6/4/21 Newsletter: Humeral Shaft Fractures Discussion

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Ortho Forge Discussion Highlights

Highlights from the Ortho Forge Community. Here is an adaptation from one of our case discussions.

~20 year old. What do you see and what should you do in the ED if this fracture just happened?

AP of a right humerus in a skeletally mature individual with a midshaft humerus fracture. The first thing I would do besides taking a good history and physical examination is checking if the limb is neurovascularly intact, if there are any skin openings, or if there is skin compromise.

Let’s say this is a closed injury. You find a neuro abnormality on your exam (what is the most common nerve to be affected, and how would you do the exam)? What are the treatment options? Do they need surgery?

You worry about the radial nerve in injuries of the midshaft humerus. You should check extension in both the wrist and with extensor pollicis longus (extension of the thumb interphalangeal joint).

With closed humeral shaft fractures, even with a radial nerve palsy, a coaptation splint + functional bracing is an option. (The coaptation splint usually goes on first to allow for swelling, then the sarmiento is placed in the clinic, although during the daytime you can usually get the prosthetic company rep to come and place a sarmiento in the ED). You would just need to follow up regularly with radiographs to ensure good reduction over time. In a closed fracture, that is vascularly intact, with an isolated radial nerve palsy, you can still proceed with non-operative management.

Yes! The radial nerve passes right across the posterior humerus ~20cm proximal to the medial humeral epicondyle, prone to injury/ entrapment due to proximity to bone. My go-to tests for radial nerve function are having patients give you a thumbs up and resist you pushing their distal thumb into flexion, and 1st dorsal web space sensitivity to light touch (documented “SILT” sensation intact to light touch).

Coaptation splints are suitable for swelling/acute periods, and then, patients often transitioned to a sarmiento brace. What xray views do you want to order after you place a coaptation splint? How do you mold the coaptation splint?

“Full humerus, AP and trans-thoracic Lateral for xray views. Coaptation splint starts medial armpit, goes under the elbow and molds up over the shoulder to the base of the neck.”

Exactly, you want to see your reduction within the ballpark of < 20° anterior angulation, < 30° varus/valgus angulation, < 3 cm shortening degrees varus/valgus/AP (the non-op acceptable angulation). You have to specify to get the lateral as a “trans-thoracic lateral” (so the xray tech doesn’t twist the broken arm/screw up your perfect coaptation splint!) You also have to place a serious valgus mold on your coaptation splint; this means pushing the distal part of the fracture away from the body’s midline.

So what do you think about this splint?

The coaptation splint above lacks a valgus mold. (Valgus always means the distal aspect of the extremity is pointing away from the midline. Varus means the distal portion is pointing towards the midline). You have to literally put your hands so that you push the proximal humeral fragment in towards the midline and push the distal portion of the humerus away from the midline (it is more than you would think would be necessary, but these tend to fall into varus, like the picture above and that is not good!).

This event is an important takeaway as well, like @shashank.c brought up. “Even with an isolated radial nerve palsy, you can still proceed with non-operative management.”

As a resident, you will need to decide whether something is operative or non-operative (this can be stressful when it is the middle of the night and you don’t know your operative indications!) Here are the operative signs for humeral shaft fractures from orthobullets.

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Ortho News

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