Humerus fracture

Proximal Humerus fracture & Shaft of Humerus Fracture.

1. Humerus Fractures Dr. Anshu Sharma Assistant Prof. Dept. of Orthopaedics , GMC&H.

2. Proximal Humerus Fractures Defined as Fx occurring at or proximal to surgical neck . 80 % of all humeral # . 7 % of all #. Pt > 65 yrs – 2 nd most common Fx of the upper extremity . 65% of # occur in Pt’s > 60 yrs F:M – 3:1 . Incidence increases with age.

3. Mechanism of Injury Old Pts - L ow energy trauma [FOOSH] . Most # are nondisplaced, good prognosis – > nonsurgical Mx . Risk factors: Poor quality bone , I mpaired vision & balance, M edical comorbidities, D ecreased muscle tone. Young Pts – High energy trauma . Severe soft tissue d amage always require Sx intervention . Seizures & electric shock – indirect causes .

4. Common mechanism for low energy proximal humerus Fx in elderly patients .

5. Anato m y Proximal humerus comprises of four major segments The Articular head The greater tuberosity Lesser tuberosity and The shaft Articular segment is almost spherical, with a diameter of curvature averaging 46 mm (ranging from 37 to 57 mm) Inclination of the humeral head relative to the shaft averages 130 degrees . Retroversion of the head varies from 18 to 40 degrees .

6. Anatomy Greater tuberosity has three regions into which the supraspinatus, infraspinatus, and teres minor insert . Subscapularis tendon  lesser tuberosity, which is separated from the greater tuberosity by the bicipital groove.

7. Deforming forces of PHF The greater tuberosity is pulled posteromedially by the effect of the supra- and infraspinatus tendons. The lesser tuberosity is pulled anteriorly by the subscapularis tendon. The shaft segment is pulled anteromedially by the pectoralis major tendon.

8. Clinical Evaluation A complete history and physical examination must be obtained about the mechanism of injury and energy of trauma . Complaints of Shoulder pain and limitation of movement . Ecchymosis appears 24-48 hrs. Look for rib, scapular, cervical # in high energy trauma. Concurrent brachial plexus injury 5 % . Axillary nerve is susceptible in anterior # D islocation . Association of arterial injury is rare . The patient will hold the arm in internal rotation . Radial pulse and capillary refill of fingers should be assessed

9. Imaging and Diagnostic studies Radiographs :- C onsist of three views AP- Perpendicular to the plane of scapula ( Grashey view) Neer View (Scapula Y view) Axillary view

10. AP Grashey view of the shoulder The patient’s torso is rotated 30–45 degrees bringing the side opposite to the injured shoulder forward. The x-ray beam is thereby aimed perpendicular to the plane of the scapula.

11. Neer view (lateral Y) of shoulder Affected shoulder located against the cassette the patient’s torso is rotated 60 degrees bringing the side opposite to the injured shoulder toward the source.

12. Axillary view The arm is abducted as much as possible, with the patient supine and the x-ray beam projected from the axilla onto the cassette located on top of the shoulder.

13. Velpeau axillary view of the shoulder The x-ray beam is projected down perpendicularly onto a cassette. The patient is asked to lean back, to place the shoulder between the x-ray source and the cassette

14. CT Scan- Allows more detailed understanding of fracture configuration, degree of osteopenia, presence and location of bone impaction and extent of fracture comminution . MRI Is rarely indicated in trauma setting . May be helpful in confirming a non-displaced Fx in a pt with shoulder trauma, normal radiographic findings and clinical symptoms . Pathological Fx . Angiography Vascular imaging is required when there is suspicion of vascular injury . CT Angiography- Diagnostic modality of choice. It allows rapid evaluation of vascular system, while simultaneously allowing assessment of bone and soft tissues

15. Proximal Humeral Fracture Classfication AO classification Is based on fracture location and presence of impaction, angulation, translation, or comminution of the fracture, as well as whether a dislocation is present. Type A- Extra-articular unifocal fractures associated with single fracture line. Type B- Extra-articular bifocal fractures accociated with two fracture lines Type C- Articular fractures which involve the humeral head or anatomic neck. Each type is further sub classified into groups and subgroups. Each subgroup fracture is assigned a level of severity.

16. Proximal Humeral Fracture Classfication Neer Classification (1970) Fractures are classified by evaluating the displacement of the Parts (head, shaft, greater tuberosity, lesser tuberosity) from each other . Criteria to consider as a part, fragment must be rotated 45 degree or displaced 1 cm from the another fragment. Classifies as One part, Two part, Three Part and Four part Fractures

17. One-Part Fractures No fragments meet the criteria for displacement; a fracture with no fragments considered displaced is defined as a one- part fracture regardless of the actual number of fracture lines or their location. Two-Part Fractures One segment is displaced . Three-Part Fractures With a three-part fracture, one tuberosity is displaced and the surgical neck fracture is displaced. The remaining tuberosity is attached, which produces a rotational deformity. Four-Part Fractures All four segments (both tuberosities, the articular surface, and the shaft) meet criteria for displacement. This is a severe injury and carries a high risk of avascular necrosis.

18. Valgus-Impacted Four-Part Fractures Neer added this pattern as a separate category in 2002 . In this situation, the head is rotated into a valgus posture and driven down between the tuberosities, which splay out to accommodate the head. Unlike in the classic four-part fracture, the articular surface maintains contact with the glenoid. Fracture Dislocations and Articular Surface Injuries Fractures combined with glenohumeral dislocation are classified as fracture dislocation. Fractures involving articular surface can be of two varieties- head-splitting fractures and impaction fractures. They are included in group of fracture dislocations

19. Fracture Frequency In 2001 Court-Brown et al published study on distribution of PHF types. Non-displaced or minimally displaced one-part fractures comprised half (49%) of all fractures. Two part- 37%. Surgical neck fractures comprised 3/4 th of these. Two part anatomic neck fractures were rare (0.2 %) Three part fractures- 9 % Four part- 3 %, of which one third were true fracture dislocations. Fractures involving articular surface occurred in 0.7 % cases.

20. Risk of Avascular Necrosis Four-part fractures and fracture dislocations are considered to have the highest risk for humeral head necrosis. Hertel criteria – Metaphyseal extension of the humeral head < 8 mm Medial hinge disruption of >2 mm, and Fracture through anatomical neck The combination above above factors had 97% positive predictive value for humeral head ischemia.

21. Metaphyseal extension of the humeral head of >9 mm Metaphyseal extension of the humeral head of <8 mm.

22. Undisplaced medial hinge Medial hinge with >2 mm of displacement

23. Non-operative Mx of Proximal Humer us F x The majority of proximal humeral fractures are nondisplaced or minimally displaced and nonoperative treatment is indicated. Fracture stability can be assessed both radiographically and clinically. Radiographically, stable fractures exhibit impaction or interdigitation between bone fragments Clinically, fracture stability may be assessed by palpating the proximal humerus just distal to the acromion with one hand, while rotating the arm at the elbow with the other. If the proximal humerus is felt to move as a unit with the distal segment, the fracture is considered stable .

24. Non-Operative Treatment Indications Stable non-displaced or minimally displaced fractures , Patients not fit for surgery , Elderly patients with low functional demands . Relative Contraindications Displaced fractures with loss of bony contact . Close follow-up is required to confirm acceptable alignment and fracture stability. Weekly radiographs should be performed during the first month of treatment, followed by biweekly radiographs until 6 weeks after injury or initial callus formation is visible.

25. Complications Major complications following nonoperative treatment of proximal humerus fractures include- Avascular necrosis Nonunion Malunion Stiffness Rotator cuff dysfunction Posttraumatic arthritis

26. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus involving surgical neck Studied 231 pt(114 in surgical group and 117 in nonsurgical group) aged 16 yrs or older (mean age 66 yrs) Patients were followed up for 2 years Results There was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence.

27. Total 518 patients (average age 70.93) met inclusion criteria. Patients were followed up for at least 1 year in all the studies. Conclusion Operative treatments did not significantly improve the functional outcome and healthy-related quality of life in elderly patients. Instead, Operative treatment for CPHFs led to higher incidence of postoperative complications.

28. CONTROVERSIAL What is optimal management for displaced Proximal Humerus Fractures?

29. Operative Treatment of Proximal Humeral Fractures Many surgical techniques have been described, but no single approach is considered to be the standard of care. Appropriate treatment is individualized and selected on the basis of the fracture pattern and the underlying quality of the bone. Surgical Options- Open Reduction and Internal Fixation Tension Band Fixation Closed Reduction and Percutaneous Fixation Hemiarthroplasty Reverse Total Shoulder Arthroplasty

30. Open Reduction and Internal Fixation (ORIF) ORIF is the most frequently used method of surgical treatment of proximal humeral fractures. Surgical Approaches Deltopectoral Approach Deltoid-Splitting Approach

31. Deltopectoral Approach

32. Fixation using Conventional Plate Prior to the use of locking-plate technology, conventional plate fixation was used for the majority of patients. Several studies have reported satisfactory healing rates and functional outcomes after conventional plate and screw fixation of proximal humeral fractures, especially in younger patient populations. Many studies have however reported high rates of infection, humeral head necrosis, and subacromial impingement. Traditional plate constructs are usually reserved for Young patients with an intact medial hinge, Adequate diaphyseal cortex(>4 mm), and No metaphyseal comminution.

33. Fixation using Locking Plate The inability of conventional plates and screws to resist varus deforming forces in the proximal humerus, particularly if the bone is osteoporotic,has led to locking plate fixation being used for these fractures. Several clinical studies have shown high rates of healing and excellent functional recovery with proximal humerus locking plates. Plate designs vary in terms of the number of proximal screws and their arrangement, as well as the ability to place screws at different angles with regard to the plate. A plate is selected to allow at least three screws to be placed into the distal shaft segment. The plate position is also selected to avoid subacromial impingement and to allow two screws to be placed into inferomedial aspect of the humeral head.

34. A minimum of five or six screws are routinely placed into the proximal segment. Screw placement should be performed by drilling through the near cortex only. This avoids perforation of the articular surface, and reduces the possibility of secondary screw penetration. Once the plate and screws have been placed transtendinous sutures are tied onto the plate to provide additional fixation.

35. The use of IM fibular strut grafting has been described to improve stability of varus-impacted fractures in which the medial calcar may not be reliably reconstructed. Goal being to create a buttress at the inferior aspect of the anatomic neck to prevent delayed varus collapse

36. Postoperative Care Patients are followed at 2 weeks, 6 weeks, and 3 months after surgery. Patients are immobilized for 6 weeks in a sling while active range-of-motion exercises of the elbow, wrist, and hand are encouraged. Depending on the fracture pattern and stability that was achieved, passive range of motion is started between 2 and 4 weeks after surgery with forward elevation, external rotation, and pendulum exercises. If healing has adequately progressed both clinically and radiographically at 6 weeks active-assisted range of motion is started.

37. Tension Band Fixation It is most frequently used as an adjunct to plates and screw fixation, IM nailing, and arthroplasty. The main goal of tension band fixation is the neutralization of tension forces generated by the rotator cuff at the level of the tuberosities, and bending at the level of the surgical neck. The main advantage of tension band fixation is the minimal amount of hardware that is required. Thus avoiding the risks associated with hardware, which include pain, neurovascular compromise, migration, failure, and the need for removal. Contraindications Previous attempt(s) at internal fixation or Fractures older than six weeks. Highly comminuted four part fractures.

38. Tension-band construct with transosseous suture fixation

39. Closed Reduction and Percutaneous Fixation It has theoretical advantage of minimizing soft tissue trauma, thereby promoting healing and reducing the risk of AVN of the humeral head. It also has the advantage of decreased scarring in the scapulohumeral interface and subsequent easier rehabilitation. Indications- Fracture without significant communition in pt with good quality bone. Pt should be willing to comply with postop care plan. Contra indications Severe comminution and osteopenia are absolute contraindications Inability to reduce Fracture Fragments Fracture Dislocation Non Compliant patients

40. To avoid injury to the axillary nerve, lateral pins should enter the humeral cortex at a point at least twice the distance from the upper aspect of the head to the inferior head margin with the wire angulated approximately 45 degrees to the cortical surface. The end point for the greater tuberosity pin should be >2 cm from the inferior most margin of the humeral head.

41. Intramedullary Nailing Biomechanical advantages in osteoporotic bone It allows stabilization with minimum surgical invasion Indications- Displaced two part surgical neck fractures Pathological fractures Contraindications- Varus four-part fractures with lateral displacement of the humeral head Head-splitting fractures

42. Hem i arthropl a sty Also known as humeral head replacement Indications- Four-part fractures, Three-part fractures in older patients with osteoporotic bone, Fracture-dislocations Comminuted head-splitting fractures Head depression fractures involving more than 40% of the articular surface Contraindications- Active infection of the shoulder joint and/or the surrounding soft tissue

43. Postoperative Care Passive range-of-motion exercises are started on the first postoperative day. They are limited to neutral rotation and 90 degrees of forward elevation. Patients are followed up clinically and radiographically at 2 weeks, 6 weeks, and 3 months. Active-assisted range-of-motion exercises are started at 6 weeks and strengthening exercises at 3 months

44. Reverse Total Shoulder Arthroplasty By placing a hemisphere onto the glenoid surface and a concave tray onto the humeral stem, reverse shoulder arthroplasty allows for rotation to occur at the glenohumeral joint through activation of the deltoid, without the need for a functional rotator cuff/tuberosity unit. Indications Complex acute proximal humeral fractures Proximal humerus malunion or nonunion where the normal anatomy of the tuberosities cannot be reliably restored Glenohumeral joint arthritis with advanced rotator cuff pathology Massive irreparable rotator cuff tears with painful pseudoparesis

45. The ideal candidate for reverse total shoulder arthroplasty in a patient with a complex proximal humerus fracture is a low demand elderly patient with pre- existing rotator cuff pathology and glenoid pathology.

46. Comparison of outcomes of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in elderly pt. Sixty-two patients older than 70 years were randomized to RSA (31 patients) and HA (31 patients) The mean functional scores and active range of motion were significantly better in the RSA group. Revision rate was lower in RSA.

47. Com p licat i ons Avascular necrosis of humeral head and/or tuberosity Non-union- The normal time for clinical union of a proximal humeral fracture is typically 4 to 8 weeks. Nonunion is said to be present if a fracture site is still mobile 16 weeks post injury. Malunion Post-traumatic Shoulder stiffness Post traumatic arthritis Infection Iatrogenic-such as inadequate reduction, incorrectly positioned implants, screw penetration into the joint, loss of fixation, tuberosity disruption, and nerve injury. Heterotopic bone formation

48. General Treatment Philosophy of Proximal Humerus Fractures All nondisplaced fractures, minimally displaced fx as well as most valgus-impacted fractures are treated non operatively especially in patients with lower functional expectations. In patients with higher baseline shoulder function and higher expectations, surgical treatment may be recommended for most displaced fractures. For patients undergoing surgical treatment fracture reduction and fixation is performed in majority of cases and effort should be made to reconstruct the proximal humerus with emphasis being placed on achieving anatomic reduction and stable fixation of the tuberosities .

49. Shoulder arthroplasty is considered in fractures in which a high suspicion of head nonviability is suspected because of severe displacement of the fracture through the anatomical neck without metaphyseal extension, disruption of the medial hinge and frank dislocation from the glenoid. In younger patients, hemiarthroplasty is the chosen treatment method, in elderly patients, reverse shoulder arthroplasty is preferred.

50. Treatment of Individual Injury Patterns of Proximal Humerus Fracture Nondisplaced or Minimally Displaced One-Part Fractures These are treated nonoperatively with initial immobilization in a sling. Weekly radiographs and clinical assessment are performed for the first 3 weeks . Elbow, wrist, and hand mobilization begins immediately. Passive range-of-motion exercises are begun at 3 weeks if no change in fracture position has been confirmed. Active-assisted range of- motion exercises are begun at 6 weeks and strengthening is started at 3 months when bony healing has been confirmed radiologically.

51. Greater Tuberosity Fractures Displacement of the greater tuberosity is poorly tolerated because of its key role in shoulder function Currently threshold of displacement for surgical treatment of greater tuberosity fractures in active patients is accepted as 5 mm (instead of 1 cm as per Neers’s criteria) Flatow et al. reported the results of 12 displaced two-part greater tuberosity fractures that were treated by heavy suture fixation and rotator cuff repair. They reported 100% excellent or good results with all fractures healing without displacement .

52. Two-Part Greater Tuberosity Fractures and Fracture Dislocations In elderly, frail patients (usually older than 80 years) with limited functional expectations, a substantial degree of displacement and these are treated non operatively. Operative treatment is advised for physiologically younger patients with fractures, which are either primarily displaced by more than 5 mm or become displaced by this amount within the first 2 weeks after injury. Fixation is obtained either with suture anchors in a double row pattern or by the use of transosseous sutures, or alternatively, a small T-plate may be fixed laterally

53. Two-Part Lesser Tuberosity Fractures and Fracture Dislocations Isolated lesser tuberosity fractures typically occur in younger or middle-aged patients and are displaced. ORIF - Preferred Single large fragment -definitive internal fixation is performed using partially threaded 3.5-mm cancellous screws, inserted through the lesser tuberosity. If communited- transosseous sutures is used for fixation.

54. Two-Part Surgical Neck Fractures All fractures in which the shaft is impacted into the surgical neck are treated nonoperatively. A substantial degree of translation of these two fragments is usually tolerated, as long as there is residual cortical contact and impaction. Displaced and comminuted surgical neck fractures in physiologically younger patients are managed with ORIF using a locking plate.

55. Three- and Four-Part Fractures In physiologically older patients these are usually treated nonoperatively if there is residual cortical continuity of the humeral head fragment on the shaft, the tuberosities are not too widely displaced, and the humeral head appears viable. Operative treatment is offered to physiologically younger patients, where the risk of nonunion, cuff dysfunction, or osteonecrosis is high. ORIF is performed whenever possible, and preoperative CT scan provide an indication of its feasibility . The patient is always preoperatively counseled that if the fracture is deemed to be unreconstructable, an arthroplasty will be performed. Young patients - Cemented humeral head replacement Older patients – Reverse total shoulder arthroplasty

56. FRACTURE SHAFT HUMERUS

57. INTRODUCTION 3% to 5% of all fractures Most will heal with appropriate conservative care, although a limited number will require surgery for optimal outcome. Given the extensive range of motion of the shoulder and elbow, and the minimal effect from minor shortening, a wide range of radiographic malunion can be accepted with little functional deficit .

58. EPIDEMIOLOGY High energy trauma is more common in the young males Low energy trauma is more common in the elderly female

59. AGE & GENDER SPECIFIC INCIDENCE OF SHAFT HUMERUS FRACTURE

60. MECHANISM OF INJURY Direct trauma is the most common especially MVA . Indirect trauma such as fall on an outstretched hand . Fracture pattern depends on stress applied Compressive- proximal or distal humerus Bending- transverse fracture of the shaft Torsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually associated with a butterfly fragment

61. CLINICAL FEATURES HISTORY Mode of injury Velocity of injury Alchoholic abuse ( prone for repeated injuries ) Age and sex of the patient ( osteoporosis ) Comorbid conditions . Previous treatment( massages ) . Previous bone pathology ( path # ) .

62. CLINICAL FEATURES Pain. Deformity. Bruising. Crepitus. Abnormal mobility Swelling. Any neurovascular injury

63. CLINICAL FEATURES Skin integrity . Examine the shoulder and elbow joints and the forearm, hand, and clavicle for associated trauma. Check the function of the median, ulnar, and, particularly, the radial nerves. Assess for the presence of the radial pulse.

64. INVESTIGATIONS Radiographs CT scan MRI scan Nerve conduction studies Routine investigations

65. IM A GING AP and lateral views of the humerus, including the joints below and above the injury. Computed Tomographic (CT) scans of associated intra-articular injuries proximally or distally. MRI for pathological #

66. CLASSIFICATION CLOSED or OPEN . LOCATION- proximal, middle , distal . FRACTURE PATTERN- tranverse , spiral , oblique,comminuted segmental . SOFT TISSUE STATUS – Tscherene , -- Gustilo & Anderson .

67. AO CLASSIFICATION 1 – HUMERUS 2--- DIAPHYSIS A – SPIRAL – PROXIMAL ZONE MIDDLE ZONE DISTAL ZONE B- OBLIQUE C- TRANSVERSE

68. ASSOCIATED INJURIES Radial Nerve injury = Wrist Drop = Inability of extend wrist, fingers, thumb, Loss of sensation over dorsal web space of 1 st digit Neuropraxia at time of injury will often resolve spontaneously Nerve palsy after manipulation or splinting is due to nerve entrapment and must be immediately explored by orthopedic surgery Ulnar and Median nerve injury (less common) Brachial Artery Injury .

69. TREATMENT OPTIONS Non operative o p erative

70. NON OPERATIVE TREATMENT INDICATION S: Undisplaced closed simple fractures , Displaced closed fractures with less than 20 anterior angulation, 30 varus / valgu s angulation Spiral fractures Short oblique fractures

71. HUMERAL SHAFT FRACTU R ES Conservative Treatment >90% of humeral shaft fractures heal with nonsurgical management 20degrees of anterior angulation , 30 degrees of varus angulation & up to 3 cm of shortening are acceptable Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace .

72. NON OPERATIVE METHODS Splinting: Fractures are splinted with a hanging splint, which is from the axilla, under the elbow, postioned to the top of the shoulder . The U splint. The splinted extremity is supported by a sling. Immobilization by fracture bracing is continued for at least 2 months or until clinical and radiographic evidence of fracture healing is observed.

73. FCB - INTRODUCTION A closed method of treating fractures based on the belief that continuing function while a fracture is uniting , encourages osteogenesis, promotes the healing of tissues and prevents the development of joint stiffness, thus accelerating rehabilitation . Not merely a technique but constitute a positive attitude towards fracture healing.

74. CONTRAINDICATIONS Lack of co-operation by the pt. Bed-ridden & mentally incompetent pts. Deficient sensibility of the limb [D.M with P.N] When the brace cannot fitted closely and accurately. Fractures of both bones forearm when reduction is difficult. Intraarticular fractures.

75. TIME TO APPLY Not at the time of injury. Regular casts, time to correct any angular or rotational deformity. Compound #, application to be delayed . Assess the # , when pain and swelling subsided Minor movts at # site should be pain free , Any deformity should disappear once deforming forces are removed , Reasonable resistance to telescoping.

76. OPERATIVE MANAGEMENT INDICATIONS Fractures in which reduction is unable to be achieved or maintained. Fractures with nerve injuries after reduction maneuvers. Open fractures. Intra articular extension injury. Neurovascular injury. Impending pathologic fractures. Segmental fractures. Multiple extremity fractures.

77. METHODS OF SURGICAL MANAGEMENT Plating Nailing External fixation

78. PL A TING Plate osteosynthesis remains the criterion standard of fixation of humeral shaft fractures . H igh union rate, low complication rate, and a rapid return to function . Complications are infrequent and include radial nerve palsy, infection and refracture. limited contact compression (LCD) plate helps prevent longitudinal fracture or fissuring of the humerus because the screw holes in these plates are staggered.

79. ANTERIO LATERAL APPROACH SUPINE ON THE ARM TABLE WITH 60 ABDUCTION AT SHOULDER

80. ANTERO LATERAL APPROACH Distally, the plane lies between the medial fibers of the brachialis (musculocutaneous nerve) medially and the lateral fibers of the brachialis (radial nerve) laterally.

81. POSTERIOR APPROACH Position of the patient for the approach to the upper arm in either the (A) lateral or (B) prone position.

82. PLATING - POSTERIOR APPROACH

83. INTRAMEDULLARY NAILING Rush pins or Enders nails, while effective in many cases with simple fracture patterns, had significant drawbacks such as poor or nonexistent axial or rotational stability With the newer generation of nails came a number of locking mechanisms distally including interference fits from expandable bolts (Seidel nail) or ridged fins (Trueflex nail), or interlocking screws (Russell-Taylor nail, Synthes nail, Biomet nail ) .

84. INTRAMEDULLARY NAILING Problems such as insertion site morbidity, iatrogenic fracture comminution (especially in small diameter canals), and nonunion (and significant difficulty in its salvage) have been reported . T he use of locking nails is restricted to widely separate segmental fractures, pathologic fractures, fractures in patients with morbid obesity, and fractures with poor soft tissue over the fracture site (such as burns).

85. EXTERNAL FIXATION Is a suboptimal form of fixation with a significant complication rate and has traditionally been used as a temporizing method for fractures with contraindications to plate or nail fixation. These include extensively contaminated or frankly infected fractures , fractures with poor soft tissues (such as burns), or where rapid stabilization with minimal physiologic perturbation or operative time is required ( D amage-control orthopaedics)

86. EXTERNAL FIXATION External fixation is cumbersome for the humerus and the complication rate is high. This is especially true for the pin sites, where a thick envelope of muscle and soft tissue between the bone and the skin and constant motion of the elbow and shoulder accentuate the risk of delayed union and malunion, resulting in significant rates of pin tract irritation, infection, and pin breakage.

87. EXTERNAL FIXATION

88. EXTERNAL FIXATION