Humeral Shaft External Fixation

Introduction:
Distal humerus fractures as well as elbow fracture dislocation are often accompanied by soft tissue
damage that warrants early fixation with an external fixator. The distal humerus is a hazardous area
for placement of an external fixator due to the close proximity of the radial nerve to the humerus in
this area. No known safe zone has been identified on the lateral border of the humerus to avoid
radial nerve damage. The aim of this study was to record the incidence of radial nerve damage by
placing two 4 mm pins into the humerus and to note the relation of the nerve to the pins.

Methods:
Two 4 mm pins used to fix an external fixator were drilled into the lateral border of the humerus at
points 100 mm and 70 mm proximal to the lateral epicondyle of both arms of 39 cadavers. The 30
mm interval between the pins is the interval between the pins in a pinblock of a commonly-used
external fixator. The arms were dissected by medical students and the incidence of radial nerve
damage was recorded.
Statistical analysis was done using a Fischer's exact test to identify the incidence of nerve damage
relative to pin insertion. The number of damaged nerves was compared to the number of non-
damaged nerves. A design based Chi Square test was carried out to test left and right arms. The
proportions of interest were estimated along a 95% confidence interval.

Results:
The radial nerve was hit (damaged) by 56.4% of the proximal and 20.5% of the distal pins. The
radial nerve ran posterior to the proximal pin in 2.57% of arms and 0% to the distal pin.

Conclusion:
Although no clear safe zone could be established, pins should be placed closer than 100 mm from
the lateral epicondyle and as posterior on the humerus as possible to minimize the risk for radial
nerve damage.
Humeral Shaft External Fixation Anatomy
• Musculocutaneous N pierces coracobrachialis 5-8cm distal to coracoid, supplies
biceps,coracobrachialis & bracialis
• See also Arm anatomy.

Humeral Shaft External Fixation Indications

• Severe open fractures with extensie soft tissue injury / bone loss
• Associated burns
• Infected humeral shaft nonunion
• Associated neurovascular injury
• Polytrauma patient with need for rapid stabilization

Humeral Shaft External Fixation Contraindications

 • Low-velocity GSW is not an indication

Humeral shaft fractures represent approximately 2-3% of all fractures, having an average incidence
of 14 out of 100.000. They present a bimodal peak incidence: they are more frequent in males
under 50 years of age, and in females over 70.In the case of males, the causative event is generally
high-energy trauma due to road accidents, sports injuries or falls from a considerable height.

The most frequent and dangerous complication of humeral shaft fractures is represented by damage
to the radial nerve, which runs along the rear surface of the bone in the spiral groove of the
humerus. This lesion is present in 11.8% of all cases (15.2% of all shaft fractures) and most
frequently associated with spiral Holstein-Lewis fractures.

The nerve may be bruised or stretched by the fracture fragments, or may even tear. In this latter
case, paralysis onsets abruptly and presents as a deficit in extension of the finger (falling hand) and
wrist, with hypo-anesthesia of the first and second fingers and the first and second metacarpus on
the back of the hand.

Partial functional recovery may take several months and is usually complete within 2 years, so
progress should be monitored with electromyograph studies.
In most of closed fractures, up to 100% for some authors, radial nerve recovery is complete and it
can last up to six months. Surgical revision of the nerve is necessary only if functional recovery has
not yet begun after six months from the traumatic event.

The appearance of nonunion is extremely variable, from 2 to 33% of humerus fractures, its
occurrence depending on many concomitant causes and factors .
In humeral fractures, nonunion is defined as radiographic detection of delayed consolidation of the
fracture six/eight months after treatment

Humeral Shaft External Fixation

Complications
• Delayed union = failure to unite in 2-3
months
• Nonunion 4-6 months
• Malunion, nonunion, vascular, radial
N(10%),
• Radial nerve palsy-most recover in 3-4
months, pts should be placed in cock-up
wrist splint, given thumb abduction and
finger/wrist extension exercises to avoid
contracture. EMG at 6 wks if no signs
 of recovery. Brachioradialis should be
first muscle to return.

Humeral Shaft External Fixation Follow-up care

• Post-op: Posterior splint, NWB.
• 7-10 Days: Remove splint, begin passive
shoulder and elbow ROM. Stress elbow
ROM. Consider converstin to Humeral
fracture brace when soft tissues permit.
• 6 Weeks: Begin strengthening exercises
provided fracture union is evident on xray.
• 3 Months: Ensure full restoration of shoulder
and elbow ROM. Consider bone stimulator if
union is delayed. Sport specific rehab.
• 6 Months: return to full activities / sport.
• 1Yr: Follow-up xrays, assess outcomes
• Shoulder Outcome measures.
• Elbow Outcome measures.
 The use of external fixation for definitive treatment of
open
long bone shaft fractures caused by high energy
trauma during
times of wars or conflicts is reliable and should be
used in
early frontline intervention and in areas with limited
access to
resources. The primary orthopaedic surgeon has to
be aware
of the principles of external fixation during disasters
in addition
to war damage control and take into account all the
patient
and environmental factors before making a decision
about the treatment plan. If appropriate guidelines
are followed, acceptable
union rates can be achieved while mitigating
complications
from the injury.

We used the Stryker Hoffmann type II external fixator, which is a modular fixator consisting of
aluminum and carbon fibers and aluminum bars.

The operative technique consists of placing the patient supine on the operating table with the
affected arm abducted at 45 °- 60 ° and elbow flexed at 90 °.

Anesthesia is generally loco-regional, with continuous interscalene brachial plexus block. This
technique enables immediate passive mobilization of the operated segment thanks to the possibility
of prolonging the analgesic effect in the postoperative period.

The screws are self-tapping with a diameter of 4 or 5 mm and are always inserted manually, usually
two proximal and two distal to the fracture site, depending on the complexity of the fracture. Some
interfragmentary screws can be used to better stabilize the fracture.
For the insertion points we follow the technique and mapping described by Professor Bianchi
Maiocchi [15] to fix all the screws on the lateral humerus.

One screw is inserted in a position just proximal to the olecranon fossa under fluoroscopic
guidance: in order to avoid the ulnar nerve, we proceed with lateral-to-medial insertion of a K-wire,
slightly tilted in the posterior-anterior direction in a selected area of the lateral cortex. Then we
remove the K-wire and use its entrance hole on the lateral cortex as a guide for the first screw.
The second screw is fixed on the same plane as the first, keeping the elbow flexed and the arm
abducted. This will slacken and shift the radial nerve forward. The area chosen for insertion is a
safe zone 8.5 cm proximal to the epicondyle. To improve security, we use the anchor positions 1-4
or 2-4 of the clamP

The proximal screws are inserted into the lateral humerus, proximal to the "V" of the deltoid
muscle, accessing the bone via a blunt dissection through the muscle fibers of the deltoid.
We proceed to installation of the connecting bars, usually two, and reduction of the fracture under
fluoroscopic guidance.