This sounds like the typical fracture seen following arm wrestling accidents. I would prefer ORIF and plating because of the following reasons: these fractures usually are displaced, the radial nerve is in danger and may already be affected at the first consultation, and this happens to young males wanting functional treatment. Actually, there are special plates on the market (as LCP Extra-articular Distal Humerus

Plate), because often the distance to the fossa olecrani is very short. You may check this link: http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/surgtech/ao/manuals/extra%20articular%20distal%20humerus.pdf.

My option is posterior approach, absolute stability with 1 or 2 lag screws and associated with a neutralization plate

Dear Hagen and Nelson,

Thank You.

I agree Plating is the Best option. But, can we choose a Conservative Hanging arm plaster application for a displaced spiral fracture of Humerus with intact distal Neurovascular status??

Dear Ashok

Certainly you can but the results are not good due the great possibility to increase the displacement and diastase in the fracture region. Actually the hanging arm plaster has limited indications in the treatment of humerus fracture.

Dear Colleagues

Sure ORIF is the best option . But in Cases of non displaced fractures with intact neurovascular structures I advise the application of only a U shaped splint for 4 to 6 weeks . This simple conservative treatment gives very good results

Dear Ashok,

I would prefer ORIF and plating too. In my opinion it is the best option for closed spiral displaced fracture of the humerus.

I think our colleagues would agree that there are not many undisplaced fractures of the humeral shaft or distal third. I would certainly treat this fracture with ORIF, because I do not believe conservative treatment would give a favorable result in a displaced fracture of this type and patern, even with intact neurovascular status. In fact, the neurovascular bandle is indeed at risk with the conservative treatment.

ORIF is my preferred option and the results have been good. Varus angluation is always an issue with conservative treatment.

Dear Ashok,

I agree with Hagen Schmal for an ORIF solution with a LCP plating, but if you can not perform an ORIF, or there are some hazard factors (risk of infection...) a conservative treatment is a choice, as it was usual some decades ago. This way has to be persecuted only if the fragments are not heavy dislocated and the radial nerve is intact. You can apply a skeletal traction with a k wire in the olecranon and maintain a zenit traction fro 10-15 days verifying the reduction with x rays. The patient has to be protected against venous thrombosis and gastric bleeding. This treatment was often used 30-40 years ago, the fractures healed but there was always a post-thraumatic stiffness.

I would rather see the actual x rays prior to posting medical advice. Having that in mind, conservative treatment for that kind of fractures is well tolerated and beneficial with good outcome. Tha fact that we have the technology shouldn't push ua towards surgeries . I am not convinced that long term follow up will encourage ORIF

I absolutely agree with David Lebel. Even (sarmiento-)bracing combined with an arm-sling might be an option.

Surgery could have nerval plexus brachialis (n medianus) interuption as risk, cave. Conservative treatment I would try although I see very rare non operated spiral fractures. Frozen shoulder at risk both operative and conservative treatment. Mobilisation GH should be priority.

Nail!

ORIF I think is the best option. Orthopedic treatment could be a chance if no displacement were found but you would have to control evolution weekly

Orif

Dear Ashok

I generally use closed reduction and internal fixation with a retrograde nailing (MV nail). in my hands it's very simple (I come from the hospital in which this device was developed) and it shows a low risk of complications (that commonly occurs during removal). recovery is generally fast and results are good or excellent in all the series reported in literature. unfortunately this nail will be no more produced, so I think that ORIF is the best solution if you are a very skilled surgeon (beware the radial nerve if you use a lateral approach) otherwise conservative treatment should be taken in account as luca said before.

Good Luck

Giovanni

The question cannot be answered properly without the radiographs. If nondisplaced, a Sarmiento cast-brace would work fine. If displaced in the typical Holstein-Lewis pattern, the radial nerve is at risk with both open and closed reduction. Either non-operative or operative treatment is acceptable. Many would opt for a retrograde nail in this case.

Thank You everyone for you precious comments.

This discussion group confirms that; 'if you have 10 orthopaedic surgeons in the room there will be 11 solutions proposed'. The best operation (if indeed you adopt that path) is the one that you do best. I tend to consider the patient, surgoen and healthcare resource factors before proposing a decision and agree that the neurovascular and skin condition are vital considerations. Personally I would generally use two perpendicular locking plates thorugh a posterior approach for the strongest construct but need a compliant patient - or the second operation will be more difficult!. I agree that x-rays need to be seen to aid the discussion but am not convinced this is an appropriate forum for such patient specific discussion. Medicaolegally we are all in different jurisdictions so we must accept that this is non-specific advice and comment, yet the eventual management plan should be patient specific. Good luck.

All answers are correct and reflect different points of view every surgeon and department. First I must see the X-ray. What is Your and Your department preference/experience? Usually the result of therapy or operation is strongly related to surgeons personal expericnce.

Treatment of choice for a closed diaphyseal humeral fracture is conservative... cast for 3-4 wks, and after that a functional brace for another 6 wks,

Dear Ireneusz, we opted ORIF with LCDCP. Thank you.

ORIF is a good option. You are able to define and protect the radial nerve. You ar able to reduce the fracture anatomical and fix this situation via one or two compression screws. Afterwards forces have to be neutralized by a stable plate (4.5/5.5 LCP). The profit in relation to conservative treatment is early functional postoperative aftercare, what is important for all kind of athletes.

Dear Philipp,

I totally agree with you.

Yes, ORIF with LCDCP and Retrograde Nail could be a good option.

Early mobilization is indeed a great advantage of ORIF over Conservative treatment.

I think Anatomical reduction is not the "Priority" when treating a diaphyseal fracture. If it would have been an intra-articular fracture then without a doubt it was "Necessary".

But, conservative management do have advantages over ORIF. Not disturbing the "Biology" is one of the most important factor in fracture healing as well, and other the "Cost" which cannot be neglected in many poor patients.

So, I was curious to know, why wouldn't we opt a conservative treatment if we were able to achieve fracture healing with it, unless 'necessary'.

Thank you.

A spiral fracture of humerus is supposed to have a good surface area of contact for healing, is likely to be a low energy injury and is relatively more stable than a transverse fracture.

Humerus does not need an anatomical reduction because the acceptability of degree of malunion is relatively higher.

So according to me, the conservative treatment with sarmiento brace should be the treatment of choice unless the X ray shows a significant gap at the fracture site signifying soft tissue interposition.

I generally use closed reduction and internal fixation with a anterograde nailing

According to a recent Meta-analysis of a Plate fixation Vs IM nailing for the shaft of humerus fractures, published in JOA 2013,

The data showed that surgical treatment with plates fixation results in significantly lower incidence of total complications, delayed-union, and re-operation for metalwork removal, lower incidence of iatrogenic fractures, better shoulder ROM, and better patient-reported early-functional outcome, which suggests plating is superior to nailing for humeral shaft fractures.

Even though, Nonoperative management continues to be the mainstay of treatment of most of these injuries and good outcomes can be expected for >90% of patients.

Operative management is recommended when non-operative management has failed to maintain the humerus in an adequately reduced position or when increasing fracture stability and comfort are not observed with time.

Above all, my apology for not uploading the X-ray which is the most important thing before deciding the management option. And Yes, Surgeons preference is equally important.

Thank You everyone for Your opinions.

Any other suggestions are welcomed.

Regarding Antegrade Vs Retrograde Nailing in the Diaphyseal Humerus Fractures,

Antegrade and Retrograde nailing have similar treatment results, including healing rate and eventual functional recovery for middle humeral fractures.

It is recommended that Retrograde nailing be used in patients with a wide medullary canal or preexisting shoulder problems and Antegrade nailing be used in patients with young age or a small medullary canal.

In critically ill patients, Antegrade nailing is preferred because of shorter operation time.

Thank You.

All fracture treatment alterbativest should be considedred with other patient related conditions. Fracture location, nerve injury risk, maintaiing of reduction etc.

The algortithym predict cast treatment in most of cases, however I usually prefer plate osteosynthesis through posterior approach.

Thank you

Humerus fractures can be notorious for non-union if not managed properly. I generally favour Conservative management for closed spiral fractures. The larger surface area supports faster union rates and 6 weeks of immobilization is really not harmful in the long run. Conservative management also means that the fracture haematoma is left undisturbed thus favoring biologic healing.

Another option for management where available is MIPO. This allows early joint mobilization.

If the fracture is displaced you have to reduced it in a surgical way (also for the humeral fracture), because to treat a displaced fracture with a conservative treatment it isn't so simple and confortable for the patient. I prefer an anterograd nail but also a plate is a good option.

Closed spiral fractures unite easily. Because of this non operative treatment may be the treatment of choice. The only problem is the parient's acceptance of any deformity (Shortening or Angulation). If patient is informed and educated on the subject usually there is no problem. Operations may be in cases of neurological deficits or if there the risk of soft tissue interposition. The type of fixation depends on the length of the fracture but plates usually are a better option, as the reason for the operation is the alleged interposition.

Treatment for this fracture depends mainly on it's involvement of the distal humerus. The gold standard treatment for diaphyseal humerus fractures is certainly non-operative with a functional brace. However, if the fracture is so distal that non-operative management would involve prolonged immobilization of the elbow than stiffness may result. In this circumstance, ORIF would be more appropriate and would permit early elbow motion.

Agree partially with this statement. Long spiral fractures may have a small degree of instability following fixation as the plate has to be long. Long plate hasto be a result of long incision. High risk of potential infection. Instability and potential infection may need augmentation with external stabilising aids. Also involvement of the lower part may result to elbow exposure at the posterior part. This may result in stiffness anyway. It is known that triceps is a "positional" muscle (helps the forearm to extent) and biceps a "funtional" muscle (brings food to our mouth) [basic rules of species survival]. Any approach going through the triceps is weakening it and this may result to lack of full extention at the elbow joint. In other words any treatment may result to stiffness. So the ideal treatment for such fractures is "treat the individual fracture according to the shape and extend of it". There is no good or bad treatment, but just treatment.

Dear colleagues, I really appreciate your opinions. Thank you all.

Dear Ashok

In veterinary Medicine with the same injury model as you described (spiral closed fractures) the method with least complication is plating technique based on my experience. However, if the fracture line was long, the I suggest to combine the plating technique with cerclage wires. This method provides good stability all over the fracture line. However selection of the method of choice is depended to several factors including, facilitations, equipments, cost and surgeon preference and expertise. Therefore I suggest that management of this model of fracture is a state of art.

In addition, spiral fractures is a kind of unstable fractures and should not be managed by casting method. We can only manage the stable fractures such a simple transverse fractures with casting method. For oblique and spiral fractures internal fixation is preferred over the external fixation (e.g. casting).

As the fracture is located at the junction of the middle and lower third of the humerus ORIF with plating is not the best option because of high risk of n. radialis damage. Close reduction, application of external fixator using Image intensifier is good for displaced fracture. For nondisplased - just cast.

My choice of treatment will be operative. It is technical very demanding and labour intensive to treat a humerus fracture conservatively. There is a shearing force acting across the fracrure line: this will presdipose the fracture to displacement. Unless the splint is adjusted regularly you will end up with a very displaced fracture. If the fracture unites, the distal fracture will unite in internal rotation. This will limit external rotation of the upper limb: the shoulder may not compensate enough for this mal-union. This deficit may be important in this sportsman.

Dear Nkosana,

Thank You.

Radial nerve is vulnerable and at risk in this type of fracture. ORIF with LCP using a posterior approach allowing radial nerve exposure and early elbow and shoulder motion should be the treatment of choice. The main force applied on humerus is rotation. Plate and screws will provide resistance against rotation and promote fracture healing.

These fractures heal quite well conservatively with a brace. If they have a butterfly fragment , then they usually will need ORIF WITH DCP/LCDCP through a posterior approach

In my experience, these patients are generally young and active and therefore I treat them with open reduction and plating. I use the anterolateral approach rather than the posterior (which I use for mid-shaft fixations).

The humerus spiral fractures particularly located at the mid & lower third of the diaphysis of humerus & during ORIF needs long exposure and risk of radial nerve injury is high. These fractures can be treated by closed method stabilization under image intensifier by ILIZAROV External fixation system as a minimal invasive procedure. Ilizarov method is stronger procedure as compared to other external fixation systems. Axial & torsional forces and compression can be controlled / achieved by this technique through the bead wires.

Open reduction internal fixation with interfragmentary screws and neutralising plate (DCP, LCDCP or locking plates) has worked well for both my cases ( I have treated only two such fractures following arm wrestling). These injuries are quite commonly closed displaced, unstable, long spiral fractures involving the mid and lower third humerus of muscular men, who are usually actively involved in sports. Posterior approach, radial nerve to be exposed and protected throughout the procedure especially while reducing the fracture.( sharp apex of fracture fragments) Maintenance of reduction by reduction forceps at proximal and distal ends+/- Kwires and steady hands of assistant. Interfragmentary screws (three or four) followed by plating

I d try first closed reduction and cast second choice for me whould have been illizarov external fixation

It really depends on a number of factors, patient specific being paramount. With a long spiral I would initially treat conservatively in a hanging collar and cuff/ functional humeral brace if alignment was acceptable and the patient was compliant. If neither of these were adequate, then external fixation utilising a circular fixator would be my method of choice.

Intramedullary nailing really isn't appropriate; antegrade nailing has too much cuff dysfunction in my experience, and it is unlikely you would get sufficient hold with a retrograde nail in this context. ORIF significantly increases the risks of infection and radial nerve injury and the rotational forces through this fracture would really risk atrophic nonunion. I not infrequently have to reconstruct humeral fracture nonunions with prior fixation in situ, despite good apparent initial osteosynthesis.

I agree entirely with Ravi Pandit. This is a fracture in an active wrestler who is interested in a rapid comeback to the ring. Operative treatment and plating is the treatment of choice. To avoid damage to the radial nerve an anterolateral approach through brachialis muscle is appropriate.

Dear Panayot,

I agree, Operative treatment and plating is a better choice.

But, can we suggest a wrestler to participate in Arm wrestling again ???

Thank You.

I think, it is possible. Of course, this hypothesis depends upon many factors: perfect reduction, stable fixation, good fracture healing, appropriate and consistent rehabilitation and physiotherapy, etc. Let me give you an example. Yvette Lalova, a Bulgarian sprinter, sustained a femoral fracture while training. After being operated she stopped training for 8 months. The fracture cured perfectly well. She was so ambitious in her recovery process and this year she became European Champion in 100 m. distance and was the fastest white woman at the last World Championship in athletics.

I get good results with conservative treatment with a functional brace

Of course, good results can be obtained by conservative treatment. But we discuss a specific case of an active wrestler who would like to practice sports in the future on a high-results level. A precise reduction, stable fixation and early onset of rehabilitation are recommendable to avoid muscle atrophy and to achieve a physical stato quo ante.

Most closed humeral diaphyseal fractures can be successfully treated with functional braces. Th best ones are oblique, comminuted ones.that show iniial overriding of the fragments and some comminution. Immediate weight bearing is contraindicated. A few days of stabilization in a cast is desirable befoire the bace is aplied. Progression of activity should be dictated by the speeed of recovery of painful symptoms and susiddance of swelin. .

FIG. 97 A–C. Comminuted fracture of the humeral diaphysis treated with a functional brace. Notice the good alignment of the fragments and the abundant peripheral callus.

Augusto Sarmiento, MD.

Dear Panayot,

Thank you.

Dear Anthony and Augusto,

I do agree with you that it can be treated successfully with conservative management especially in the under-developed countries where patient cannot afford the operative cost. However, if Patient can afford it, and since this patient is an "Arm wrestler", so I think Operative treatment would be a better option regardless of the potential danger.

Thank You.

Sarmiento's protocol is well known and successful. But we discuss a case of a spiral fracture in a active wrestler, not a communited one in a non-sportsman. 8-10 weeks of functional bracing may be a reasonable option for healing but early muscle training during this period would not possible as compared to the option with a stable osteosynthesis. In this case the goal is to avoid muscle hypotrophy through early and efficient exercises. The "large" callus after conservative treatment does not always mean strong callus. The remodelling of the bone in the fracture site takes a longer time. The early removal of the plate when the fracture heals will decrease stress protection and will give a better chance for restitutio ad integrum. In my practice, especially with sportsmen, I prefer the AO principles.

I partly agree with Dr Panayot, In this specific case when you want more predictable results and sooner rather than later, it is better to go for plate osteosynthesis. However the reason is not to get him back to start wrestling early, but not to wait for the smal chance of delayed or non union and than do a plating which will obviously waist precious time for this patient before he can start work. There is obviously a risk of refracture which the patient should be informed about. The torsional forces going through the humerus doing arm wrestling are tremendous, it is for the patient to decide weather he wants to try it again.

In routine cases I would go for U slab for a couple of weeks followed by functional bracing depending on allignment and healing of the fracture. they heal very well with conservative management.

Dr. Sarmiento said "most of the closed diphyseal fractures can be treated successfully with functional braces". It is absolutely true.However, there are some cases with spiral fractures in which there is muscle interposition that brings trouble to the healing process. In my practice I had similar cases which needed surgery later. In this particular case of an arm wrestler, I can imagine that he has massive musculature which predisposes to this problem. Anyway, I agree that after healing of this fracture (conservative or operative) the wrestler should decide about his future sports activity himself. Of course this will depend on the functional result.

We apply the classic principle of AO to put mono-cortical screws at the end holes in striving to reduce the stress risers in this zone. Thank you for your interest in this discussion.

Frontal lobotomy