformity. Fractures associated with vascular injury that requires repair of the vessel will need to undergo open reduction and internal fixation of the fracture to protect the repair.

Application of the functional brace must be delayed, as the patient may initially have too much and pain and swelling for proper application. These patients may first be treated with either a hanging cast or a coaptation splint. As soon as symptoms allow, the functional brace is fitted and placed. The cylindrical sleeve should begin about 2 cm distal to the axilla and terminate about 2 cm proximal to the humeral condyles. The treatment regiment is started as soon as symptoms allow. The patient is encouraged initially to partake in range-of-motion exercises, especially at the elbow, with particular emphasis on extension. Shoulder exercises should be limited to pendulums only, as active abduction and elevation of the arm may lead to the development of angular deformities. The brace in most studies is usually be removed by about 10 to 13 weeks, or when union of the fracture is confirmed both radiographically and clinically (4,14). Most studies show excellent results with these methods, with nonunion rates comparable to those from open fixation, at about 1 to 6% (4,13-16).


While most humeral shaft fractures can be successfully treated by nonoperative methods, several types of fractures warrant open reduction and internal fixation. When such indications do arise, several treatment options are available. The main decision in considering open reduction involves plating of the fracture versus intramedullary nailing. Much controversy still exist as to whether one method is truly superior; in most cases, the decision comes down to the surgeon's personal preference and his or her level of comfort with a particular procedure.

In considering which fracture pattern may require open reduction, several principles must be considered. The key to the success of closed treatment of humeral shaft fractures is an intact soft tissue envelope to act as a splint for the fracture fragments. If this envelope is violated or disrupted, the use of functional bracing will very likely lead to nonunion or an unacceptable deformity. Therefore it is widely accepted that type III open injuries and even type II injuries with significant soft tissue damage (as may occur from a gunshot wound) are more likely to be successfully treated by plating or nailing of the fracture.

In addition, polytrauma patients who are bed-bound and unable to sit up are not good candidates for functional bracing as they are unable to benefit from the effect of gravity to reduce the fracture fragments. Patients with associated ipsilateral forearm fractures (the "floating elbow") will also not truly benefit from functional bracing due to the inherent instability of this fracture pattern and should have both fractures fixed at the same time. Patients with bilateral fractures should also be treated operatively so as to promote earlier recovery and mobilization.

Failure of closed treatments should also warrant open fixation. Many authors have studied the outcome of closed treatments, with special consideration to varus angulation. There have been no adverse functional effects seen with varus deformities in excess of 30 degrees. However, any angulation of greater than 15 degrees will usually result in an expressible deformity. Klenerman showed

Table 2 Indications for Surgical Treatment

Open fractures with significant soft tissue injuries (type II and greater) Bed-bound polytrauma patients Ipsilateral forearm fracture ("floating elbow") Bilateral fractures Failed closed treatment Neurovascular injury requiring complications Pathological fractures Relative indication Obese patient that the humerus can accommodate up to 20 degrees of anterior angulation, 30 degrees of varus angulation, and 3 cm of shortening without any loss of function, strength, or cosmesis (19). Obese patients, although more difficult to treat by closed methods, are also better able to conceal greater degrees of deformity.

Other indications for operative treatment include associated nerve and vascular injury. With the repair of the neurovascular structures, it is recommended that a formal approach and repair of the fracture be undertaken so as to protect the repair. Finally, pathological fractures, especially those involving poor bone stock or impending potential fractures, should also be treated operatively.

External fixation may also be used as a method of operative fixation of humeral shaft fractures. Indications for external fixation are limited to highly comminuted fractures or fractures with significant soft tissue damage. Management with external fixation may also allow for quick stabilization of the fracture in patients unable to tolerate a formal internal fixation.

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