Shoulder Fracture Treatment

Disclosures

Kenneth Koval, MD

Introduction

At the 21st Annual Orthopaedic Trauma Seminar held Feb 28-March 3, 2000, in Snowmass, Colorado,
Matthew L. Jimenez, MD presented the evaluation and treatment of displaced proximal humerus
fractures. These fractures account for more than 75% of humerus fractures in patients older than 40
years of age. After age 50, women have a much higher incidence than do men. In patients younger
than 50 years, high-energy trauma is the most common cause of proximal humerus fractures; after
age 50, minimal-to-moderate trauma is the most common cause. [1]

Classification

The Neer classification is based on the anatomical relationship of the 4 major segments of the
humerus: the articular segment, greater tuberosity, lesser tuberosity, and the proximal shaft. [2] Fracture
types are classified according to the presence of displacement of 1 or more of the 4 segments. To be
considered displaced, a segment must be displaced more than 1 cm or angulated more than 45
degrees from a normal anatomical position.

One-part, or minimally displaced, fractures of the proximal humerus are the most common type and
account for up to 85% of all proximal humerus fractures. [3-5] A 2-part fracture is characterized by
displacement of 1 of the 4 segments, with the remaining 3 segments either not fractured or not fulfilling
the criteria for displacement. A 3-part fracture is characterized by displacement of 2 of the segments,
with the other 2 segments nondisplaced. And a 4-part fracture is characterized by displacement of all 4
segments.

Evaluation

The symptoms and signs associated with proximal humerus fractures can vary greatly. Pain,
especially during an attempt to move the shoulder, is almost always present. Palpation of the shoulder
usually reveals tenderness around the proximal humerus. The entire upper extremity should be
examined. Assessment of fracture stability is an essential part of the examination.

Radiographic Evaluation

Radiographs to evaluate shoulder trauma should include (1) anteroposterior and lateral views of the
shoulder obtained in the plane of the scapula and (2) an axillary view. The scapular lateral view assists
in delineating the position of the humeral head relative to the glenoid process and is particularly useful
in showing posteriorly displaced fragments and shaft displacement. The axillary view permits
assessment of the glenohumeral relationship. It can also be useful in identifying fractures of the
glenoid rim, posterior displacement of the greater tuberosity, medial displacement of the lesser
tuberosity, and articular impression fractures of the humeral head. [6]

Computed tomography of proximal humerus fractures and fracture dislocations may be indicated when
the trauma series radiographs are nondiagnostic . These scans have been recommended to evaluate
the rotation of fragments, the degree of tuberosity displacement and articular impression fractures,
head-splitting fractures, and chronic fracture-dislocations.

Treatment
The indications for operative verses nonoperative management of proximal humerus fractures are
determined by numerous factors, including patient age, arm dominance, associated injuries, type of
fracture, degree of fracture displacement, and bone quality.

One-Part Fractures

Minimally displaced fractures account for more than 80% of all proximal humerus fractures. [2] This type
of fracture is stable, and an early range-of-motion program is appropriate. Elderly patients must be
watched carefully for skin problems, even with use of the simple sling. Patients with stable minimally
displaced fractures should be started on a range-of-motion program as soon as the initial discomfort
subsides.

Two-Part Fractures

Displaced anatomical neck fractures without tuberosity displacement are quite rare. In young patients,
open reduction and internal fixation (ORIF) is preferred, with the goal of avoiding prosthetic
replacement. In elderly patients, a choice must be made between ORIF and primary hemiarthroplasty.

Two-part lesser tuberosity fractures in the absence of posterior dislocations are uncommon. These
fractures are of minimal clinical significance unless the fragment is large and includes a substantial
portion of the articular surface. If a large fragment is involved, open reduction and internal fixation are
indicated.

Two-part greater tuberosity fractures are relatively common and can be the source of significant
disability. ORIF of the fragment and repair of the rotator cuff tear is the preferred treatment approach. [2,
7-9]
Displacement of less than 1 centimeter may be problematic, particularly if the displacement is
located superiorly into the subacromial space. Active patients with significant functional demands
should have surgical treatment . Techniques for repair include screw fixation alone or combined with
tension band wire or suture when good-quality bone is present.

Two-part surgical neck fractures are very common in the elderly. The shaft may be completely
displaced and pulled medially by the deforming force of the pectoralis major, or it may be impacted
and angulated at the surgical neck area. Treatment depends on fracture stability and the displacement
pattern. Posterior angulation is more tolerable than varus or anterior angulation. Impacted fractures
with an anterior angulation of more than 45 degrees may limit forward elevation. Therefore,
disimpaction followed by reimpaction to achieve better alignment should be considered in active
patients. Operative stabilization techniques include closed reduction and percutaneous pinning, use of
suture or wire, intramedullary fixation, and plate fixation.

Three-Part Fractures

Treatment options for 3-part fractures include closed reduction, ORIF, and prosthetic replacement.
Adequate closed reduction is difficult to achieve and even more difficult to maintain because the
deforming muscular forces cannot be adequately offset by the position of immobilization.

ORIF is currently the treatment of choice for uncomplicated 3-part fractures of the proximal humerus. [10-
12]
Different techniques for internal fixation have been used for these fractures, including plate and
screws, percutaneous pins, tension band wires, and intramedullary devices. Paavolainen and
colleagues[13] reported 74% satisfactory results in a series of 14 three-part fractures treated operatively
with screws alone or a plate and screw devices.[13] Hawkins and coworkers[14] reported 87% satisfactory
results by using a tension band wire technique in 15 patients with an average age of 61 years.
Postoperative forward elevation averaged 126 degrees, and osteonecrosis occurred in 13% of
patients. Cuomo and coworkers[15] reported 100% satisfactory results after open reduction and internal
fixation of 3-part fractures in 8 patients with an average age of 45 years. Forward elevation averaged
150 degrees, and no osteonecrosis occurred after an average follow-up of 3.3 years.

Four-Part Fractures
In "classic" 4-part fractures, all 4 segments are displaced and the articular surface is devoid of soft
tissue attachments. This disrupts the blood supply to the humeral head and increases the risk for
osteonecrosis. The results of nonoperative treatment for these fractures have been consistently
unsatisfactory. ORIF of 4-part fractures have also consistently yielded poor results, and adequate
open reduction and secure internal fixation are difficult to achieve. In the elderly, the head segment is
often a shell that cannot be adequately stabilized by using tension band techniques. Because of the
problems in achieving stable internal fixation and the high risk for osteonecrosis, primary
hemiarthroplasty with tuberosity reconstruction has become the treatment of choice for 4-part
fractures, particularly in the elderly. In selected younger patients with good bone stock, open reduction
and internal fixation may be attempted, but the risk for osteonecrosis is high, particularly because
these fractures usually result from high energy injuries. [16,17] Hardware problems are also common.

The reported results of humeral head replacement for a 4-part fracture vary but have generally been
satisfactory.[18-21]. The variability is probably related to both patient selection and the outcome criteria.
Pain relief after humeral head replacement is fairly predictable in most series. Functional results can
vary greatly.[22]

References

1. Jensen GF, Christiansen C, Boesen J, et al. Relationship between bone mineral content and
frequency of postmenopausal fractures. Acta Med Scand.1983;213:61-63.
2. Neer CS II. Displaced proximal humeral fractures: part I. classification and evaluation. J Bone
Joint Surg. 1970;52A:1077-1089.
3. Neer CS, Rockwood CA Jr. Fractures and dislocations of the shoulder. In: Rockwood CA,
Green DP, eds. Fractures in Adults. 2nd ed. Philadelphia: JB Lippincott;1984:675-721.
4. Rose SH, Melton LJ, Morrey BF, Ilstrup DM, Riggs LB. Epidemiologic features of humeral
fractures. Clin Orthop. 1982;168:24-30.
5. Horak J, Nilsson B. Epidemiology of fractures of the upper end of the humerus. Clin
Orthop.1975;112:250-253.
6. Cuomo F. Proximal humerus fractures in the elderly. Program and abstracts of the American
Academy of Orthopaedic Surgeons Annual Meeting; February 14, 1997; San Francisco,
California. Lecture 247.
7. Bateman JE. The Shoulder and Neck. Philadelphia: WB Saunders;1972.
8. DePalma AF. Surgery of the Shoulder. 2nd ed. Philadelphia: JB Lippincott;1973.
9. Post M. The Shoulder. Surgical and Nonsurgical Management. 2nd ed. Philadelphia: Lea &
Febiger;1988:535-536.
10. Bigliani LU. Fractures of the shoulder. Part I: fractures of the proximal humerus. In: Rockwood
CA, Green DP, Bucholz RW, eds. Fracture in Adults. 3rd ed. Philadelphia: JB
Lippincott;1991:871-927.
11. Bigliani LU. Fractures of the proximal humerus. In Rockwood CA, Matsen FA, eds. The
Shoulder. Philadelphia: WB Saunders;1990:278-334.
12. Savoie FH, Geissler WB, VanderGriend RA. Open reduction and internal fixation of three-part
fractures of the proximal humerus. Orthopedics. 1989:12:65-70.
13. Paavolainen P, Bjorkenheim JM, Slatis P, et al. Operative treatment of severe proximal
humeral fractures. Acta Orthop Scand.1983:54:374-379.
14. Hawkins RJ, Bell RH, Gurr K. The three-part fracture of the humerus. Operative treatment. J
Bone Joint Surg. 1968;68-A:1410-1414.
15. Cuomo F, Flatow EL, Maday MG, et al. Open reduction and internal fixation of two- and three-
part displaced surgical neck fractures of the proximal humerus. J Shoulder Elbow Surg.
1992;1:287-295.
16. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted
fractures of the proximal humerus. J Bone Joint Surg. 1991;73B:295-298.
17. Kristiansen B, Christensen SW. Proximal humeral fractures. Late results in relation to
classification and treatment. Acta Orthop Scand. 1987;58:124-127.
18. Kraulis J, Hunter G. The results of prosthetic replacement in fracture dislocations of the upper
end of the humerus. Injury. 1976;8:129-131.
19. Switlyk P, Hawkins RJ. Hemiarthroplasty for treatment of severe proximal humeral fractures.
Program and abstracts of the American Shoulder and Elbow Surgeons Meeting; February 12,
1989; Las Vegas, Nevada.
 20. McIlveen SJ, Neer CS. Recent results and technique of prosthetic replacement for four-part
proximal humerus fractures. Program and abstracts of the American Shoulder and Elbow
Surgeons Meeting; February 1988; Atlanta, Georgia.
21. Willems W, Lim TE. Neer arthroplasty for humeral fracture. Acta Orthop Scand. 1985:56:394-
395.
22. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after
humeral head replacement for acute three- and four-part proximal humeral fractures. J
Shoulder Elbow Surg. 1995: 4:81-86.

Injuries of the Scapula, Acromioclavicular Joint, and Clavicle: A

Discussion of Associated Injuries, Treatments, and Outcomes

Disclosures

Andrew H. Schmidt, MD

Introduction

A variety of topics relating to injuries of the shoulder girdle and humeral shaft were discussed at the
15th Annual Vail Orthopaedic Symposium. Presentations were given on the management of patients
with acute fractures as well as those with nonunions of the clavicle, scapular fractures, and
acromioclavicular and scapulothoracic joint injuries. A review of the spectrum of management of
humeral-shaft fractures (nonoperative management, plate fixation, intramedullary nail fixation, and
management of humeral nonunions) is presented.

Acute Management of Clavicular Fractures

Renner M. Johnston, MD, from the University of Minnesota, Minneapolis, noted that clavicular
fractures are among the most common of fractures (5% to 12% of all fractures), and have very high
union rates (95% to 99.9%).[3] However, the treatment of patients with clavicular fractures is not without
its problems. History shows that King William III of England and Sir Benjamin Peel died from
complications of clavicular fractures. Although braces for clavicular fractures were described in the
1860s, it was not until 100 years later that the first large series of patients to use braces was reported
by both Charles Neer and Carter Rowe.

The majority of fractures (80%) of the clavicle occur in the middle third ; 15% are located in the lateral
third and the remainder in the medial third. Falls on the shoulder account for the majority of cases.
Associated injuries to the sternoclavicular or acromioclavicular joints may occur, and clavicular
fractures may occur as part of a more severe scapulothoracic dissociation or double-disruption of the
shoulder. Finally, pleural and/or lung injuries may result from these fractures; the fracture may be
open; or the nearby subclavian vessels or brachial plexus may be injured. Therefore, the physician
must conduct an examination that includes not only the fracture site but also the surrounding soft
tissues and joints, in order to avoid missing associated injuries.

Establishing the clinical diagnosis of a fractured clavicle is generally straightforward, but radiographic
imaging of the clavicle is required to confirm the location of the fracture and the degree of
displacement. The primary radiographic views are an anteroposterior (AP) view and a 40 cephalic-tilt
view. For fractures of the lateral third of the clavicle, another AP view with the arm hanging
unsupported is helpful to identify displacement. Medial-third injuries may require axial imaging
(computed tomography [CT] or magnetic resonance imaging [MRI]) to fully assess potential posterior
displacement.

The treatment for most clavicular fractures is nonoperative, with the clear exceptions of open
(complex) fractures or fractures with severe displacement that may compromise the skin or
surrounding neurovascular structures. Manipulative reduction has been recommended for fractures
with more than 2 cm of shortening or greater than 150 of displacement, but maintaining such a
reduction is problematic and may require a brace to retract the shoulders into position. More
commonly, no attempt is made to reduce the fracture, and a simple supportive sling is used. In adult
patients, union is expected to occur in 6-8 weeks.

There have been a few prospective randomized trials that compared different techniques for the
treatment of displaced fractures. In1 such study, reported by Andersen and colleagues, [1] 61 patients
were randomized to a "Figure of 8" brace or a sling. No significant differences in outcome were found,
but the patients preferred the sling. Neither method was able to reduce the fracture displacement.

This issue of whether operative treatment of displaced fractures (those with more than 2 cm of
shortening) improves outcome is very controversial. Hill and associates [2] reported 1 series of 52
patients who had displaced fractures that shortened the clavicle and who were treated nonoperatively.
Investigators noted that 30% of the patients were symptomatic and 15% of the fractures did not unite.,
and suggested that open reduction and internal fixation of displaced fractures of the middle third of the
clavicle may improve outcome.

In contrast, Nordqvist and colleagues[3] reported on the outcomes of 225 patients with midshaft
clavicular fractures who were treated nonoperatively and followed for a range of 12-22 years. In this
group, 129 of the fractures were initially displaced, but only 48 of these (37% of the displacements)
resulted in malunion, less than 5% of the cases did not unite, and 77% of all of the patients were pain-
free with normal function. If the decision (or study protocol) had been to operate on all patients with
displaced clavicular fractures, initially, approximately 75% of the patients may then have had
unnecessary surgical procedures.

Operative stabilization of clavicular fractures is commonly performed with compression plates ,

however, intramedullary devices have also been used. Plates applied to the inferior surface of the
clavicle may result in fewer local symptoms. Although surgery is effective at maintaining the length of
the clavicle, the incidence of nonunion after surgery on displaced fractures is 3- to 4-fold higher than
after closed treatment.

Finally, Dr. Johnston reviewed the Neer Classification of Fractures, [4] as applied to the lateral third of
the clavicle. He also reviewed the anatomy of the coracoclavicular ligaments, which tend to remain
attached to the distal fragment while the medial fragment is pulled cephalad by the trapezius, resulting
in significant displacement and an increased incidence of nonunion. Treatment of these difficult injuries
requires reduction of the fracture and repair of the coracoclavicular-ligament attachment to the medial
fragment.

Acromioclavicular Joint Injuries

Michael D. McKee, MD, FRCS, from the University of Toronto, Ontario, Canada, discussed the
mechanism of injury and management of patients with acromioclavicular joint injuries. The mechanism
of injury is a blow to the superior aspect of the shoulder, with varying degrees of injury to the
acromioclavicular joint and capsule, coracoclavicular ligaments, and delto-trapezoidal fascia.

The diagnosis and classification of acromioclavicular injury is based on the radiographic evaluation of
the shoulder. The traditional classification that divides these injuries into 3 types, based on the degree
of displacement, has been modified by Rockwood to include 6 types. [5] These include Type III injuries,
which have 100% to 300% displacement; type IV injuries have posterior displacement of the clavicle;
type V injuries have more than 300% of superior displacement; and finally, type VI injuries have
inferior subcoracoid displacement of the clavicle.

The treatment of an acromioclavicular joint injury is based on the radiographic classification, the
patient's age and activity level, and the patient's expectations and requirements of treatment outcome.
Types I and II injuries are treated nonoperatively, with the expectation of good results. A small
proportion of these patients may develop degenerative changes of the acromioclavicular joint. If the
severity of symptoms warrant, these patients may be successfully treated by resection of the distal
clavicle and transfer of the coracoclavicular ligament attachment to the lateral end of the clavicle.

Types IV, V, and VI injuries are often treated surgically because the degree and direction of
displacement dictate that without reduction of the clavicle to the acromion, poor results are likely. The
management of patients with type III injuries remains especially controversial. Many patients with type
III injuries do well with normal function and little cosmetic deformity.[6] However, some surgeons
consider patients with injuries to the dominant arm, who also engage in frequent, strenuous, arms-
overhead activities, to be candidates for early surgery.

When surgery is performed at the time of injury for patients with acromioclavicular joint dislocations,
the extent of injury is reduced and the coracoclavicular ligaments and acromioclavicular joint capsules
repaired. The criteria defining the need for supplementary internal fixation are a subject of controversy.
Dr. McKee prefers to use a coracoclavicular screw or suture anchor, placed into the base of the
coracoid process. An alternative technique is to use transacromial fixation. If internal fixation is
performed with screws or pins, the devices are generally removed at 12 weeks after placement, owing
to the risk of migration or hardware breakage that increases with time.

Clavicular Nonunions

William H. Seitz, Jr, MD, Case Western Reserve University, and Director of the Cleveland Orthopaedic
and Spine Hospital, Cleveland, Ohio, spoke about the problem of nonunion of the clavicle and other
injuries of the shoulder suspensory mechanisms (acromion, acromioclavicular joint, sternoclavicular
joint). Patients with nonunion of clavicular fractures or symptoms related to an unreduced
acromioclavicular joint injury often complain of pain, arm weakness, or a sense of instability and
"giving out" of the shoulder (unreliable shoulder strength and joint stability).

Dr. Seitz discussed the treatment of symptomatic clavicular nonunion, noting that a successful surgical
outcome requires a stable fixation system, a good intramedullary blood supply, and adequate bone
stock. In Dr. Seitz' opinion, percutaneous screw fixation is inadequate; open reduction and plate
fixation with bone grafting is usually necessary.

Scapulothoracic Dissociation

Andrew H. Schmidt, MD, from the University of Minnesota and Hennepin County Medical Center,
Minneapolis, discussed the rare injury of scapulothoracic dissociation. The hallmark of this injury is
lateral displacement of the scapula, associated with neurovascular injury to the upper limb. The injury
has an effect similar to that of a closed forequarter amputation, and the morbidity and mortality of the
injury is high. Up to 50% of patients who have this injury are left with a flail limb, and the mortality rate
is said to be as high as 10%.[7]

Scapulothoracic dissociation should be suspected in anyone with blunt trauma to the shoulder,
especially with swelling and any sign of diminished distal pulses or a neurologic injury to the limb.
Clavicular fractures occur in the majority of cases, but there may be injuries that are less obvious. The
diagnosis is confirmed by noting lateral displacement of the scapula on a nonrotated chest radiograph
(the normal ratio of the distance between the spinous processes and the medial border of the scapula
is 1.07 or less).[8]

The majority of these patients have vascular disruption of the axillary or subclavian artery and a
brachial plexus injury. The neurologic injury may be partial or complete; the latter may be associated
with stretch injury to the brachial plexus proper, or to avulsion of the cervical nerve roots from the
spinal cord.

Patients with scapulothoracic dissociation are managed, surgically, by immediate vascular repair and
stabilization of the associated musculoskeletal injuries. Exploration of the brachial plexus should be
carried out at the time of revascularization. If a complete injury of the brachial plexus is found, some
recommend primary above-the-elbow amputation. Otherwise, serial electromyography is performed to
determine if neurologic recovery is possible. Cervical myelography may be considered as well, in order
to diagnosis avulsion of nerve roots, the prognosis of which is very poor.

Scapular Body Fractures

Charles N. Cornell, MD, from Weill Medical College of Cornell University and the Hospital for Special
Surgery, New York, NY, reviewed the management of patients with scapular fractures.

Scapular fractures are most often seen after blunt trauma, and are usually apparent on chest
radiography. The presence of a scapular fracture is evidence that a significant force was dissipated by
the shoulder girdle and chest, and associated injuries, such as rib fractures, pneumothorax, or even
aortic or diaphragmatic rupture, may be present. Radiographic imaging of this complex bone is
difficult, and Dr. Cornell recommends that CT scans be obtained to delineate most of these injuries.

Fractures of the scapula may involve the body of the scapula or may involve the coracoid or acromial
processes. Fractures of the body of the scapula may involve the medial or lateral borders of the
scapula, or may represent an intra-articular fracture of the glenohumeral joint.

Nonoperative treatment is appropriate for most scapular fractures. Patients are treated conservatively,
with an elbow sling, and range-of-motion exercises should be started as soon as the patient is able to
tolerate the pain associated with motion.

Operative treatment should be considered for displaced fractures of the glenoid fossa, or displaced
fractures of the medial or lateral border of the scapula that interfere with scapulothoracic glide. For
simple posterior-glenoid rim fractures, or for transverse fractures of the glenoid, a standard posterior
approach to the shoulder, splitting the interval between the infraspinatus and teres minor, may be
used. More complex fractures may be treated with the extensile Judet-Letournel approach. [9]

Nonoperative Management of Patients With Humeral Shaft Fractures

Dr. Cornell also discussed the closed treatment of humeral-shaft fractures, noting that nonoperative
treatment has been the traditional method for managing patients with fractures of the humeral shaft.
Such methods include hanging casts and coaptation splints, with healing typically occurring in 10
weeks. However, persistent problems with patient discomfort, elbow and shoulder stiffness, and
nonunion in 10% to 12% of the cases led to a search in the 1970s for better methods of treatment.

Sarmiento and colleagues[10] developed the prefabricated functional brace during the same time that
internal fixation techniques began to improve. Sarmiento's experience was recently reported [10] and is
notable for a union rate of 97% in an average of 10-12 weeks, with minimal deformity and minimal-to-
slight loss of motion in the majority of cases (80% to 90%). Nonunions typically occurred in transverse
fractures with distraction. Sarmiento's series results have shortcomings, because one third of the
patients were lost to follow-up.

In summary, nonoperative treatment with functional bracing is the method of choice for most closed
low-energy humeral shaft fractures. One must be wary of transverse fractures that remain distracted.
Radial nerve palsies, even those that occur after fracture manipulation, usually recover spontaneously.
Fractures that are difficult to manage nonoperatively include those in obese patients, especially those
with very distal or proximal fractures.

Successful nonoperative treatment of a patient with humeral-shaft injuries mandates the immediate
application of a "collar and cuff" splint, applied in the emergency department. Approximately 1 week
after injury, the patient is fitted with the prefabricated brace. The brace must be adjusted and tightened
regularly, and active muscle function is encouraged. Compression gloves are worn to control hand
swelling and physical therapy is started at 4-6 weeks, postinjury.

Humeral Plate Fixation

Douglas P. Hanel, MD, from the University of Washington, Seattle, spoke about the indications and
techniques for plate fixation of humeral-shaft fractures. Indications for surgical treatment include the
presence of vascular injury, floating elbow or shoulder, failure of closed treatment, open fractures,
polytrauma, nonunion, or pathologic fractures.

When surgical treatment is indicated, Dr. Hanel notes that humeral plate fixation remains the "gold
standard." Rates of union after plate fixation range from 95% to 100%. Plate fixation allows for direct
observation of the radial nerve, and does not require special intraoperative techniques or procedures,
such as fluoroscopy. Recently published prospective randomized trials comparing the use of humeral
nail fixation to plate fixation have shown a high incidence of shoulder pain following the use of humeral
nails.[11,12]

Humeral plate fixation can be performed from many approaches. The medial approach is used when
an associated vascular injury is repaired. The classic approach to plate fixation is the anterior and
anterolateral approach. Posterior approaches are also commonly used, but may jeopardize the radial
nerve and require bisecting the triceps. Dr. Hanel prefers the direct lateral approach. [13] The benefits of
this approach are that the radial nerve is easily identified and the triceps is spared. The lateral
approach is extensile, from the shoulder to the elbow.

Regardless of the approach, a standard compression plate is used. There is no particular need to use
the broad, large-fragment plate; instead, the appropriate size plate for the patient is selected. The
most important factor is to capture at least 7 cortices of fixation on each side of the fracture. After plate
fixation, early range-of-motion exercises for the shoulder and elbow should be encouraged.

Dr. Hanel also discussed the management of radial nerve palsy associated with humeral shaft
fractures. These occur in 10% of all cases, and 75% of those affected recover spontaneously.
Commonly cited indications for acute exploration include an open (complex) fracture, a fracture
associated with the so-called Holstein-Lewis pattern, or a secondary palsy. However, in closed
fractures, these indications may be too aggressive. Surgeons should wait at least 3 months before
considering exploration.

Humeral Nail Fixation

Dr. Schmidt also spoke about the technique of humeral nail fixation, agreeing that plate fixation
remains the gold standard, unless the results of humeral nail fixation become more predictable.
Humeral nail fixation is especially useful for the management of patients with pathologic fractures,
segmental fractures, and fractures in the presence of osteopenia.

Humeral nail fixation may be performed via antegrade or retrograde approaches. Shoulder pain is the
primary problem associated with the antegrade approach, and is thought to be due to the violation of
the rotator cuff. However, the approach used for antegrade humeral nail fixation may have a significant
impact on the incidence of shoulder pain. Dr. Schmidt reviewed the paper by Reimer and associates, [14]
noting that patients appeared to be in less shoulder pain when nail fixation was performed from an
anterior acromial approach, instead of the traditional lateral approach. Anatomically, the anterior
acromial approach leads directly to the supraspinatus tendon, whereas the lateral approach violates
the infraspinatus tendon.

The retrograde approach for nail fixation is performed through a distal triceps-splitting incision, with
entry made just above the olecranon fossa. Postoperative elbow stiffness is the main problem with the
retrograde approach, and elbow ankylosis due to heterotopic ossification has been reported.

Nail fixation should be performed with interlocked nails. Technical pearls include avoiding distraction at
the fracture site, gentle handling of the rotator cuff, and initiating immediate shoulder and elbow
rehabilitation.

Humeral Nonunions
Randall E. Marcus, MD, from Case Western Reserve School of Medicine, Cleveland, Ohio, spoke
about management of patients who have humeral shaft nonunions. In general, nonunion of the
humerus is rare, occurring in less than 5 % of cases in most series. [10-12,15] Although nonunion may
follow either the operative or the nonoperative treatment of these fractures, there are often several
similar features, mainly that of distraction at the fracture gap. A factor common among postoperative
cases, which is associated with nonunion after plate fixation, is the use of an inadequate number of
screws (capturing less than 7 cortices on each side of the fracture).

Key principles for the successful treatment of patients who have humeral-shaft nonunions include
maintaining osseous stability, eliminating any gap, maintaining or restoring vascularity, and eradicating
infection.

Although plate fixation and autogenous bone grafting are the treatment gold standards for patients
with symptomatic humeral-shaft nonunions, Dr. Marcus noted that the results of treatment with locked
reamed nail fixation are just as good as results from using the gold-standard techniques, and there
may be fewer complications. Nail fixation should be considered, specifically, in cases of nonunion in
the midshaft of the humerus or in cases of nonunion that are associated with any significant
osteoporosis or other bone loss. Plate fixation is essential for the treatment of fractures of the proximal
or distal thirds of the humerus. When performing humeral plate fixation, one should ensure the
placement of sufficient numbers of screws to achieve at least 7 cortices of fixation on each side of the
fracture. Bone graft is generally performed for osteogenesis.

Key Points

There is recent evidence suggesting that the outcomes after displaced fractures of the middle
third of the clavicle may not be as good as is assumed. Patients with these injuries whose
activity levels and requirements for treatment outcome are high should be considered for
internal fixation to maintain clavicular length, thus preserving full range of motion.
The management of patients with type III acromioclavicular injuries remains controversial, with
no clear benefit to either operative or nonoperative treatment.
Clavicular nonunions are best treated by open reduction, with restoration of clavicular length,
plate fixation, and bone grafting.
Scapular fractures are generally treated nonoperatively, with the exception of those displaced
fractures of the glenoid fossa or scapular borders.
Scapulothoracic dissociation has a very poor prognosis, and some cases are best treated by
early amputation.
Nonoperative treatment is appropriate for most humeral-shaft fractures. Distraction of the
fracture gap must be avoided. Radial nerve palsies, alone, are generally not an indication for
surgery, even if they occur after manipulation of the fracture.
Humeral plate fixation is predictably successful, so long as adequate fixation is achieved.
The problem of rotator cuff pain after antegrade humeral nail fixation is lessened by using an
anterior acromial approach.
Humeral nonunions may be treated successfully by either plates or reamed nails, so long as
adequate fixation, elimination of gaps, and bone grafting is performed.

References

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