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Medical course data
Parent Humeral Fracture Fixation
Required
time
2 hours

Caption underneath

This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the rod-to-rod modular frame as part of external fixation procedures for open humeral shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.

Learning Objectives[edit | edit source]

By the end of this module, learners will:

  1. Know how to avoid injuring the two nerves that can be damaged when operating on the humeral shaft when the patient is in a supine position.
  2. Know how to apply the Gustilo Open Fracture Classification to open humeral shaft fractures
  3. Understand how the Gustilo Open Fracture Classification impacts the selection of antibiotic therapy for open humeral shaft fractures
  4. Know the principles of surgical care and management for open humeral shaft fractures
  5. Know the indications for modular external fixation for a patient with an open humeral shaft fracture
  6. Know the indications for referral of a patient with an open humeral shaft fracture to a tertiary center for specialist care
  7. Know the acceptable parameters for reduction of open humeral shaft fractures

Anatomy Review[edit | edit source]

Axillary Nerve[edit | edit source]

  • The axillary nerve runs dorsolaterally around the humeral neck (metaphysis), approximately 5-7 cm below the acromion.[1] Therefore, the far Schanz screw in the proximal fragment must be inserted at least 7 cm below the acromion to avoid damaging the axillary nerve.

Radial Nerve[edit | edit source]

  • In the middle third of the humeral shaft, the radial nerve is in close relationship with the dorsal diaphyseal cortex and can be damaged.[2] Therefore, the near Schanz screw of the proximal fragment in the middle third of the humeral shaft should be placed in the anterolateral region of the diaphysis to avoid damaging the radial nerve.
  • In the distal third of the humeral shaft, the radial nerve is in close relationship with the lateral diaphyseal cortex and must be identified through directly visualization or palpation prior to Schanz screw insertion when a lateral incision is made in a patient in the supine position.[3]

Additional Resources:[edit | edit source]

Gustilo Open Fracture Classification[edit | edit source]

Gustilo Open Fracture Classification[4][5]
Gustilo Type I: An open fracture with a wound less than 1 cm long and clean.
Gustilo Type II: An open fracture with a laceration more than 1 cm long without extensive soft tissue damage, flaps, or avulsions.
Gustilo Type IIIA: Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound.
Gustilo Type IIIB: Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination.
Gustilo Type IIIC: Open fracture associated with arterial injury requiring repair.

The Gustilo Open-Fracture Classification impacts the selection of antibiotic therapy for open humeral shaft fractures:

Antibiotic Therapy[edit | edit source]

All patients should be managed with intravenous antibiotics immediately at the time of presentation to the emergency department.[6][7][8] Antibiotics may be changed, added or extended depending on clinical findings. Doses will be adjusted based on patient weight when indicated.

Recommended Antibiotic Therapies for Open Fractures*
Injury Characteristics Systemic Antibiotic Regimen Penicillin Allergy
Gustilo Type I and II Cefazolin 2 g IV immediately and q8 hours for a total of 3 doses[6][7][8] Clindamycin 900 mg IV immediately and q8 hours for a total of 3 doses
Gustilo Type III
  • Ceftriaxone 2 g IV immediately for a total of 1 dose, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
  • Aztreonam 2 g IV immediately and q8 hours for a total of 3 doses, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
Farm or fecal

contamination

Add Penicillin G IV (e.g., 5 million-10 million units/24 hours)[6][7] Add Metronidazole IV
Freshwater or

saltwater

contamination

Add Levofloxacin IV or Ciprofloxacin IV[8] Add Levofloxacin IV or Ciprofloxacin IV[8]

These therapies may vary due to regional differences in antibiotic regimens for open fractures.

Principles of Management of Open Humeral Shaft Fractures[edit | edit source]

Indications for Modular External Fixation for an Open Humeral Shaft Fracture[edit | edit source]

After completing the entire module, learners should be able to perform modular external fixation of open humeral shaft fractures with the following features:

  • Gustilo Type II or Gustilo Type IIIA open humeral fracture; and
  • Non-comminuted, humeral shaft (extra-articular) fracture

Indications for Referral to a Tertiary Center for Specialist Care[edit | edit source]

  • Non-palpable radial pulse
  • Symptoms consistent with acute compartment syndrome
  • Gustilo Type IIIB or Gustilo Type IIIC open humeral fracture
  • Comminuted or segmental humeral fracture
  • Bilateral humerus fractures
  • Metaphyseal humeral fracture with intra-articular extension
  • Concomitant ipsilateral or contralateral forearm fracture
  • Severe traumatic brain injury (Glasgow Coma Scale <12)
  • Severe spinal cord injury (lower extremity paresis/paralysis)
  • Severe burns (involving >10% of the total body surface area or >5% of the total body surface area with full-thickness or circumferential injury)

Reduction Parameters for an Open Humeral Shaft Fracture[edit | edit source]

The acceptable reduction parameters for open humeral shaft fractures are:

  • > 50% bone apposition
  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm limb shortening (cannot be measured intraoperatively)[9][10][11][12][13][14][15]

Acknowledgements[edit | edit source]

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References[edit | edit source]

  1. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-proximal-third
  2. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#no-safe-zone-in-the-middle-third
  3. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-distal-third
  4. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID:773941.
  5. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma.1984 Aug;24(8):742-6. doi: 10.1097/00005373-198408000-00009. PMID:6471139.
  6. 6.0 6.1 6.2 Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020 Apr 15;28(8):309-315. doi: 10.5435/JAAOS-D-18-00193. PMID: 31851021.
  7. 7.0 7.1 7.2 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#principles-of-surgical-care-for-open-fractures
  8. 8.0 8.1 8.2 8.3 Zhu H, Li X, Zheng X. A Descriptive Study of Open Fractures Contaminated by Seawater: Infection, Pathogens, and Antibiotic Resistance. Biomed Res Int. 2017;2017:2796054. doi: 10.1155/2017/2796054. Epub 2017 Feb 20. PMID: 28303249; PMCID: PMC5337837.
  9. Greene, W.B., Heckman, J.D., & American Academy of Orthopaedic Surgeons. (1994). The clinical measurement of joint motion. Rosemont, Ill: American Academy of Orthopaedic Surgeons.
  10. Klenerman L. Fractures of the shaft of the humerus. J Bone Joint Surg Br. 1966 Feb;48(1):105-11. PMID: 5909054.
  11. Spiguel AR, Steffner RJ. Humeral shaft fractures. Curr Rev Musculoskelet Med. 2012 Sep;5(3):177-83. doi: 10.1007/s12178-012-9125-z. PMID: 22566083; PMCID: PMC3535078.
  12. https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures
  13. Casadei K, Kiel J. Anthropometric Measurement. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537315/
  14. https://www.wheelessonline.com/bones/humerus/humeral-shaft-fracture/
  15. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/nonoperative-treatment#general-considerations
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