Humeral shaft fractures are a common injury, representing 3% of all fractures.1 They occur in a bimodal distribution and are most commonly the result of a fall.2 Most humeral shaft fractures can be managed nonoperatively, frequently with functional bracing as described by Sarmiento et al.1–3 However, some patients may benefit from operative treatment, including those with open fractures, associated articular fractures, neurovascular injuries, floating elbow injuries, polytrauma, interest in early return to activity, or failure of closed management.
There are several surgical approaches to the humeral shaft, and although they have their own unique advantages and disadvantages, the choice is often guided by fracture location: mid-shaft to more distal fractures are typically approached posteriorly or laterally, whereas the anterior and anterolateral approaches are favored for proximal one-third to mid-shaft fractures. One of the main advantages of an anterolateral approach is the possibility for an Extensile exposure, as the approach can be extended both proximally and distally. The anterolateral approach has also been shown to result in lower rates of iatrogenic radial nerve palsy (4%) compared with lateral (20%) and posterior approaches (11%) while also allowing for supine positioning in polytrauma patients.4
The patient in this video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A381) is a 32-year-old man who sustained multiple injuries in a motor vehicle collision including bilateral occipital condyle fractures and a lateral compression pelvic ring injury in addition to a mid-shaft right humerus fracture. This was a simple, transverse fracture (AO/OTA 12 A3b). This was a closed injury and the patient was neurovascularly intact. Because of the multiple injuries sustained, open reduction internal fixation was recommended and pursued after informed consent was obtained. An anterolateral approach to the humerus was planned based on fracture location, associated injuries, and surgeon preference.
The patient is positioned supine with their arm abducted to approximately 60 degrees on a radiolucent arm board, with the C-arm positioned toward the head of the bed, which is rotated 90 degrees relative to the anesthesia team. The entire upper extremity is prepped and draped in a sterile fashion, and a surgical timeout is performed.
Anatomic landmarks including the deltopectoral groove, lateral border of the biceps and its tendon, and mobile wad are identified. Local infiltration with 0.25% Marcaine with 1:100,000 epinephrine may be used for improved hemostasis. A curved, longitudinal incision is made beginning just proximal to the elbow flexion crease, curving laterally over the lateral border of the biceps, and continuing toward the deltopectoral groove. The dissection is carried down while protecting the cephalic vein found in this interval. In this case, the patient did not have an identifiable cephalic vein, which is a documented variant seen in 5% of the population.5 The deep fascia is incised and biceps retracted medially, revealing the brachialis and brachioradialis. Although the brachialis can be reflected laterally, we use a brachialis splitting approach, preserving its radial and musculocutaneous innervations. The humeral shaft is exposed and fracture site debrided of hematoma and interposed periosteum. Serrated reduction clamps are used to control the fragments while traction allows for reduction, which is provisionally held in place with the pointed reduction clamps.
Appropriate hardware is trialed in position and selected. In this case, a narrow, 4.5-mm 8-hole limited contact dynamic compression plate (DePuy-Synthes, West Chester, PA) was selected and positioned on the anteromedial face of the humerus. To achieve compression across the fracture plane, a static push–pull screw may be temporarily placed distal or proximal to the plate in a colinear fashion. Two 4.5-mm bicortical screws are placed in the fragment opposite the static screw after predrilling with a 3.2-mm bit. A Verbrugge bone clamp is then used to pull the plate toward the static screw, thereby compressing the proximal and distal fragments. An alternative method to achieve axial compression is to prebend the plate; however, we did not use this technique for the case demonstrated in the video. Three screws are then placed in the fragment opposite the push–pull screw and a final screw placed in the other fragment, resulting in 3 bicortical screws on either side of the fracture. The push–pull screw is removed, and final reduction and implant position are confirmed fluoroscopically. The wound is closed in a layered fashion and the extremity is placed in a sling for comfort with the patient permitted to weight bear as tolerated after surgery, given that a load-sharing construct has been created. This patient had an uncomplicated recovery and postoperative course.
This surgical technique video demonstrates open reduction internal fixation of a simple, transverse, mid-shaft humerus fracture performed through an anterolateral approach. As shown, this approach provides safe and effective access to the humeral shaft. Although fracture location frequently determines the approach used, the anterolateral approach offers an exposure that can be lengthened both proximally and distally, giving extensile access to the humerus. In addition, it is safe to use in polytraumatized patients as it is performed in the supine position. The video also demonstrates the use of a push–pull screw to gain compression across the fracture plane, a fundamental technique with wide applicability.
1. Carroll EA, Schweppe M, Langfitt M, et al. Management of humerus shaft fractures. J Am Acad Orthop Surg. 2012;20:423–433.
2. Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and Green's: Fractures in Adults.
8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
3. Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82:478–486.
4. Claessen FM, Peters RM, Verbeek DO, et al. Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. J Shoulder Elb Surg. 2015;24:e307–e311.
5. Loukas M, Myers CS, Wartmann ChT, et al. The clinical anatomy of the cephalic vein in the deltopectoral triangle. Folia Morphol (Warsz). 2008;67:72–77.