Shoulder – Humerus Fracture
Fracture type
Open Fractures
Gustilo classification of open fractures
Type Ⅰ:
- Wound < 1cm
- Little to no contamination
- Fracture pattern usually simple
Type Ⅱ:
- Wound > 1cm
- Tissue has minor contusion
- No dead muscle
- Fracture pattern instability moderate to severe
Type Ⅲ:
- Extensive soft tissue injury
- Severe wound contamination
- Fracture unstable with comminution
Type ⅢA:
- Adequate soft tissue coverage of the fracture
Type ⅢB:
- Extensive soft tissue loss with periosteal stripping and exposed bone
- Usually massive contamination
Type ⅢC:
- Any open fracture with an arterial injury requiring repair
Radial nerve palsy
Radial nerve palsy may occur up to 9% of associated humerus shaft fractures.
Humerus shaft fractures
Radiological series workup for humerus fracture include:
- Coronal & sagittal X-Rays views
- X-Ray shoulder and elbow joints with similar views
Considerations of acceptable humerus fracture malalignment managed nonoperatively
Humerus surgery fixation options
Surgery fixation options
- Plate and screws
- Nail & screw fixation
- External fixation: open fracture
Surgery considerations for humerus shaft fracture
Indications
- Concomitant vascular injury
- Open fracture
- Articular displaced fracture
- Pathological fracture
- Segmental
- Unable to maintain reduction
- Polytrauma patient
- Transverse or short oblique in athlete
Surgery Implant options:
- Nail and screw fixation
- Plate and screw fixation
- External fixator
Surgery Technique
Supine patient position
Muscle: Biceps brachii
Origin:
- Consists of a short and long head
- Short head: originates from scapular coracoid process
- Long head: originates from the scapular supraglenoid tubercle
Insertion:
- Radial tuberosity and forearm fascia via the the bicipital aponeurosis
Nerve supply:
- Musculocutaneous nerve (C5-7)
Blood supply:
- Brachial artery
Function:
- Elbow flexion and forearm supination
- Weak arm flexor and add to dynamic stability of the shoulder joint in the initial 30° of elevation
Muscle: Brachialis
Origin:
- Anterior distal half of humeral surface
Insertion:
- Coronoid process and tuberosity of the ulnar
Nerve supply:
- Musculocutaneous nerve (C5-6) and radial nerve (C7)
Blood supply:
- Brachial artery, radial recurrent ands ulnar collateral arteries at elbow joint anatomosis
Function:
- Elbow flexion
Proximal Deltoid direct lateral approach to the humerus
Patient position for nail and screw fixation
Muscle: Deltoid
Origin:
- Consists of three distinct portions :anterior, middle and posterior
- Anterior: anterior surface of
- Middle: Scapular acromion process and superior surface
- Posterior: Spine of the scapular, posterior border
Insertion:
- Humeral deltoid tuberosity
Nerve supply:
- Axillary nerve (C5,C6)
Blood supply:
- Posterior circumflex humeral artery
Function:
- Shoulder abduction, flexion and extension
Humerus plate fixation
Approaches:
- Anterolateral approach for proximal & middle third humerus fractures
- Distal third: posterior
Principles of fixation:
- Reduce fracture
- If possible try to compress the fracture site with a lag screw if oblique fracture configuration, then plate as a neutralizing device. If the fracture is transverse then use the plate as a compression device by drilling the initial plate screws across the fracture site in an eccentric position to compress the fracture
- Complex fracture: plate as a bridging device
Humerus nail and screw fixation
Approach:
- Deltoid
Principles of fixation:
- Reduce fracture
- Proximal and distal screw fixation
References
- Radial palsy in shaft fracture of the humerus. O Bostman, G Bakalim, S Vainionpaa et al. Acta Orthop Scand 1986;87: 316-319.
- What should be the timing of surgical treatment of humerus shaft fractures? S Yiǧit. Observational Study. Medicine (Baltimore). 2020 Apr;99(17): e189858.
Contributors
Dr M Y Hassan
Dr N J Kauta
Prof Maqungo