Open Reduction and Internal Fixation of a Diaphyseal Humeral Fracture
- Posterior Skin Incision
- Dissection Lateral to Triceps Muscle
- Identify Proximal and Distal Fragments
- Debride Fracture
- Clamp Humerus Out to Length
- X-ray Confirmation
- Dissect Triceps from Distal Fragment
- Select Plate
4. Insert Lag Screws
- Drill Across Fracture
- Measure for Screw Length
- Insert Screw
- Repeat for 2nd Screw
5. Plate Fixation
- Position Plate
- X-ray Confirmation
- Contour Plate
- Provisional K-wire Fixation
- Drill, Measure, Insert Screws
- Final X-rays and Radial Nerve Review
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
I'm Mike Weaver. I'm one of the orthopedic trauma surgeons here at the Brigham and Women's Hospital. Today we have a 57 year old woman who sustained a fall, and she has a distal third humeral shaft fracture. Previously she had a failed shoulder replacement and so had this revision onto a reverse total shoulder prosthesis. It's hard to see on the X-ray, but there is a cement mantel that goes down and you can see the cement restrictor here. So kind of as expected you have the stiff construct and so you see a fracture below it. This make sings a little bit tricky. She has a radial nerve palsy she is at tolerating a splinting very well and she's a little bit larger body habitus, and so those combination of things are pushing us to fix it for pain control and function.
So the plan today is going to be to do a posterior approach. The approach I use for this is a little bit different. I don't split the tricep but it's more of a posterior lateral approach, so a posterior skin incision and then come around. What I'm looking for is the brachial cutaneous nerve and that's going to take me to the radial nerve, which is really the key to this case. You know a lot of people have anxiety operating on the humerus for the risk of radial nerve palsy and so I think you want to find it and protect it every single time. So this approach allows you to see the radial nerve very well. We're going to dissect out the whole thing in the posterior aspect of the arm to look for a direct entry, although the vast majority of the time in a situation like this is just a neuropraxia from a bruise. So will come around the radial side of the triceps, expose our fracture site. It's a relatively simple fracture pattern so I'm expecting that we should be able to achieve absolute stability using a couple lag screws and then neutralize with a long plate. Here traditionally in the humerus people use large fragment fixation; however, you can use small fragment fixation. The plate that we're going to use today as the Synthes product, although all of the other companies make these. It's a thicker small fragment plate, so even though using 3 5 screws you're getting a thicker plate which is going to give you a little bit more support for the humerus. That plate comes all the way down distally so we will get plenty of fixation here, and then proximally we're either going to get screws around the stem, which is pretty small so hopefully we can get some screws around it through the cement mantel. If that fails we do have the periprosthetic set available to us so we can put cerclage cables at the top. Cerclage in the humerus is a little bit tricky but if you're looking at the radial nerve that something you're worried about and so we should be okay. So should be alright.
I'll switch with you. Okay. So there you go, so you got midline incision maybe slightly radial and now we're just going to come over here and look for that little nerve. So this is all triceps. So what I want you to do is dissect up here with your mets and it'll be right up here. Dissect down here a little more. Then switch this cause I think this will be a better retractor up high.
So the skin incision is posterior but really the deep dissection is lateral. What we're going to do is protect, preserve, the entire triceps. I'll be right with you. No you don't to get in the muscle...it's more like that. What you want to do is get on this plane. See you want to elevate off the triceps. So you want to look like this. This is intermuscular septum. So that humerus. Feel right here. That’s bone there. This is the radial column of the humerus, all the way down here, so our plates going to sit all the way down here.
So you know that triceps entire face of the humerus but we're going to preserve everything else. You can feel if you feel with your finger up there. You can feel the fracture way up there. I need a new glove. Umm - right side please.
For today you can start there. That's what we're looking for alright, so we are not going through the triceps we are just going around it. So this is the triceps here when you start. That's so we're just going around and then that just takes you right down to the bone. Alright so we found that and we are at the fracture, but we can't do anything more without being proximal, but I think we found the nerve so I think we're okay to let our tourniquet down.
So you know ideally you know someone that's thinner you can get the tourniquet up here do the whole thing without a tourniquet. With her I figured I would have to let it down to get the very proximal exposure cause you know cause it’s a pretty high fracture to be doing from the back. This makes me much happier you know we're going to be looking right at the nerve. The plate will be under it. I don't care about getting every last bit of skin I just want it for the bulk of the bacteria.
Here we go. The fracture’s here. Where you need to be up probably about to there. Micah, I will always come up this way to give you stuff. Yup good. Tourniquet is good for the surgeon bad for the patient.
So here this is just split that with your fingers. See that loose areolar tissue. This is what I did down below. See that goes right back. Then we are up on here on humerus again. Way up there. Way way way… The hard part is that we have to do both sides of that. That’ll do it. Actually I like those better don’t I - the wider ones.
So everytime I put one of these on I want to be really careful because of that nerve. So we're looking right up in there that's not on the nerve, it’s holding it back. So that's the proximal piece. You can see a split of it that I saw on the … That we're going to have to deal with. That I saw on this Scout film, you know CRM image but not on the plane film so that makes it a little bit more tricky but like I said I think it will be ok. There’s that. Thank you very much. That’s good.
Alright so, there’s proximal fragment, distal fragment. There’s the fracture. I’m right over the fracture right by that spike of bone. Let me a get a snitz and pull that little clot out. Oh beautiful. Switch sucker tips and I want you to clean out that section. I find the Frazier tip to be the best best cleaning device cause it sucks it and it's like it's like a curette at the same time. This is the stuff you have to get out right there. There’s a little bit of clot right here. Angle it like that. I like that right there.
Ok now let’s work on this piece there. So you see here this is the clot we have to get rid of, right. So whenever I'm cleaning a clot in a long bone I try to work through the fracture. If you look at the bone it’s still covered in pink periosteum. We haven't devitalized it.
Oh, oh look at that. Makes me feel better. Let’s work above the nerve there. So all the way up to the apex, I want to see the apex up there. Do you have a cobb elevator? Small please. So now I just want make a path for our plate you know we're not going to deal with the top of our plate for little while but we know we have to be up there to put up but a cable on it. That’s going to be the hardest part of the case. Way up there. Oh boy. Ok there we go. Alright let’s reduce it. What do you want? Small fracture reducing forceps please.
Let’s see where we are at. Why don’t you just give it a little pull and key that spike. Be ultra-mindful of the other tine. Good that’s it. That’s all you need. So now what you've done is establish length.
Now let’s look up here. Can we have that weitlaner back. The bigger of the two. Can we have a freer?
So here this is the spike is right over here. No its right there. Release here. I think that’s a better vector there. I just want to see the apex. The apex is keyed in nicely there. So we have anatomic reduction of that apex. Good. Alright suck in there. Do you think a vector a little more distal? Can I see the pointed. I think it’s more A to P. Let’s hold that there. I think I am not going to be able to do it from that side of the nerve, I am going to have to do it under the nerve. I think it’s more of this kind of vector here.
The dot? Xray there. We look like we have an anatomic reduction there. Xray there. That looks good. Alright good thank you. Normally you want to check in two planes, but to check a lateral here you have to twist the arm and we don’t have that great of clamps in and we don’t need to cause we are looking at it.
Weitlaner. Oh boy. Way to think of this as if you're doing an olecranon osteotomy on this side. You know you can follow that same path down all the way to the ulna if you want to. Do you have another smaller of the weitlaner? And the freer? So here we just need to release a little bit of the muscle off the bone.
An just to show you that’s the olecranon fossa right there. See that. So we probably have to go a touch more distal, cause this plate that we are using today goes pretty distal. Kinda aim back towards here. Good.
There’s the main part of the radial nerve down there. That’s the main radial nerve right there this is that little nerve. That's the main one right there. Oh we lost that. This clamp is not holding anything. I'm going to try one clamp in the middle this time. That works a little less than ideal. Hold that in with your sucker. Can I see the BennetT? Can you hold this back for me? That’s better, there we go. I think we are good.
So we can see it at the top you can see the bottom so I think we ready for a landing. There's a nerve and then hiding underneath it is the real nerve. Cause that's the radial nerve right there. That’s good there. I think we're going to have one here that's going to be kinda with your hand flat like this and then this one's going to be more A to P.
So you know every different set has different things but these are the two radial column plates that are in the Synthes set. So you can see that the top plate here is very thin. This is pretty malleable you can bend it in your fingers. This is really stout. So even though this takes small fragments screws the plaTE itself is a lot more rigid so can support a little bit more load. So this is our… we're going to be plate benders as well but they can be the ones in there.
Why don't we drill for the screw. So where do you want your first lag screw? Where’s the bovie? I am just going to move this up a micron. Freer. So I just wanted to move that tine up a tiny that because you know the tip of the fracture is right here. So I think you have to be pretty angled right up against that tine. I do not like that stress. I would be a little bit closer to that tine. Not so close to head won't go down but a tiny bit closer. There you go just like that.
Once your starting I'm going to drop it in a little bit like… there you go. Good that’s it. You can come right out. It’s not going anywhere. I want you to stop the drill when it goes through. There have been cases of wrapping up the nerve in the drill bit on the far side. The nerve shouldn't be there but… Countersink before you depth gauge because it changes the length a little bit. Thank you. So we just use a slightly smaller countersink for a 2 - 7 screw. Little bit more. Remember your angle looks like that.
It's important hold that angle cause if you think about it the bone that you want to remove is that bone back there. So that when the screw head engages it's going to be the same shape as a countersink. There we go. Now I am happy. Depth gauge. Going to be short. 24. 24 please.
Will you be doing another? Just twist it. I want to be super gentle here. Yes one more just like that. A little bit more like that. It’s more just tapping into the far cortex there. Give that a little bit more. That’s actually down now. Good. Hold on. You’ve got the nerve. Can I get the freer? So that rotation, you get that under the drill and you are just going to wrap it right up. That stuff right there, it needs to be completely free. Good and your angle is going to be like that and then down. Right by the radial nerve. Hope I don’t have to take this one out. There you go. Good. Good. Doesn’t need as much on this cause it's not as oblique of that in the circum-fracture that's all you need. 22.
So now we have it reduced. The nerve is out of the way. Now it’s time to put a plate in. That clamp I think can stay there. This clamp can come off, but to be honest it would be nice to leave it because it’s kinda just protecting us. Why don’t we see if we can slide it up.
Plate. Here we go. I think this is the one that’s got to go. So you see it doesn’t fit perfect, that’s because no one is built like the model. Actually it fits pretty good. Oh no it doesn’t. See that rock there, so we have to give it a bit of a bend in the middle portion right where the radial nerve is. But I like that distally.
Come in for a shot please. What I want to do is see that I'm happy distally and if that's right where we want it like I think it is then we'll bend it up at the top. Shot. We're definitely high enough with the plate. It’s under all the clamps. Distally we aren’t going to see it. Xray there. Xray there. Xray there. Ok, good. You can see we are distal enough with the plate. So now let’s mark where we are going to bend it. We are going to bend right about, see the bend right at the radial nerve, that’s the radial nerve fold right there. So keep your finger there, keep your finger there. So right there.
Ok. Plate benders. Give it a contour there. You want to bend it down. The other way. Yeah that sounds good. Suck please. Right here. I’d say we are halfway there. No one’s humerus is actually straight it does have a little bit of bow in the AP plane. So there’s a narrow and a big and then the opposite so that one’s big then narrow. Towards you. Yeah like that. Looks like it bent more. It’s something you feel. That’s pretty good. Maybe a tiny tiny tiny bit more. Nah its flexing on to it, so it’s good. Locking tower please. Put a locking tower up there by my index finger. We are going to do 1-6 K wires now. Yes. So this is a technique I use a lot. Using locking tower, inserting K wires to hold the plate exactly where I want. Then when I am happy I fill it up. It wants to live there. Alright K wire. Now these distal ones are uni-cortical locking ending right at the capitulum. Usually it’s only the distal one or two that are like that. Now can I see a freer? Here we are going to feel if we are really centered on the bone? It feels pretty damn good.
Why don’t we try it and see what it looks like. One cortex only and be gentle. That’s it. Just little bites. Come on in. Ok, let’s get rid of some of this stuff so we can interpret our X-Rays a little better. Shot there. Ok, you can see proximally we are a little ulnar and distally we are a little radial. So all we have to do is center up the plate some. Back out for a second. It feels like that too, so we just need to move it towards you some. Watch out. Come off please.
Come on in. So now that sits a little better now too. Shot there. That’s a lot better. So we are centered at the top. I like that. Distally that’s the hardest part. X-ray. X-ray. We have to be even more, ever so slightly radial. I think maybe if we do that it will be okay. X-ray. This is really annoying. X-ray. Yeah if we could be just 1 or 2 mm more ulnar. Watch out. Come out. I am going to change it to there, so it gets a new hole. I am going to move it more my way. Okay. Good.
Come in. Okay, I think that’s going to be good. If we like that… shot… So we are centered all the way up which is nice and then just to see that last bit… X-ray. That’s good. And when you actually put the plate on the bone. X-ray. X-ray. It’s sitting right where we want it. Nice. So that’s good. If anything it looks like we could be more, I think we need to move it more over. I think we are off the bone here a little bit. We need to move it over. I think this clamp was blocking us.
Sorry. Wire driver. Let’s take that off. Normally I hate having that clamp off. I like having a clamp over my fracture. There you go. Real gentle please. You are pushing really hard, be gentle please. Okay, so I will just go right here. Now remember you’re not… just in the middle right there. And just remember you are not centered on the bone you are on the radial side of it. So you have to aim a little. Yeah good. Good. Now I am thinking to myself that was a nice boomp-boomp, so you are pretty centered on the bone so your angle must have been pretty good.
24 please. So what I want is two good screws distally, two screws proximally and we can check an AP and a lateral and then we can fill it up. This one I wouldn’t get all the way super snug, just down and now let’s work up here. The plate is sitting nice on the bone so you did a nice job contouring it. Suck in there. Okay. Right at that hole, parallel to this guide. Here you are centered. You are not going to get a cortex here I don’t think. Cement or plastic. Keep going. Classic, now that’s going to be the far cortex. Good. Some of the arthroplasty surgeons really frown on it, but I think drilling gives you the best bite you will ever get. 24 maybe. It’s off the bone a touch. Suck in there. Suck over here.
Good. Why don’t we do another none locker. Looking at your x-ray this one should be fine. This one’s fine too. Why don’t you just put this one in because it’s a better bite. I got the screw driver. Can you give us the drill? Right there. Right at the top of the hole please. Yup like that. Remember your angle. Good. 24 please. One thing you want to make sure of is that you aren’t in the olecranon fossa, which we are not because we are looking at it. But you want to be able to extend your arm. Alright.
What screws did we put in so far? Just 24. I actually want to take another picture before we put in more screws, because I don’t know where we are with respect to stem. And I think we want to do some locking screws so I want to figure out if there’s room to get a locking screw in that area. That should be a little bit better. That’s better than this one was.
Shot there. So that is right at the tip. It looks like. X-ray there. The tip of implant is in locking hole right adjacent to where we are. So I think what we can do is… X-ray there… C-ray there… That’s not so hot. X-ray there. X-ray. I think we can miss the implant with some screws. I think it will be close, but I think we can do it. X-ray again. That would be this way so it’s going to be missing this side. X-ray. X-ray. X-ray there. Well you can’t miss it with locking screws. X-ray there. Well we did a good job of centering it. It’s like too centered. Back out for a second.
I think we are going to have to put one here. 2-5 drill. Do you have a weitlaner first and then a baby bennett? There just like that, we don’t need it very far. Depth gauge. No those are large frag. I don’t believe in those stabilizing the stressor of the fracture anyway. They are good for periprosthetic femur fractures but not so good for these. Hold on. Let me come out with this. Can I get another bennett? Okay. Top part of the hole, guide all the way down. Guide all the way down, it’s not down yet. Then try like that. Try to be as AP as you can. That will work. Good. Alright. Make sure you got your angle. It’s a little bit more towards me.
We may get away without cables, Paul. Suck in there for me. Hold the for a sec. Can you hold those apart? So this is why it’s so important to me to have drill guide down, because if it’s not down the head of the screw engages the side of the plate before it gets down. You have to get past that to really be down. See now it’s sitting in the hole. Wire driver. 2-5 drill. That will work. That will work.
That one we didn’t need to do that for, but since we have to anyway, I figure. There we go. All the way down with the drill guide. This is going to be pretty close to an AP. Cement. That’s fine. That’s cement. You can feel a difference as you go through there. Thank you. Alright that’s tight. Do you want to call that good proximally? Can I see that screwdriver back?
You know what, I want to do one more. The reason is there was that non displaced crack here. So those two screws are somewhat compromised, so we only really have two screws above that. So why don’t we just do another here. A couple of non-locking screws is not going to break the bank.
That time you are skidding across the implant. Do you hear that? Titanium is even better biting. Here you go. We are going to switch to locking here. It gets harder then easier then harder again. A lot of people leave those screws loose and you can’t do that.
Alright let’s pick our pattern convention. I always like the last hole filled. This is going to be a kinda funny angle. This is going to be that. Like that and then probably that one. So then we will go 1 2 3 and that way we have five on either side. This will be bi-cortical. Do you have a wire driver? You can drill that one. This will be uni-cortical. That’s fine. Do you have a wire driver? We will just drill them all and then just be done drilling.
Can we get a gram of vanco powder? I don’t think we need a drain cause it’s pretty dry. This is the scary thing to me, that’s not even the nerve. That’s the brachial cutaneous nerve and then you see it’s hiding there.
This is the time where I would say we do not need to use a cable. We are going to take our pictures and unless something looks really screwy we are done. One of the things I always document in the op report, is the location of the nerve. I try not to put a screw head under it. Here I will document it as under the, between the most proximal lag screw and most distal plate screw. Really it’s under that, when the muscle comes back it’s right over that screw. You want, if you are the one who has to take it out, you want to know where it is. Taking plates out is one of the hardest things. The distal part here is prominent. I would consider even cutting the plate instead of risking the nerve. It would be cool to get the whole plate out, but if it was bothering her I would just cut the plate off cause you don’t have to worry about it.
Can I see that screwdriver? Excellent. This is a really satisfying surgery because these people are miserable and when they wake up they are still miserable but a few days later they are not miserable. Their arm works.
Come on it. Shot. Shot. X-ray there. There’s our plate. I like where it sits distally. Can you put that straight up and down for us? Thank you. X-ray there. Can you now flip it upside down? Shot there. X-ray there. X-ray there. X-ray there. X-ray there. So you can see we are square up there, so that’s really good. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray. X-ray. That’s the cement restrictor. X-ray. X-ray there. Alright now go over the top. Actually try this. X-ray there. X-ray. Here you can see there is a slight bow to the humerus, but we have an anatomic reduction so that looks really good. Alright thank you. Save that.
So this is the brachial cutaneous nerve, so we found that at the intermuscular septum and traced it back to the radial nerve. So the radial nerve is right here, which is kind of hard to see but I don’t want to dissect it out because I don’t want to devitalize it. Underneath this you can see there’s the radial nerve. It’s up here and courses down and then down all the way. We have a nice view of it from down distally from the humerus all the way, through the spiral groove, over the plate and then back now up here proximally. Alright. Nice work.
We will take the stuff. Magic powder please. This nice thing is that this is a true internervous… we didn’t disrupt any muscle. The people love it, well I shouldn’t say love it. But people recover pretty quickly from this. They tolerate it.
You know I would much rather have someone larger this way than larger this way. A 20 year old dude who spent too much time at Gold's Gym is harder than this. A body mass index of -3 or whatever it is.
The surgical treatment of humerus fractures is a little bit contentious. Up until the mid-to-late 80s the vast majority of these were treated nonoperatively and still a lot of people use functional bracing as their primary mode of treating humerus fractures. And in fact most of the patients that I see I try to recommend nonoperative management before deciding to fix it. In this particular case the patient was obese and she had a functional problem, she with her lower extremity. She had Ataxia from Gentamicin toxicity years ago and so she really needs her her upper extremities so given the the pain control issues and she had a difficulty with bracing she elected to have this fixed. The other kind of thing that have evolved overtime is the thinking of the radial nerve. So she had a radial nerve palsy there was a time when people used radial nerve palsy as an indication for surgery; however, now I think that's pretty much irrelevant except in the case of an open fracture. So the big indication for me is an open fracture, so all open fractures I'm going to treat operatively. I think if you're there and you're there and debriding it then you should stabilize it at the same time. Pathologic fractures again are a time when fixing humorous makes more sense. Then the other big indication for me is polytrauma. So a lot of times people have other extremity injuries they need to use their arm and especially the young person with good bone quality you're going to let them be full weight-bearing after fixing your humerus and so it allows them to get up and walk. So so poly trauma open fractures and pathologic fractures are my three main indications.
So similar to other extremity things really you know we're looking for function. The big issue is going to be radial nerve. So she had a radial nerve palsy to begin with and so the recovery of the radial nerve is really going to affect how she does. Otherwise we’re looking for you know motion of the shoulder the elbow joint which you know I think fixing it gives you an advantage because you're going to start moving it early. But then again you have to deal with the the problems of surgery, scar tissue and things like that.
The technique we used today is pretty standard. It’s absolute stability, so lag screw fixation and a neutralization plate. The particular plate we used today I really like and like we talked about during the surgery. There a lot of different companies that make the same style of plate and it's essentially a small fragment plate using small fragment screws but it's much thicker. So it has the thickness of a large fragment plate. So in the humerus you want a little bit extra support and a standard small fragment plate probably not strong enough where as a plate like this I think gives you that extra support.
Treating humeral shaft fracture surgically is extremely rewarding to patients if you don't get a radial nerve palsy. So I think that's why we don't do it more often is this big fear of the radial nerve. You know patients that have humeral shaft fracture is acutely are miserable it's very hard to deal with the brace it's very painful it's hard to get around and surgery fix is that, so they feel immediately better. So it's really rewarding on that side, but you do have to accept this risk of a radial nerve palsy and although most of them get better some of them don't and so that would be the big worry.
So I think with this technique and in when you're treating periarticular fractures in general you know there you can get into trouble if you were like too much on your hardware. So you know all the implant companies have done a fantastic job of designing periarticular plates that fit the average person, but no one's average and so like you saw in this case no we're able to get a really nice reduction and use the lag screws to fix it. If we put the plate on without further contouring it it would have just ripped that reduction apart right because because the humerus wasn't perfectly straight there was a little bit of a bow to it. So I think just like in any other periarticular situation if you take your time and really make sure things fit, sometimes it takes a little work to contour the plates, it ends up working a little bit better.
As far as plating humeral fractures I think really… you know there been a lot of advances with variable angle plates and screws so I think the implant technology is pretty good. I do think there's some work that can be done though for periprosthetic fractures. This fracture was a little bit unique in that there was a stem above it and you know really we have 3 options. One is putting screws through the cement mantle and in this case it worked out pretty well but sometimes you can't do that. If you can't do that you're left with short locking screws or cerclage cables both of which are kind of cumbersome to use. The short locking screws are easy to put in but they don't really work very well they're pretty weak in the cerclage cables particular round the humerus are very challenging and you know fraught with risk. So I think, you know, fixation around periprosthetic fractures in both the humerus and also the lower extremity are something we need to work on.
Postoperatively I just use a sling. So the patient wakes up in an Ace Wrap. They are in a sling, so they come out of it right away for motion. I typically limit geriatric patient to 5 or 10 pounds and the younger patients have no restrictions and that's just simply a matter of bone quality and I'm worried a little bit about the fixation. As far as the radial nerve is concerned I put people in a cock-up wrist splint and then they work with occupational therapy to maintain their motion and we expected it should get better. If there's no improvement at 3 months we will get an EMG, but there's no really no indication to do it before that. We saw the radial nerve we know it’s intact, it’s just matter of it waking up.
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