5 Fractures of the Humerus (12-A, B, and C)

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5.2 Indications for Surgery

5 Fractures of the Humerus (12-A, B, and C)

J. Schatzker

5.1 Introduction

Most fractures of the humerus can be treated suc- cessfully by closed means. They unite rapidly. Minor angular and rotational deformities do not result in loss of function, and shoulder and elbow stiffness does not occur. There are circumstances, however, when an open reduction and internal fixation is indi- cated.

5.2 Indications for Surgery

5.2.1 Failure to Obtain a Satisfactory Reduction

Long Spiral Fractures

If displaced with a gap that does not close when rotational alignment is restored (Fig. 5.1), long spiral fractures are almost impossible to reduce because of muscle interposition. If left in good alignment, but with a significant gap between the fracture frag- ments, the outcome of these fractures is always an atrophic nonunion.

a b

Fig. 5.1. a A long spiral fracture of the humerus. The gap did not close when rotational alignment was restored because of soft tissue interpo- sition. b Complete failure of healing at 3 months

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Transverse Fractures

Similarly, a transverse fracture that is overdistracted, either as a result of the initial trauma or closed treat- ment (traction or hanging cast), should be operated upon (Fig. 5.2). Attempts to treat such fractures closed are frustrating to both the patient and the surgeon, first, because the fracture gap cannot be closed by nonoperative means, and second, because alignment is difficult to control. Prolonged immobi- lization, although frequently employed, is in vain. By the time the clinician finally accepts that nonunion has occurred, some permanent shoulder and elbow stiffness will have become established.

Short Oblique Fractures

Short oblique fractures through the distal portion of the shaft just above the olecranon fossa, if displaced, are difficult to reduce and very difficult to maintain in the reduced position. Furthermore, because they are periarticular, prolonged immobilization leads to irreversible elbow stiffness. For these reasons, an open reduction and internal fixation is frequently the best form of treatment.

Fig. 5.2. a A transverse fracture of the humerus. Note the slight distraction at the time of the initial X-ray. b The same fracture after the application of a sugar-tong plaster splint and a sling. The distraction is more marked. c The arm was transferred into a cast brace in the hope that active muscle contraction would bring the fracture ends together. The fracture brace could not control the instability of the fracture, and it displaced

a b

c

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5.2.2 Failure to Maintain Reduction

The “sugar-tong” plaster of Paris splint, combined with a Velpeau bandage, is the most effective and most commonly employed method of immobili- zation of humeral fractures. Very occasionally, we have used a thoracobrachial spica to prevent exces- sive internal rotation of the fracture. We have found the hanging cast a somewhat illogical and unsuc- cessful method. In order for the hanging cast to exert any degree of traction to effect alignment, the patient must remain upright at all times. As soon as the patient lies down, all traction is lost and the cast acts like a lever, causing displacement, since frequently its upper end is at or just above the frac- ture. Whenever the patient moves while upright, despite the collar and cuff, the cast tends to swing.

This not only causes a great deal of pain, but also excessive movement at the fracture. Therefore, we feel that if a fracture cannot be controlled in a sugar-tong cast, the hanging long-arm cast is not a logical solution.

In the majority of patients, if the arm in the sugar-tong cast is bound to the chest wall, the fracture remains reduced, the patient is comfort- able, and the fracture unites. However, if a satisfac-

tory position cannot be maintained, then an open reduction and internal fixation is indicated. Some- times reduction is lost because of the deformity of the chest wall. This is true in very obese patients and in women with very large breasts (Fig. 5.3).

Further manipulative attempts are futile, and open reduction and internal fixation should be carried out.

5.2.3 Injuries to the Chest Wall

Patients with coexistent injuries to the chest wall (e.g., rib fractures, flail chest, sucking wound) cannot have the arm bound to the chest wall because it would interfere with ventilation and with care of the chest wall injury.

5.2.4 Bilateral Humeral Fractures

In patients with bilateral fractures, at least one humerus should be stabilized to facilitate self-care.

Otherwise, the immobilization results in total dis- ability.

Fig. 5.3. a A comminuted fracture of the humerus in an obese woman with large breasts. Note the initial satisfactory align- ment. b An attempt to brace the humeral shaft against the bulging breast and chest wall resulted in unacceptable displace- a ment

b

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5.2.5 Multiple Injuries

Occasionally, in patients with multiple injuries, open reduction and internal fixation of the humerus are required to facilitate the care and rehabilitation of the patient.

5.2.6 Vascular Lesions

In fractures associated with vascular lesions, the frac- ture should be stabilized before the vascular repair is carried out.

5.2.7 Neurological Lesions

Fractures of the humeral shaft are at times associated with injury to the radial nerve. The management of the fracture associated with a radial nerve lesion con- tinues to be a controversial issue, with some favoring a delay to see whether the radial nerve will recover and others favoring a policy of immediate explora- tion, reduction, stabilization of the fracture, and pri- mary nerve repair if the nerve is torn.

The radial nerve is commonly at risk if the frac- ture is at the junction of the middle and distal thirds of the humeral shaft, and particularly if the fracture is associated with lateral displacement of the distal fragment (Fig. 5.4). At this point, the radial nerve emerges from the spiral groove and is tethered as it pierces the intermuscular septum. It cannot yield to the lateral displacement of the distal fragment and is therefore frequently seriously damaged. We feel, therefore, that in the presence of this fracture pattern, immediate exploration is indicated.

If radial nerve function disappears as a fracture is manipulated and reduced, the nerve is caught in the fracture. Spontaneous recovery will not occur if the nerve is not freed and, if the nerve is not explored immediately, the nerve becomes even more enveloped in the callus of fracture repair. This makes its ultimate exploration very difficult. Therefore, we feel immedi- ate exploration with freeing of the nerve and surgi- cal repair of the fracture is indicated in all instances where radial nerve function is lost as a consequence of closed reduction. In all other closed fractures of the humerus associated with radial nerve lesions, if there are no other indications for surgery, a delay of 3–4 months is justifiable. By then the fracture should have united and rehabilitation begun. If the nerve has not recovered, electromyography (EMG) of the most proximal muscles supplied by the radial nerve

Fig. 5.4. Fracture of the humerus at the junction of the middle and distal thirds (Holstein fracture). Note the lateral displacement of the shaft and the tethering of the nerve by the intermuscular septum

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distal to the fracture should be performed. If there is no sign of recovery, the lesion was a neurotmesis and the patient will require either a free nerve graft or multiple tendon transfers.

5.2.8 Fractures of the Shaft Associated with Intra- articular Fractures or Articular Extensions of the Fracture

The successful outcome of all intra-articular frac- tures depends on the anatomical reduction and stable fixation of the fragments and early motion. There- fore, if a fracture of the humerus either extends into a neighboring joint or is associated with a separate intra-articular fracture of the shoulder or the elbow (Fig. 5.5), then both the shaft and the intra-articular fracture are best managed by an open reduction and internal fixation. This will ensure that the outcome of the intra-articular fracture is not prejudiced by the desire to treat the shaft fracture nonoperatively.

There is no adequate method of splinting the shaft and permitting full mobilization of the shoulder and elbow. If the joint were to be kept immobilized after an open reduction and internal fixation, then serious stiffness of the joint would be certain.

5.2.9 Open Fractures of the Humerus

All open fractures, after thorough débridement, require skeletal stability (see Chap. 3).

5.2.10 Pathological Fractures of the Humerus

Many pathological fractures of the humerus will unite if splinted and treated with radiation. In some patients such immobilization may be impractical because of other considerations such as loss of use of the other upper extremity or inability to splint the humerus to the chest wall. Locked intramedullary nailing is an excellent method of securing stability and function (see Fig. 5.12). Composite fixation is another useful method but one that requires more surgery (see Fig. 5.14). Regardless of the method chosen, the fractures can then be radiated if the tumor is radiosensitive. The indications for inter- nal fixation of pathological fractures will depend, of course, not only on the factors mentioned but also on the extent of pathological involvement. Some bones are so extensively involved that surgical stabilization is not possible.

Fig. 5.5. a Association of a mid- shaft fracture of the humerus with a fracture of the olecranon. b Internal fixation of both fractures

a b

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5.3 Surgical Approaches

We feel that the best approach to the proximal third of the shaft is the standard deltopectoral approach.

The more proximal the fracture, the more likely it will be necessary in order to gain exposure to release the deltoid distally from its insertion into the deltoid tuberosity. Reattachment of the deltoid is not neces- sary, as the muscle reattaches to bone spontaneously without any subsequent functional deficit. Occasion- ally it may become necessary to detach the anterior third of the deltoid muscle from the clavicle. In doing this, it is important to preserve both the superficial and deep fascia that invests the deltoid muscle. We no longer leave a cuff of muscle attached to the clavicle to effect a closure, because we have found the follow- ing method to be more effective. We pass our sutures carefully through both the deep and superficial fascia of the deltoid and then through the fascia of the tra- pezius muscle at its insertion into the clavicle. As the sutures are tied, the deltoid is drawn snugly up to and over the edge of the clavicle, effecting a strong muscle closure.

In order to protect the resutured portion of the deltoid from avulsion during early mobilization, we insist on passive elevation and abduction for the first 4 weeks. With this method, we have not had a single deltoid avulsion. As we extend the incision distally, we approach the insertion of the deltoid. At this point it is important to identify the origin of the brachialis muscle, which merges here with the insertion of the deltoid, because the radial nerve lies a fingerbreadth below and behind the deltoid insertion as it comes for- ward around the humerus. This is invariably an area where brisk bleeding is encountered as the planes are developed, and the surgeon should be ready to coag- ulate the bleeding vessels. Further exposure distally is gained by splitting the brachialis muscle down its middle. The lateral half of the muscle is used to pro- tect the radial nerve. By splitting the brachial muscle, exposure can be extended as far as the elbow joint.

For this part of the approach, we like to have the patient positioned supine with a folded sheet under the scapula to lift the shoulder off the table. This facilitates cleansing of the skin posteriorly and sub- sequent draping of the shoulder to leave the arm free and fully exposed. The arm is positioned at the patient’s side and is supported on an arm board.

It is best to approach the distal third of the humerus posteriorly. For this exposure, the patient is positioned lying on the uninjured side. After draping, which

should leave the shoulder and elbow fully exposed, the arm is supported on a rolled sheet and the elbow is flexed. It is extremely advantageous to support the humerus while it is being exposed, because it obvi- ates the need for an assistant and makes the handling of the fracture fragments much simpler. The triceps aponeurosis is split down the middle or is reflected down as a tongue. The underlying triceps is then split in line with its fibers. If the approach must be extended more proximally or if the humerus must be approached from the back, as might occur in the case of an open fracture which has penetrated muscle and skin posteriorly, then a formal posterior approach to the bone must be used. This is done by developing the interval between the long head of the triceps medi- ally and the lateral head laterally. The radial nerve is encountered in the more proximal portion of the exposure coursing from high medial to low lateral.

It is important to realize that, although described as running along the radial groove of the humerus, the nerve does not lie on bone but on the medial head of the triceps.

5.4 Surgical Methods of Stable Fixation

5.4.1 Biomechanical Considerations

The cortex of the humerus splinters very easily.

Therefore, even long spiral fractures must be pro- tected after lag-screw fixation with a neutralization plate, and it is imperative never to rely on screw fixa- tion alone. Furthermore, to prevent longitudinal fis- suring whenever the humerus is plated, a broad plate should be used. The screw holes in these broad plates are staggered, which increases the distance between successive screws and decreases the likelihood of fis- suring the bone longitudinally.

In patients with a normal elbow, the posterior cortex is under tension (Müller et al. 1970). If the patient has a stiff elbow, the anterior cortex becomes the one under tension (Weber and Cech 1976). This would mean that in patients with a mobile elbow, the “compression” or tension band plates should be applied posteriorly, and in patients with a stiff elbow, anteriorly.

Because the radial nerve lies in the spiral groove posteriorly, the posterior surgical approach to the mid-diaphysis is more difficult and the radial nerve is

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5.4 Surgical Methods of Stable Fixation

at great risk of injury. For this reason, we prefer Hen- ry’s anterior approach to the upper and mid-diaphy- sis (Henry 1959) and apply the plates most commonly to the anterolateral surface of the bone. Because the humerus is not a weight-bearing bone and is not sub- jected to forces as great as those acting on the femur or the tibia, this biomechanical infringement has not resulted in any failures of fixation.

Fractures of the distal third should be plated pos- teriorly. There are four reasons for this. The humerus is flat posteriorly and it is easier to apply the broad plate to that surface. It is much easier to insert the most distal screws from the posterior approach because the surgeon is not close to the cubital fossa with all its converging soft tissue structures, which create a very tight envelope and make anterolateral or ante- rior screw insertion difficult and hazardous. If applied posteriorly, the plate can also reach further distally without compromising elbow flexion. Furthermore, a distal diaphyseal fracture of the humerus sometimes lends itself to stabilization with two semitubular plates (Fig. 5.6) or two 3.5-mm dynamic compression (DC) plates. This greatly increases the stability of fixation in this difficult transition zone of the humeral shaft.

When exposing the distal third of the humerus pos- teriorly, the surgeon must remember that the radial nerve will be close to the upper end of the exposure. It may have to be isolated and protected. If the exposure approaches the elbow, then the ulnar nerve must be isolated and protected as it passes behind the medial epicondyle.

With the exception of the supracondylar area, where the small-fragment 3.5-mm cortex screws and cancellous screws and the corresponding plates are used, the 4.5-mm large-fragment screws and the corresponding plates should be used for fixation of the humeral shaft. As already emphasized, the broad plates should be used on the diaphysis to prevent lon- gitudinal fissuring of the bone. An exception might be made in an extremely small individual with very slender bones; in such cases, the narrow 4.5-mm lim- ited contact (LC)-DC plate can be used. The 3.5-mm LC-DC plates should be used only in the supracon- dylar area (Fig. 5.7). In the proximal portion of the shaft, where the bone flares to meet the metaphysis, the cortex is very thin and very difficult to tap. If the tap is inadvertently allowed to wander, it can easily miss the hole in the far cortex and then either strip the thread in the near cortex or break out a segment of bone from the opposite cortex. Great care must be exercised to prevent this complication.

As already emphasized, even in long oblique or spiral fractures, lag screws must not be used alone to secure internal fixation (Fig. 5.8). The lag screw is the most efficient means of securing interfragmental compression, and as such it is the principal means of securing a stable fracture interface and structural continuity of fragments. However, mechanically, such fixation is not sufficiently strong to withstand the forces of bending shear and torque. Therefore, the lag-screw fixation must be protected with a neutral- ization plate (Fig. 5.9).

Fig. 5.6. a A single plate failed to pro- vide adequate stability, and the outcome of the fracture was nonunion. b In the metaphysis, we can use two plates without running the risk of stress shielding.

Thus, two shorter and thinner plates (semitubular) applied to the rounded posteromedial and posterolateral edge have provided significant stability

a b

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Transverse or short oblique fractures are stabilized by means of axial compression. The stability of the fixation is greatly enhanced if a lag screw is passed through the plate and across the fractures. If techni- cally, because of the configuration of the fracture, the lag screw cannot be passed through the plate, it should still be inserted across the fracture to improve the sta- bility of the fixation (Fig. 5.10). In the distal third of the humerus, there is only a small portion of the bra- chialis muscle that separates the radial nerve from the plate applied to the anterolateral surface of the bone.

In some patients, the nerve has been left in direct con- tact with the plate. We have not observed any damage to the nerve, either early or late, as a result of this. The relationship of the nerve to the plate and, in particular, where it crosses the plate in relationship to the screw holes, should be carefully recorded in the operative

Fig. 5.7. The different plates and their place on the humerus:

A, T plate; B, narrow 4.5-mm dynamic compression (DC) plate; C, broad 4.5-mm DC plate; D, 3.5-mm DC plate; E, one- third tubular plate (3.5-mm screws); F, semitubular plate (4.5- mm screws)

Fig. 5.8. Even in a long spiral fracture, lag screws alone cannot provide adequate stability

Fig. 5.9. Lag screws provide the principal means of achieving interfragmental compression and, in this way, structural continuity. The neutralization plate protects the stability achieved by means of lag screws

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report. This will protect the nerve from damage at the time of plate removal if this becomes necessary.

For stable fixation of the humerus, screw purchase is necessary in the cortex in six places on each side of the fracture. This means that the shortest plate that can safely be used on the humerus is a six- to seven- hole plate. With osteoporosis, the number of screws on each side of the fracture need not be increased, but a longer plate must be used and the screws staggered to increase the distance between them. This greatly increases the strength of the fixation in osteoporotic bone. The fixation on each side of the fracture must be equally strong. Therefore, as we approach the metaph- ysis, we use either two plates or specially shaped but- tress plates which permit the insertion of a greater number of screws through a shorter segment of the plate.

When one is plating a multifragmentary fracture, all of the principles of indirect reduction and preser- vation of the blood supply to bone apply. In these situ-

ations bridge plating is indicated, and where possible submuscular insertion of the plate.

The new family of angular stable fixation as pres- ent in the “locked compression plates (LCPs)” will unquestionably facilitate further plate fixation of the humerus, particularly when the bone is osteoporotic.

It must be remembered, however, that although the LCP has biological and mechanical advantages, it is still a plate and all of the above-mentioned consider- ations apply.

Unlocked intramedullary nailing has had little place in the treatment of acute fractures. We have used Hackethal retrograde stacked pinning with success in the treatment of undisplaced pathological fractures of the humerus (Fig. 5.11). This type of fixation does not provide sufficient stability for the treatment of displaced acute fractures. In recent years, surgeons have developed locked intramedullary nailing for the humerus. The Seidel nail was the first one we used.

This nail was locked proximally by a screw. For distal locking the Seidel nail depended on deployment of intramedullary fins. This nail provided reasonable axial stability but very poor rotational stability. It was also extremely difficult to remove because bone blocked the intramedullary fins from retraction. We abandoned its use shortly after its introduction . More recently, different implant manufacturers have devel- oped nails that lock with screws both proximally and

Fig. 5.11. Hackethal stacked intramedullary pinning of the humerus

Fig. 5.10. Lag screw used to increase the stability achieved by means of a tension band plate

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distally. We have used these nails with success, but they are not without problems, and not all of the theoretical advantages of intramedullary nailing of the humerus, a long bone, have materialized. Locked nails should be used preferably in the treatment of segmental and complex fractures of the shaft, which are difficult to stabilize with plates and screws because of their frac- ture morphology. Proximal insertion of the nail carries the risks of damage to the rotator cuff and of stiffness of the shoulder. This can be avoided to some degree if the nail is inserted through a minimal split in the deltoid just below the rotator cuff insertion between the superior facet and the lesser tuberosity (Fig. 5.12).

Despite all these modifications and great care, ante- grade insertion of the nail carries major risk to shoul- der function and should never be used in patients with pre-existing shoulder pathology. An articulated nail that is stiffened after insertion was recently developed by Synthes USA and used in clinical trials. Because it is flexible on insertion it can be inserted more dis- tally without damage to the rotator cull. We have had no personal experience with this nail. Its theoretical advantage is offset by the theoretical disadvantage that should the locking cable break, extraction of the articulated pieces from the medullary canal may prove extremely difficult. Distal retrograde insertion carries the risk of fracturing of the humerus and of myositis ossificans of the triceps and subsequent elbow stiff-

ness. Whenever we have used an intramedullary nail in acute fractures, we have always carried out a limited exposure of the displaced portion of the fracture to make certain that the radial nerve was not interposed.

Other authors who have reported on intramedullary nailing of the humerus without exposure of the nerve have all reported an incidence, albeit low, of damage to the radial nerve. Locked intramedullary nailing has also proven very useful in the treatment of pathologi- cal fractures of the humerus (Fig. 5.13). Intramedul- lary nailing has not proven itself a good method in the treatment of nonunions of the humerus. In addition, nonunions following intramedullary nailing should be treated by plating and bone grafting rather than re- nailing, since re-nailing has failed in an unacceptably high number of cases. Fractures of the humerus distal to the tip of the locked intramedullary nail have also been reported (McKee et al. 1996). Thus, in conclusion our feeling is that either antegrade or retrograde nail- ing of the humerus should be reserved for segmental fractures or complex multifragmentary fractures that are difficult to stabilize with plates and screws because of their fracture morphology. In all other cases, if sur- gery is indicated, we feel one should resort to the use of plates and screws.

In displaced pathological fractures, we have found the so-called composite type of fixation of methyl methacrylate and plating to be most reliable (Fig. 5.14).

Fig. 5.12a–d. Note the insertion point of the nail as well as the two locking screws. Note also that the displacement between the fragments did not prevent union. Postoperatively the patient was allowed to mobilize the limb but was advised to avoid torsion and lifting. Union is by callus

b c d

a

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The fracture is reduced before any attempt is made to evacuate the tumor mass. A plate is then contoured, applied to the anterolateral surface of the bone, and fixed with one or two screws proximally and distally. In pathological fractures, because of the frequent destruc- tion of cortex and osteoporosis, longer plates must be used than in nonpathological fractures. Care should also be taken that the plate does not stop at or near a metastatic deposit. Once the bone is provisionally sta- bilized, a window is cut to permit the introduction of a curette and methyl methacrylate. This window should bridge both fragments and encompass at least three or four screw holes on each side of the metastatic deposit, but it should not extend to the end of the plate. Once the window is cut, all of the tumor is removed with curet- tage and suction. The screw holes are then predrilled, measured, and tapped, and the screws prepared in the order of insertion. Methyl methacrylate bone cement is then mixed and, while in the early doughy stage, rapidly pushed into the prepared trough and defect.

Before the cement sets, the screws are rapidly screwed in and finally tightened once the methyl methacrylate has polymerized.

Fig. 5.13a–d. This pathological fracture was stabilized with the locked intramedullary nail without the adjunct of methyl methacrylate. Some shortening resulted, but this was of no functional significance

Fig. 5.14. Composite fixation (plate and methyl methacrylate cement) of a pathological fracture of the humerus. (From McKee et al. 1996)

a b c d

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5.6 Removal of Internal Fixation

5.5 Postoperative Regimen

Following surgery, it is best to immobilize the arm on a posterior plaster splint with the elbow in almost full extension, and to suspend it for 24–48 h from an intravenous drip pole to minimize postoperative edema. The patient is allowed up for meals and to go to the toilet. Suction drains are removed after 24–36 h, depending on the amount of drainage. The wound is inspected daily. If healing is progressing satisfactorily without any complicating features such as hematoma or sepsis, active mobilization is started on the second or third postoperative day, and the patient can be discharged from hospital.

If the fixation is stable, apart from minor wound discomfort, mobilization is painless. A cooperative patient will carry out active mobilization exercises as instructed and will not require a formal program of rehabilitation. An anxious or less well-motivated individual requires supervision, but strict instruc- tions must be issued to the physiotherapist not to carry out joint manipulations or resisted exercises lest the fixation be lost from mechanical overload.

The surgeon is the only individual able to judge accurately the stability of any fixation, because only the surgeon knows how well each screw held as it was tightened in bone. If the fixation is judged to be unsta- ble, then of course this program of early mobilization must be modified and the extremity protected.

In cases of early failure of the fixation, either in the early postoperative period or during the phase of fracture healing, a surgical revision of the fixation should be undertaken if it is technically feasible. It is important to recognize modes of failure.

Early failure, the result of mechanical overload, either because of inadequate primary fixation or because of the patient overloading the fixation, should be revised surgically to a stable internal fixation.

If failure of fixation is recognized at, say, 6 weeks or later, it is important to differentiate between instability in the presence of an irritation callus and instability without an irritation callus, which displays a widen- ing fracture gap, a halo around the screws, periosteal reaction at the plate ends, and resorption of cortex deep to the plate. In the former, with an evident irrita- tion callus, protection of the extremity from load by immobilizing it in a cast will usually result in the irri- tation callus changing to a fixation callus with healing of the fracture. In the latter, with evidence of failure but no callus, further immobilization and protection are of no avail. Surgical revision must be performed.

Stable fixation must be achieved by revising the exist- ing internal fixation. Usually it is also necessary to perform bone grafting to promote union.

The above applies only if absolutely stable fixation has been attempted. If a complex or wedge fracture has been stabilized with a bridge plate following an indirect reduction with attention paid to the pres- ervation of the blood supply of all the intervening fragments, then union will be by callus. This fixa- tion callus, which characterizes the union of viable fragments of bone in the presence of motion, is characteristically seen in fractures which have been splinted, such as those fixed with a bridge plate or an intramedullary nail. It is smooth and rounded in out- line, homogeneous in consistency, continuous, and it bridges the fragments. Irritation callus is ill-defined, nonhomogeneous, and not smooth in outline, and it does not bridge the fragments.

Fractures of the humerus are usually solidly united in 3 months. If union should be delayed but the fixa- tion remains stable, unlike in the lower weight-bear- ing extremity, where failure of the plate would be almost certain, in the upper extremity we can afford to wait for consolidation to occur. Clearly the patient would be completely symptom-free, and the only clue to the delayed union would be radiological.

5.6 Removal of Internal Fixation

Plates should be removed only if they give rise to symptoms. In removing plates from the humerus, the proximity of the radial nerve to the plate and the danger of leaving the patient with a radial nerve palsy should always be borne in mind. Following plate removal, the patient should abstain from heavy lifting for a period of 6–8 weeks.

References

Henry K (1959) Extensile exposure. Livingstone, Edinburgh, p 25

McKee MD, Pedlow FX, Cheney PJ, Schemitsch EH (1996) Frac- tures below the end of locking humeral nails: a report of three cases. J Orthop Trauma 10(7):500–504

Müller ME, Allgöwer M, Willenegger H (1970) Manual of internal fixation, 1st edn. Springer, Berlin Heidelberg New York, p 121

Weber BG, Cech O (1976) Pseudoarthrosis. Huber, Bern, p 109