Diaphyseal and Distal Humerus Fractures

Abstract

The majority of humeral shaft fractures in adults and children can be treated nonoperatively. Multiple methods of immobilization have been used successfully in children. The functional brace popularized by Sarmiento remains the mainstay of treatment in adults and achieves consistently favorable outcomes. Specific indications for operative treatment include open, segmental, or pathologic fractures, failure of nonoperative management, and certain associated injuries. ORIF with compression plating is effective in both adults and children. Antegrade or retrograde intramedullary fixation can be achieved with multiple pins or rods in children and with interlocked nails in adults. Plating and nailing result in reliable rates of union. Radial nerve palsy is commonly associated with humeral shaft fractures and their treatment, but the majority of cases resolve spontaneously. Distal humerus fractures in adults generally require operative treatment with ORIF. Multiple surgical approaches can be used to gain access to the distal humerus for anatomic reduction. For complex articular fractures, olecranon osteotomy provides the best exposure and can be repaired reliably with a tension band wire construct. Dual plating is recommended using either an orthogonal (“90–90”) or parallel configuration. Pediatric supracondylar humerus fractures are extremely common. Pulseless but well-perfused hands can be observed closely and generally do not require vascular exploration or repair. Type I fractures can be treated nonoperatively with a long-arm cast. Type II, III, and IV fractures generally require closed vs. open reduction and pinning. Two or three lateral-entry pins provide equivalent stability to crossed pinning with a lower rate of iatrogenic ulnar nerve injury.