Less Invasive Plate Osteosynthesis in Humeral Shaft Fractures fileLess Invasive Plate Osteosynthesis...

602 Oper Orthop Traumatol 2009 · Nr. 6 © Urban & Vogel

Operative Orthopädie und Traumatologie

Less Invasive Plate Osteosynthesis in Humeral Shaft FracturesTheerachai Apivatthakakul, Chanakarn Phornphutkul, Anupong Laohapoonrungsee, Yuddhasert Sirirungruangsarn1

AbstractObjective

Stable internal fixation of the humeral shaft by less inva-sive percutaneous plate insertion using two separate (proximal and distal) incisions, indirect reduction by closed manipulation and fixation to preserve the soft tis-sue and blood supply at the fracture zone. Early mobiliza-tion of the shoulder and elbow to ensure a good function-al outcome.

IndicationsHumeral shaft fractures (classified according to AO classi-fication as: 12-A, B, C). Humeral shaft fractures extending to the proximal or distal shaft, small or deformed medullary canal or open growth plate.

ContraindicationsHumeral shaft fractures with primary radial nerve palsy.Proximal humeral shaft fractures extending to the humer-al head.Distal humeral fractures extending to the elbow joint.

Surgical TechniqueTwo incisions proximal and distal to the fracture zone are used. A 3-cm proximal incision lies between the lateral border of the proximal part of the biceps and the medial border of the deltoid. Distally, a 3-cm incision is made along the lateral border of the biceps. The interval be-tween biceps and brachialis is identified. The biceps is re-tracted medially to expose the musculocutaneous nerve. The brachialis muscle has dual innervation, the medial half being innervated by the musculocutaneous nerve and the lateral half by the radial nerve. The brachialis is split longitudinally at its midline. The musculocutaneous nerve is retracted along with the medial half of the bra-

chialis, while the lateral half of the brachialis serves as a cushion to protect the radial nerve. A deep subbrachial tunnel is created from the distal to the proximal incision. The selected plate is tied with a suture to a hole at the tip of the tunneling instrument for pulling the plate back along the prepared track. The plate is aligned in the cor-rect position on the anterior surface of the humerus. Trac-tion is applied and the fracture reduced to restore align-ment by image intensifier, followed by plate fixation with at least two bicortical locking screws or three bicortical conventional screws in each fragment.

ResultsBetween January 2003 and January 2006, 23 patients were operated on using the less invasive plate osteosyn-thesis technique. The minimum follow-up period of 12 months was completed in 20 patients. The mean heal-ing time was 14.6 weeks, defined as three of four cortices having stable bridging callus. In one patient with delayed union, healing was observed after 28 weeks. Functional outcomes were evaluated using the Constant Score and the Hospital for Special Surgery (HSS) Score. 19 patients had good to excellent elbow function with a mean HSS Score of 93.5 points. All patients achieved satisfactory shoulder function with a mean Constant Score of 85.8 points compared to 90.6 on the healthy side. Complica-tions observed were one paresthesia of lateral cutaneous nerve of forearm (no radial nerve injury) and one loosen-ing of the LCP (Locking Compression Plate) screws due to technical error.

Key WordsLess invasive plate osteosynthesis · Humeral shaft fracture · Radial nerve palsy

Oper Orthop Traumatol 2009;21:602–13

DOI 10.1007/s00064-009-2008-9

1 Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Thailand.

Apivatthakakul T, et al. Less Invasive Plate Osteosynthesis in Humeral Shaft Fractures

603Oper Orthop Traumatol 2009 · Nr. 6

Introductory RemarksMost humeral shaft fractures can be successfully treated by nonoperative (U-slab or hanging cast) methods [3, 16]. However, these methods require a good compli-ance, and patient selection is a critical factor leading to success or failure. In obese patients, controlling fracture alignment is difficult. Prolonged immobilization of the

arm has an unfavorable short-term outcome and can lead to disability.

Compression plate fixation, which is a widely accept-ed operative method [5], gives a high union rate and al-lows early active motion of the shoulder and elbow. However, the compression plate requires extensive sur-gical dissection with risk of injury to the radial nerve [5].

ZusammenfassungOperationsziel

Stabile interne Fixation von Humerusschaftfrakturen durch indirekte Reposition und perkutanes Einschieben einer Plat-te unter Verwendung von zwei getrennten Inzisionen (pro-ximal und distal). Schonung des Weichteilgewebes und der Blutversorgung in der Frakturzone. Frühmobilisation der Schulter und des Ellenbogens.

IndikationenHumerusschaftfrakturen (AO: 12-A, B, C).Humerusschaftfrakturen mit Frakturausläufern in den pro-ximalen oder distalen Schaftbereich, bei schmalem oder deformiertem Markraum sowie bei offenen Wachstums-fugen.

KontraindikationenHumerusschaftfrakturen mit primärer Radialisparese.Proximale Humerusschaftfrakturen mit Frakturausläufern in den Humeruskopf.Distale Humerusschaftfrakturen mit Beteiligung des Ellen-bogengelenks.

OperationstechnikEs wird jeweils eine Inzision proximal und distal der Frak-turzone verwendet. Die proximale Inzision wird in einer Länge von etwa 3 cm zwischen dem lateralen Rand des pro-ximalen Anteils des Musculus biceps brachii und dem me-dialen Rand des Musculus deltoideus angelegt. Die distale Inzision einer Länge von ebenfalls etwa 3 cm wird am late-ralen Rand des Musculus biceps brachii angelegt. Das Inter-vall zwischen dem Musculus biceps brachii und dem Mus-culus brachialis wird identifiziert. Der Musculus biceps brachii wird nach medial retrahiert, um den Nervus musculocutaneus darzustellen. Die mediale Hälfte des Musculus brachialis wird vom Nervus musculocutaneus innerviert, die laterale Hälfte vom Nervus radialis. Dement-sprechend wird der Musculus brachialis in der Mitte längs gespalten. Der mediale Anteil wird mit dem Nervus musculocutaneus nach medial, der laterale Anteil nach lateral weggehalten, um den Nervus radialis zu schonen.

Es wird ein submuskulärer Tunnel unter dem Musculus bra-chialis von der distalen zur proximalen Inzision angelegt. Die gewählte Platte wird mit einer Naht an einem Loch des Tunnelierungsinstruments fixiert und so entlang dem prä-parierten Tunnel von distal eingeschoben. Die Platte wird an der Vorderseite des Humerus angelegt. Die Fraktur wird indirekt durch Zug unter Bildwandlerkontrolle reponiert. Die Platte wird mit mindestens zwei winkelstabilen bzw. drei konventionellen bikortikalen Schrauben auf beiden Seiten der Fraktur fixiert.

ErgebnisseZwischen Januar 2003 und Januar 2006 wurden 23 Pati-enten mit Humerusschaftfrakturen mittels minimalinva-siver Plattenosteosynthese versorgt. Der minimale Nachun-tersuchungszeitraum betrug 12 Monate. 20 Patienten konn-ten nach dieser Zeit untersucht werden. Die knöcherne Heilung wurde definiert als das Vorhandensein eines sta-bilen Brückenkallus bei drei von vier Kortikales. Die Zeit bis zur knöchernen Heilung betrug durchschnittlich 14,6 Wo-chen. In einem Fall konnte eine verzögerte Heilung nach 28 Wochen beobachtet werden. Der Constant-Score und der HSS-Score (Hospital for Special Surgery) wurden zur Beur-teilung des funktionellen Ergebnisses verwendet. 19 Pati-enten zeigten eine gute oder exzellente Ellenbogenfunkt-ion mit einem durchschnittlichen HSS-Score von 93,5 Punk-ten. Alle Patienten erreichten eine zufriedenstellende Schulterfunktion mit einem durchschnittlichen Constant-Score von 85,8 Punkten (90,6 Punkte auf der unverletzten Seite). Als Komplikationen traten in einem Fall postopera-tive Parästhesien im Bereich des Nervus cutaneus antebra-chii lateralis (Ast des Nervus musculocutaneus) und in einem weiteren Fall eine Lockerung von winkelstabilen Schrauben aufgrund eines technischen Fehlers auf. Es wurden keine postoperativen Radialisparesen beobachtet.

SchlüsselwörterMinimalinvasive Plattenosteosynthese · Humerusschaftfraktur · Radialisparese

Minimalinvasive Plattenosteosynthese von Humerusschaftfrakturen


604 Oper Orthop Traumatol 2009 · Nr. 6

The locking intramedullary nail has been reported to produce satisfactory outcomes with less soft-tissue in-jury, relatively percutaneous insertion and biomechani-cal advantage [6, 13]. Delayed union is significantly greater compared with open reduction and compression plating, and there is a higher incidence of pain and shoulder dysfunction in patients treated by nailing [6]. Intramedullary nailing is limited in some conditions, for example in patients with a small or deformed medullary canal, open growth plate, or where intramedullary nails are not available.

In recent years, minimally invasive plate osteosyn-thesis (MIPO), which was proposed by AO’s expert

group, has gained popularity in the treatment of lower extremity fractures with favorable outcomes [9, 11, 12, 15], but there are few reports of MIPO in upper extrem-ity fractures including humeral shaft fractures [1, 2, 7, 10, 14].

It has been shown in cadaveric study [2] that MIPO of the humerus shaft can be done via the anterior approach. However, it requires the anatomic knowledge of the structure at risk and it is a technically demanding proce-dure. This article demonstrates a less invasive surgery for plating humeral shaft fractures.

Surgical Principles and ObjectiveLess invasive percutaneous insertion of the plate in a subbrachial tunnel on the anterior surface of the hu-merus using separate proximal and distal incision. Soft-tissue preservation at the fracture zone by indi-rect reduction of the fracture promotes healing. At the distal incision, the musculocutaneous nerve on the anterior surface of the brachialis is identified. The

brachialis is split in its midline and used as a cushion to protect the musculocutaneous nerve (medial half), while the radial nerve on the posterolateral is protect-ed by the lateral half of the brachialis. Reduction by manual traction and internal fixation with 4.5-mm narrow DCP (Dynamic Compression Plate) or LCP (Locking Compression Plate).

Advantages• Indirect reduction of the fracture by closed manipu-

lation preserves the soft tissue and blood supply of the fracture zone to promote rapid indirect bone healing by callus formation.

• Minimal soft-tissue dissection to avoid iatrogenic in-jury to the radial nerve.

• Small incisions, less bleeding, early rehabilitation.

Disadvantages• Surgically demanding procedure. Cadaveric surgical

dissection will help the surgeon to know the danger zone and the structure at risk.

• The indirect reduction of the fracture requires an im-age intensifier.

Indications• Humeral shaft fractures (classified according to the

AO classification as 12-A, B, C). • Humeral shaft fractures extending to proximal or dis-

tal shaft, small or deformed medullary canal prevent-ing intramedullary nailing.

• Humeral shaft fractures in open growth plate such that intramedullary nailing may injure the growth plate.

Contraindications• Humeral shaft fractures with primary radial nerve

palsy.• Proximal humeral shaft fractures extending to the

humeral head.• Severe tissue loss without coverage of exposed bone.• Local infection or osteomyelitis.• Delayed surgery with shortening so that closed re-

duction is difficult.• Reconstructive surgery requiring open surgery (de-

layed union with necessary bone grafting).

Patient Information• Usual surgical risks such as infection, wound healing

disturbances.• Injury to the radial nerve with temporary impairment

of motor function and sensation.• Injury to the musculocutaneous nerve with tempo-

rary impairment of sensation.



• Postoperative radiographs showing that the bone is not entirely reduced but is acceptable for good func-tion.

• Period of limited activity, especially when rotation of the arm is required in case of proximal or distal shaft fractures and, thus, fixation of each fragment can be done with only two locking screws.

• Expected healing time of 12–20 weeks.

Preoperative Work Up• Lateral and anteroposterior (AP) radiographs of

the involved arm. The humeral head must be clearly seen to ensure that no fracture involves the humeral head.

• The most proximal extension of the fracture should be distal to the bicipital groove to allow fixation with at least two locking screws or three conventional screws.

• The most distal extension of the fracture should be proximal to the olecranon fossa to allow fixation with at least two locking screws or three conventional screws.

• Preoperative planning, determination of the plate length, position, sequence of the screw fixation and reduction maneuver (Figures 1a to 1c).

• Slight precontouring of the 4.5-mm narrow DCP to fit the proximal part of the anterior ridge before im-plant sterilization.

• Precontouring of the 4.5-mm narrow LCP is not nec-essary.

• In osteoporotic bone, LCP is preferable.

Surgical Instruments and Implants• Instrument set for LCP large-fragment instruments

(Synthes 115.400).• Instrument for tunnel preparation.• Soft-tissue retractor, small, complete (Synthes

325.010, Figure 2a).• Tunneling instrument (locally fabricated) adapted

from removed narrow and broad DCP attachment with handle (Figure 2b).

Anesthesia and Positioning• General anesthesia is preferred for complete relax-

ation of the arm muscle during closed manipulation. Local anesthesia is optional.

• Supine position with the arm in 60° abduction and the forearm in full supination. The arm is rested on a ra-diolucent side-table.

• The surgeon sits on the lateral side of the arm and the assistant sits on the medial side. An image intensifier

is positioned on the same side of the arm opposite the surgeon. The image is checked to visualize the hu-meral head to the olecranon fossa.

• Free draping of the shoulder and the arm.

Figures 2a and 2ba) Soft tissue retractor, small, complete (Syn-thes 325.010).b) The tunnel-ing instrument.

Figures 1a to 1cExample of preoperative plan, with step-by-step demonstra-tion of the procedure [1].

a b c

a

b



Surgical Technique

Figures 3 to 11

This technique uses only two 3-cm incisions in the prox-imal part and another 3-cm incision in the distal part of the standard anterior approach to the humerus.

Deltoid muscle

Biceps muscle

Musculo-cutaneous

nerve

Triceps muscle

Deltoid muscle

Pectoralis major muscle

Biceps muscle

Musculo-cutaneous nerve

Coraco-brachialis muscle

Radial nerve

Figures 3a and 3b The proximal incision, the in-terval between the lateral border of the proximal part of the biceps, and the medial border of the deltoid are pal-pated. A 3-cm proximal inci-sion is made approximately 6 cm distal to the anterior part of the acromion process and the dissection is carried down to the humerus [1].

Figures 4a and 4b The 3-cm distal incision is made along the lateral bor-der of the biceps approxi-mately 5 cm proximal to the flexion crease of the elbow. The interval between the bi-ceps brachii and the brachia-lis is identified. The radial nerve lies posterior to the brachialis between the bra-chialis and the brachioradia-lis. The forearm must be kept in full supination. When the forearm is supi-nated, the radial nerve moves more laterally away from the distal humerus and the plate, and thus is less likely to be injured. The bi-ceps is retracted medially to expose the musculocutane-ous nerve on the anterior surface of the brachialis [1].

Deltoid muscle

Biceps muscle

Musculo-cutaneousnerve

Brachialis muscle

Radial nerve

Biceps muscle

Musculocutaneous nerve

Biceps muscle

Brachialis muscle

Radial nerve

Brachio-radialis muscle

Triceps muscle

ba

b

a



Biceps muscle

Brachialis muscle


Radial nerve


Triceps muscle


Biceps muscle

Brachialis muscle

Radial nerve


Triceps muscle

Figures 5a and 5bThe brachialis is split lon-gitudinally along its mid-line to reach the anterior surface of the distal hu-merus (a). The musculocu-taneous nerve is retracted along with the medial half of the brachialis using the Army-Navy retractor. The lateral half of the brachia-lis which serves as a cush-ion to protect the radial nerve is retracted with the Army-Navy retractor (b). The Hohmann retractor must not be used because its tip will compress the ra-dial nerve.

ba

Figure 6A subbrachial tunnel is created by passing the tunneling in-strument deep to the brachialis from the distal to the proximal incision. Some difficulty may be encountered during passage of the tunneling instrument at the proximal part of the tunnel, due to the intimate blending of the fibers of the brachialis and deltoid muscles along the anterolateral aspect of the tunnel. Incision of these muscle fibers at the tip of the tunneling in-strument will allow its passage through to the proximal inci-sion. To avoid injury to the radial nerve at the lateral aspect of the distal humerus, the tunneling instrument should be touched and passed along the anterior or slightly anteromedi-al aspect of the humerus.



Figures 7a and 7bAfter preparation of the anterior subbra-chial tunnel, the selected narrow 4.5-mm DCP or LCP is tied with a suture to a hole at the tip of the tunneling instrument (a). The tunneling instrument is then withdrawn, pulling the plate back along the track that it has created (b). This method ensures that the plate is guided into the correct tunnel and avoids injury to the radial nerve. The plate is adjusted to the correct position ac-cording to the fracture level.

ba



Figures 8a to 8eThe plate is aligned on the exact anterior surface of the distal humerus by palpating the medial and lateral epicondyles and set-ting the image intensifier for true AP view of the distal humerus (a). When using the DCP, the plate is first fixed to the distal hu-merus with one or two screws (b, c). Reduc-tion of the fracture is usually achieved by manual manipulation. Traction is used to restore the length and rotation (d). When the length and rotation are corrected, one screw is inserted into the proximal frag-ment. At this point, the varus-valgus angu-lation can be corrected by manipulation using the image intensifier. Finally, the fix-ation is completed with at least three screws in each fragment (e). When using the LCP, insertion of the plate can be done by the same technique as the DCP or, alter-natively, two 5.0 LCP drill sleeves attached to the distal end of the plate can be used as the handle for tunneling and plate inser-tion. The plate is temporarily fixed to the humerus with the 2.0-mm Kirschner wire perpendicular to the anterior cortex of the distal humerus by using the TomoFix guide sleeve for 2.0-mm Kirschner wires (Synthes 324.168) inserted into the 5.0 LCP drill sleeve. Manual reduction is done in the same manner as using the DCP, with tem-porary fixation of the proximal fragment by the Kirschner wire as in the distal frag-ment. Varus-valgus and AP angulation are checked with the image intensifier. When the alignment is correct, one locking screw is inserted into each fragment. The align-ment is reassessed with the image intensi-fier to ensure that the locking screw is in the proper position. If satisfactory, the fixa-tion is completed with at least three bicor-tical locking screws in each fragment. For distal and proximal shaft fractures, two bi-cortical locking screws are acceptable with some limited postoperative activity. Suc-tion drain is not necessary. (With permis-sion from [1].)

a

b

c

d

e



Tips to Avoid Nerve Injury

Figure 9In the proximal and distal incisions, Hohmann re-tractors must not be used because the tip will catch the radial nerve on the medial of the proxi-mal incision and on the lateral of the distal inci-sion (arrows).

Figure 10The musculocutaneous nerve has to be identified before split-ting the brachialis to ensure that the nerve will be retracted with the medial half of the brachialis.

Figure 11In the middle part of the humerus, bicortical drilling and screw fixation from anterior to posterior has a high risk of radial nerve injury. If the midshaft area needs fixation, screw(s) should be applied monocortically whenever possible.

Brachial muscleRadial

nerve

Radial nerve

Ulnar nerve Median nerve



Radial nerve



Special Considerations• Comminuted fractures are easier

to reduce than transverse frac-tures. Slight shortening is accept-able for comminuted fractures while transverse fractures need the correct length to reduce the frag-ments; otherwise the fracture will be angulated.

• Fracture shaft of the humerus with primary radial nerve palsy is not recommended for the MIPO tech-nique because the radial nerve in-jury after surgery cannot be differ-entiated between primary injury or iatrogenic injury.

• In young patients with good bone quality, the narrow DCP with three screws in each fragment is acceptable. When the fragment is short and the length allows for on-ly two screws, the LCP is preferable. In osteopenic bone, the LCP provides angular stability, if applied correctly, and decreases the risk of implant failure.

• The TomoFix guide sleeve for 2.0-mm Kirschner wires (Synthes 324.168) inserted into the 5.0 LCP drill sleeve is very helpful in temporary fixation of the plate to the bone during reduction and also to ensure that the plate is in the center of the bone by passing the Kirschner wire through both cortices.

Postoperative Management• The patient is encouraged to move the shoulder and

elbow as tolerated on the 2nd day after surgery with-out external support.

• When the fixation is limited by only two screws in any fragment, flexion and extension of the elbow and pendulum exercise of the shoulder are allowed, but rotation of the arm is limited until the callus is seen, usually after 6 weeks.

Figures 12a to 12dCase demonstration: MIPO shaft of the humerus with ten-hole narrow DCP (with permission from [1], pp 157–162).a) A 23-year-old male had a motorcycle ac-cident and sustained a fracture of the hu-meral shaft and an ipsilateral fracture of the femoral shaft.b) Postoperative X-rays show fixation of the main fragments.c) X-rays at 6 months show complete frac-ture healing.d) Functional result at 6 months.

a b

d

c



• Follow-up radiographs are taken at 6, 12 and 20 weeks, and at 12 months.

• Removal of implant is optional.

Errors, Hazards, Complications• The musculocutaneous nerve has to be identified (see

Figure 10) before splitting the brachialis to ensure that the nerve will be retracted with the medial half of the brachialis: sensory impairment resulting from in-jury to the nerve is minimal and, in most cases, re-versible. No surgical intervention is recommended.

ResultsBetween January 2003 and January 2006, 56 patients with acute humeral shaft fracture were treated by plat-ing. 23 patients (seven women, 16 men, average age 45.8 years [range 20–72 years]) were operated on using the less invasive plate osteosynthesis technique. The min-imum follow-up period of 12 months was completed

in 20 patients. The average duration of follow-up was 14.3 months. The following fracture types according to the AO classification were treated: four A-type fractures, five B-type fractures, and eleven C-type fractures.

Assessment of the results was based on the Constant Score [4] and the Hospital for Special Surgery (HSS) Score [8]. All patients achieved satisfactory shoulder function with a mean Constant Score of 85.8 points com-pared to 90.6 on the healthy side. The average HSS Score was 93.5 points. All patients were able to perform a full range of motion with the shoulder and elbow, except for one patient with a B-type fracture of humeral shaft and distal humeral fracture C3 who had limited full elbow ex-tension of 20°. The mean healing time was 14.6 weeks (12–28 weeks). In one patient with an A-type fracture and slight distraction of the fracture who had delayed union, healing was seen after 28 weeks. There was no in-fection. Complications observed were one paresthesia of lateral cutaneous nerve of forearm which completely re-

Figures 13a to 13dCase demonstration: MIPO shaft of the humerus with nine-hole narrow LCP (with permission from [1], pp 173–178).a) A 24-year-old female had a motorcycle accident and sustained a right humeral shaft fracture and an undisplaced fracture of the distal radius.b) Postoperative X-rays show good frac-ture alignment.c) X-rays at 6 months show complete frac-ture healing with callus bridging.d) Functional result at 6 months and small surgical scars.

a b

d

c



covered in 2 months with no radial nerve injury. One pa-tient had an LCP screw loosening due to the technical error of unicortical fixation; the fracture healed with 15° angulation.

Figures 12 and 13 show two illustrative cases. The advantages of this less invasive surgery com-

pared to conventional plating include less surgical trau-ma, preservation of the blood supply at the fracture zone, early rehabilitation and functional recovery, and lower risk of radial nerve injury [5]. The limitations of our study include lack of a comparison group.

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Address for CorrespondenceTheerachai Apivatthakakul, MDDepartment of OrthopaedicsFaculty of MedicineChiang Mai UniversityChiang Mai 50200ThailandPhone (+66/53) 94-5544, Fax -6442e-mail: [email protected]

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