What is the treatment for a complete humerus fracture?

Treatment for Complete Humerus Fracture

The treatment for a complete humerus fracture requires surgical intervention with open reduction and internal fixation (ORIF) using locking plates for displaced fractures, while hemiarthroplasty or reverse shoulder arthroplasty may be indicated for severely displaced fractures in elderly patients with poor bone quality or pre-existing rotator cuff dysfunction. 1

Diagnostic Evaluation

• Initial evaluation should include radiographs to assess the fracture pattern, displacement, and comminution 2
• CT scan is the preferred imaging modality for complex humerus fractures as it better delineates fracture patterns and is superior to MRI for characterizing proximal humerus fractures 2
• Three-dimensional volume-rendered CT images help characterize fracture patterns and humeral neck angulation, which can affect functional outcomes 2

Treatment Algorithm

Surgical Management

• Open reduction and internal fixation (ORIF) with locking plates is recommended for:

  • Displaced fractures
  • Comminuted proximal humerus fractures 1, 3

• Minimally invasive plate osteosynthesis (MIPO) is appropriate for:

  • Simple or AO/OTA type A fractures
  • Cases where preserving periosteal blood supply is critical 3

• Intramedullary nailing (IMN) is an alternative option that has gained popularity with improved implant designs 3

• Arthroplasty options for severe fractures:

  • Hemiarthroplasty for severely displaced fractures in frail patients
  • Reverse shoulder arthroplasty for geriatric patients with pre-existing rotator cuff dysfunction 1

Vascular Complications Management

• For patients with vascular injury and absent wrist pulses after reduction, open exploration of the antecubital fossa is recommended 2, 1
• Management of vascular injuries should include:
  • Warming the extremity
  • Vascular surgery consultation
  • Exploration for brachial artery entrapment
  • In-hospital observation for at least 24 hours after vascularity is restored 1

Rehabilitation Protocol

• Early active motion is critical to prevent stiffness 1, 4
• Rehabilitation should begin immediately to avoid the harmful effects of immobilization 4
• Controlled stresses throughout the fracture site at an early stage optimize bone repair without increasing complications 4
• Focus should be on advice, exercise, and mobilization of limited joints to restore upper limb function 4

Complications to Monitor

• Mechanical failure of fixation
• Nerve injuries (particularly radial and ulnar nerves)
• Joint stiffness
• Heterotopic ossification
• Nonunion or malunion
• Infection
• Complications from surgical approaches 5, 6

Prevention of Nonunion

• Immediate surgical management is recommended for nonunion cases 7
• The best prevention of nonunion is correct management of the initial fracture 7
• For established nonunions, revision ORIF with supracondylar shortening, bone grafting, and contracture release may be necessary 6

Special Considerations

• Elderly patients with osteoporosis require special attention as they have poor neuromuscular control mechanisms and are predisposed to future falls 4
• Patients may continue to have shoulder problems for many years after the injury, requiring ongoing rehabilitation 4
• Cooperation between the surgeon and therapist is essential to optimize shoulder function and maintain functional independence 4