import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, VivaScenario, VivaScenarioSection } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} 20° varus, >30° AP angulation, >3cm shortening)", treatment: "ORIF vs functional bracing" }, { type: "Non-operative", description: "Closed, acceptable alignment, intact nerve function", treatment: "Sarmiento functional bracing (85-88% union)" } ] }} mustKnow={[ "**Internervous plane**: Between biceps (musculocutaneous) and brachialis - BUT brachialis has DUAL innervation (musculocutaneous medially, radial laterally) requiring longitudinal split", "**Radial nerve** crosses from posterior to lateral at spiral groove (mean 14cm proximal to lateral epicondyle - Gerwin 1996) - PRIMARY structure at risk", "**Holstein-Lewis fracture** (distal 1/3 spiral) has HIGHEST iatrogenic nerve injury risk (18% vs 2-5% for standard mid-shaft - Ring 1999)", "**Subperiosteal dissection ONLY** - never dissect posteriorly around spiral groove (nerve adherent to bone via lateral intermuscular septum)", "**Immediate post-op palsy** (pre-op intact) = iatrogenic injury → urgent re-exploration within 24-48 hours for neurolysis or repair", "**Primary fracture palsy** (at injury) = observe 3-4 months first (70% spontaneous recovery - Shao 2005)" ]} examPearls={[ "Best for middle/distal 1/3 shaft fractures - NOT proximal 1/3 (use deltopectoral)", "Functional bracing STILL first-line for closed, isolated fractures with acceptable alignment", "Plate fixation superior to IM nailing (94% vs 87% union, less shoulder dysfunction)", "Proximal-to-distal exposure reduces risk of encountering radial nerve unexpectedly" ]} summary="The anterior (Henry) approach provides direct access to the middle and distal 1/3 humeral shaft for ORIF of fractures, nonunion repair, and tumor excision. Key advantages include supine positioning, familiar anatomy, and optimal plate biomechanics on the anterolateral tension side. Critical challenge is radial nerve protection at the spiral groove (14cm from lateral epicondyle), with highest injury risk in Holstein-Lewis fractures (18%). Modern ORIF achieves 92-95% union rate, superior to functional bracing (85-88%), though functional bracing remains first-line for closed fractures with acceptable alignment." /> {/* SECTION 2: EXAM WARNING */} **Most vulnerable structure**: The radial nerve crosses from posterior to lateral humerus at the **spiral groove** (mean 14.2cm proximal to lateral epicondyle, range 10-17cm - Gerwin 1996). At this location, the nerve is **firmly adherent to bone** via the lateral intermuscular septum and cannot be easily mobilized. This zone of adherence creates highest injury risk during fracture fixation. **Distal 1/3 spiral fracture** where the radial nerve crosses the spiral groove AT the fracture site. **Highest iatrogenic injury risk**: 18% (vs 2-5% for standard mid-shaft fractures - Ring 1999). The spiral fracture line crosses the nerve precisely where it adheres to bone. **MUST identify nerve at lateral intermuscular septum BEFORE fracture manipulation** to reduce injury risk. **Three key techniques**: (1) **Proximal-to-distal exposure** - encounter nerve predictably if it crosses surgical field. (2) **Subperiosteal dissection ONLY** - never dissect posteriorly around spiral groove. (3) **For Holstein-Lewis**: Identify nerve at lateral intermuscular septum before reducing fracture. Use vessel loop for gentle protection during reduction. **CRITICAL distinction**: **Immediate post-op palsy** (pre-op intact) = **iatrogenic injury** → **urgent re-exploration within 24-48 hours** for neurolysis or repair. **Primary fracture palsy** (at injury) = **observe 3-4 months** (70% spontaneous recovery - Shao 2005). Serial EMG at 6-8 weeks shows reinnervation. Explore only if no recovery by 4-6 months. {/* SECTION 3: MNEMONICS */} {/* SECTION 4: OVERVIEW */} The **anterior approach to the humeral shaft** (also known as the **Henry approach** or **anterolateral approach**) provides direct access to the **middle and distal 1/3 of the humerus** for fracture fixation, nonunion repair, and tumor excision. First described by Henry in 1945, this approach has become the most commonly used surgical corridor for humeral shaft fractures requiring operative fixation. **Historical evolution:** - 1945: Henry described the anterior approach for humeral shaft access - 1970s-1980s: Functional bracing (Sarmiento) became gold standard for non-operative management - 1980s-1990s: AO principles established plate fixation techniques (6-8 cortices, compression) - 2000s-present: Modern locked plating expanded indications (osteoporotic bone, comminution) **Modern applications:** 1. **Displaced humeral shaft fractures** (middle/distal 1/3) - ORIF with plate fixation 2. **Humeral nonunion/malunion** - revision ORIF with bone grafting 3. **Pathological fractures** - prophylactic fixation for metastatic lesions 4. **Polytrauma** - early stabilization in multiply-injured patients The anterior approach is best for **middle and distal 1/3** humeral shaft fractures. For **proximal 1/3** fractures (above deltoid insertion), use the **deltopectoral approach** for better proximal exposure. For **mid-shaft at spiral groove**, consider the **posterior approach** for direct radial nerve visualization (lower iatrogenic injury risk 1-3% vs 2-5%). {/* SECTION 5: ANATOMY */} ### Internervous Plane The anterior approach utilizes an **internervous plane with brachialis muscle splitting**: **Primary Interval:** - **Between**: Biceps muscle (medial, musculocutaneous nerve) and lateral edge of brachialis - **Brachialis splitting**: The brachialis muscle has **DUAL INNERVATION** - medial portion (musculocutaneous nerve) and lateral portion (radial nerve) - **Splitting technique**: Split brachialis LONGITUDINALLY in its midline (internervous plane WITHIN the muscle) - separates musculocutaneous-innervated medial fibers from radial-innervated lateral fibers **Critical concept:** This is NOT a "pure" internervous plane (like Thompson or Henry radius approaches) because brachialis must be SPLIT to access humerus. However, splitting in the midline respects the dual innervation and minimizes denervation. ### Critical Neurovascular Structures **1. RADIAL NERVE (PRIMARY HAZARD):** **Anatomic Course:** - **Origin**: Posterior cord of brachial plexus - **Proximal humerus**: Lies posteromedial to humerus (behind brachial artery) - **Spiral groove crossing**: Crosses from POSTERIOR to LATERAL surface of humerus at **spiral groove** (also called radial groove) - **Spiral groove location**: Mean **14.2cm proximal to lateral epicondyle** (range 10-17cm - Gerwin 1996) - **Distal course**: Enters **lateral intermuscular septum** and descends between brachialis (anterior) and brachioradialis/ECRL (posterior) - **Bifurcation**: Divides into **PIN** (motor) and **superficial radial nerve** (sensory) at level of lateral epicondyle (2cm proximal) **Surgical Importance:** - Radial nerve is **MOST VULNERABLE** at spiral groove (adherent to bone via lateral intermuscular septum) - **Holstein-Lewis fracture** (distal 1/3 spiral fracture) traps radial nerve in fracture site - HIGHEST iatrogenic injury risk (18% - Ring 1999) - Radial nerve injury risk: **2-5%** for standard mid-shaft fractures, **18%** for Holstein-Lewis **Protection Strategy:** - **Identify radial nerve** at lateral intermuscular septum (palpable as cord crossing spiral groove) - **Subperiosteal dissection ONLY** (avoid dissecting around spiral groove - nerve adherent to bone) - **Proximal-to-distal exposure** (reduces risk of dissecting into nerve at spiral groove) - **NEVER explore nerve** unless pre-operative function was intact and post-operative palsy occurred (iatrogenic injury indication) **2. BRACHIAL ARTERY:** **Anatomic Course:** - **Location**: Lies MEDIAL to biceps muscle throughout arm - **Relationship**: Accompanied by median nerve - **Surgical relevance**: Usually NOT visualized in anterior approach (lies medial to surgical field) **Protection:** - Retract biceps MEDIALLY (pulls brachial artery and median nerve away from surgical field) - Avoid dissection medial to biceps **3. MEDIAN NERVE:** **Anatomic Course:** - **Proximal arm**: Lies MEDIAL to brachial artery - **Mid-arm**: Crosses ANTERIOR to brachial artery - **Distal arm**: Lies LATERAL to brachial artery - **No branches** to muscles in proximal arm (first branch: pronator teres at elbow) **Protection:** - Retract biceps and brachial artery MEDIALLY as a unit (median nerve accompanies artery) - Rarely visualized unless dissection extends to distal humerus **4. MUSCULOCUTANEOUS NERVE:** **Anatomic Course:** - **Entry into biceps**: Enters biceps muscle **6-8cm distal to coracoid** process (variable) - **Course**: Runs between biceps and brachialis muscles - **Exit**: Emerges lateral to biceps tendon as **lateral antebrachial cutaneous nerve (LABC)** at elbow **Surgical Relevance:** - Usually NOT at risk (lies within biceps muscle, medial to surgical field) - LABC may be injured with excessive distal dissection {/* SECTION 6: INDICATIONS */} ### Operative vs Non-Operative Decision-Making **ABSOLUTE INDICATIONS FOR OPERATIVE FIXATION:** 1. **Open fractures** (Gustilo I-III) - require irrigation, debridement, and stabilization 2. **Vascular injury** requiring repair (brachial artery laceration - 2-3% of humeral shaft fractures) 3. **Polytrauma** requiring early stabilization (chest trauma, multiple long bone fractures, head injury) 4. **Bilateral humeral shaft fractures** (functional bracing impossible) 5. **Floating elbow** (ipsilateral humerus + forearm fractures) 6. **Pathological fractures** (metastatic disease - prophylactic fixation if >50% cortical destruction) **RELATIVE INDICATIONS (Operative vs Non-Operative Decision):** 1. **Failed closed reduction** with unacceptable alignment (>20° varus/valgus, >30° anterior/posterior angulation, >3cm shortening) 2. **Radial nerve palsy** with fracture manipulation (suggests nerve entrapment - EXPLORE nerve) 3. **Progressive displacement** on serial X-rays despite functional bracing 4. **Segmental fractures** (two distinct fracture lines with intercalary fragment - unstable) 5. **Patient factors**: Obesity (functional brace difficult to fit), non-compliance, bilateral upper limb injuries **NON-OPERATIVE MANAGEMENT (Functional Bracing - STILL FIRST-LINE):** Sarmiento functional bracing remains GOLD STANDARD for closed, isolated humeral shaft fractures with acceptable alignment: - **Union rate**: 85-88% (Sarmiento 2000) - **Acceptable alignment**: <20° varus/valgus, <30° anterior/posterior angulation, <3cm shortening - **Advantages**: No surgery risks, no anesthesia, immediate ROM - **Disadvantages**: 12-15% nonunion rate (vs 5-8% with ORIF), prolonged immobilization (8-12 weeks) ### Approach Selection {/* SECTION 7: SURGICAL TECHNIQUE */} ### Setup and Positioning **Patient Position:** - **Supine** position on operating table - **Arm on side table** or **radiolucent arm board** (allows circumferential access) - **Shoulder positioned** at edge of table (allows arm to hang freely for posterior access if needed) - **Alternative**: Arm across chest on radiolucent board (better for proximal shaft exposure) **Equipment:** - **Tourniquet**: Optional (most surgeons do NOT use tourniquet for humerus - pneumatic tourniquet on proximal arm risks brachial plexus compression) - **Fluoroscopy** (C-arm) available for intraoperative reduction/fixation verification - **Radiolucent side table** essential for intraoperative imaging **Anesthesia:** - General anesthesia OR regional anesthesia (interscalene brachial plexus block) - Regional anesthesia provides excellent perioperative analgesia (12-18 hours) ### Skin Incision **Incision Course:** - **Proximal extent**: 2-3cm distal to anterior axillary fold (coracoid level) - do NOT extend more proximally (axillary nerve risk) - **Distal extent**: To 5cm proximal to antecubital crease (avoid crossing elbow flexion crease) - **Course**: Follows **lateral border of biceps muscle** from proximal to distal arm **Landmarks:** - **Proximal**: Palpate coracoid process (marks superior extent) - **Mid-arm**: Follow lateral border of biceps (easily palpable with elbow flexion) - **Distal**: Biceps tendon (palpable with elbow flexion) - stay 5cm proximal to elbow crease **Incision Length:** - Typically 15-20cm for mid-shaft fracture exposure - Extend as needed for fracture pattern (comminution, butterfly fragments) The incision follows the **lateral border of the biceps muscle** from coracoid level to 5cm above the elbow crease. This places the incision directly over the interval between biceps (medial) and brachialis (lateral). Avoid extending proximal to the coracoid (axillary nerve risk) or distal across the elbow crease (unsightly scar, LABC injury risk). ### Superficial Layer Development **1. Subcutaneous Layer:** - Incise skin and subcutaneous tissue sharply - Identify and protect **cephalic vein** (runs in deltopectoral groove proximally, continues distally in lateral subcutaneous plane) - Ligate small perforating veins crossing surgical field **2. Deep Fascia:** - Identify **biceps muscle belly** medially (easily palpable) - Identify **lateral border of biceps** (key landmark for plane identification) - Incise **deep fascia along lateral border of biceps** longitudinally **3. Identify Muscular Interval:** - Retract skin edges to visualize deep structures - Palpate biceps muscle medially (soft, mobile) - Identify brachialis muscle laterally (firm, covering anterior humerus) ### Brachialis Splitting Technique **1. Retract Biceps Medially:** - Use retractors to retract biceps muscle belly MEDIALLY - This exposes underlying **brachialis muscle** covering anterior humerus - **Critical**: Biceps retraction pulls brachial artery and median nerve MEDIALLY away from surgical field **2. Identify Brachialis Muscle:** - Brachialis covers anterior humerus from deltoid insertion to coronoid process - Dual innervation: **Medial** portion (musculocutaneous nerve), **Lateral** portion (radial nerve) - **Splitting plane**: Midline of brachialis (internervous plane within muscle) **3. Split Brachialis Longitudinally:** - Identify midline of brachialis (approximate longitudinal midpoint) - Split brachialis in **LINE OF ITS FIBERS** (longitudinally, parallel to humerus) using blunt dissection - Extend split proximally and distally to expose required humeral shaft length - **Critical**: Do NOT split brachialis transversely (violates muscle fibers and innervation) **4. Identify Radial Nerve (Optional - High-Risk Cases):** For **Holstein-Lewis fractures** or **revision surgery** - consider radial nerve identification BEFORE fracture manipulation: - **Nerve location**: Lateral intermuscular septum at spiral groove (14cm proximal to lateral epicondyle) - **Identification technique**: - Palpate lateral humerus for **spiral groove** (bony depression on lateral shaft) - Incise lateral intermuscular septum longitudinally - Identify radial nerve as **cord-like structure** (4-5mm diameter) crossing spiral groove from posterior to lateral - Protect with vessel loop or gentle retraction **CAUTION**: Routine nerve identification is NOT recommended for standard mid-shaft fractures (increases dissection time and injury risk) - only for high-risk cases **5. Subperiosteal Dissection:** - After splitting brachialis, identify humerus periosteum - Use **subperiosteal elevation** with Cobb elevator to expose humeral shaft - Elevate brachialis from humerus circumferentially (volar, medial, lateral surfaces) - **Critical**: NEVER dissect POSTERIORLY around humerus (radial nerve on posterior surface at spiral groove) - Expose fracture site with **proximal-to-distal** technique ### Reduction and Fixation **Fracture Reduction:** - **Direct manipulation** of proximal and distal fragments with bone clamps - **Traction**: Assistant provides longitudinal traction on arm (restores length) - **Rotation control**: Hold proximal fragment with bone clamp, rotate distal fragment to match - **Reduction clamps** for provisional fixation (pointed reduction clamps or Weber clamps) - **Fluoroscopy** for reduction verification (AP and lateral views) **Plate Fixation (GOLD STANDARD):** - **Implant**: 4.5mm narrow LCP or LC-DCP plate (narrow plate conforms to humeral shaft better) - **Plate position**: **Anterolateral humerus** (NOT direct anterior - allows bone graft placement medially if needed) - **Screw fixation**: **6-8 cortices proximal and distal** to fracture (AO principles for diaphyseal fractures) - **Compression**: Use compression screws (LC-DCP) or lag screws through plate for simple transverse/short oblique fractures - **Locking screws**: For osteoporotic bone, comminuted fractures, or metaphyseal extension - **Bridge plating**: For comminuted fractures - span comminution with plate, do NOT reconstruct every fragment **Meta-analysis (Bhandari 2006)** comparing plate fixation vs IM nailing: - **Union rate**: Plating 94% vs IM nail 87% (plating SUPERIOR) - **Shoulder dysfunction**: Plating 8% vs IM nail 23% (IM nail INFERIOR due to rotator cuff violation) - **Re-operation**: Plating 8% vs IM nail 14% - **Recommendation**: Plate fixation is FIRST-LINE for humeral shaft fractures ### Wound Closure **Deep Layers:** 1. **Brachialis muscle repair** - reapproximate split muscle fibers with interrupted absorbable sutures (2-0 Vicryl) - NOT MANDATORY (muscle heals spontaneously) 2. **Hemostasis** - meticulous cautery (avoid cautery near radial nerve at lateral border if identified) **Superficial Layers:** 1. **Deep fascia closure** - interrupted absorbable sutures (2-0 Vicryl) 2. **Subcutaneous layer** - interrupted absorbable sutures (3-0 Vicryl) 3. **Skin closure** - running subcuticular (4-0 Monocryl) or interrupted nylon sutures **Postoperative:** - **Coaptation splint** (U-shaped posterior splint from axilla to forearm) for 7-10 days - **Sling** for comfort - **Wound check** at 1-2 weeks - **Early ROM** at 2 weeks (shoulder/elbow pendulum exercises, passive ROM) - **Active ROM** at 6 weeks (after early callus formation) - **Radiographic follow-up** at 2, 6, 12 weeks for union assessment {/* SECTION 8: EVIDENCE BASE */} 3 months): 68% recovery" ]} clinicalImplication="This systematic review established that OBSERVATION is the GOLD STANDARD for radial nerve palsy associated with humeral shaft fractures (70.7% spontaneous recovery vs 42% with early exploration). CURRENT RECOMMENDATION: Observe radial nerve palsy for 3-4 months. Serial EMG at 6-8 weeks shows reinnervation. Explore nerve if NO recovery by 4-6 months." /> {/* SECTION 9: COMPLICATIONS */} ### Intraoperative Complications **1. RADIAL NERVE INJURY (2-18%):** **Mechanism:** - Holstein-Lewis fractures (distal 1/3 spiral) - nerve trapped in fracture site (18% iatrogenic injury) - Excessive lateral retraction during fracture reduction - Subperiosteal dissection AROUND spiral groove (violates nerve on posterior humerus) - Drill penetration through lateral cortex during screw placement **Prevention:** - **Subperiosteal dissection ONLY** - do NOT dissect circumferentially around spiral groove - **Proximal-to-distal exposure** - encounter nerve predictably - For **Holstein-Lewis fractures** - identify nerve at lateral intermuscular septum BEFORE fracture manipulation - Use **drill depth gauge** for screw length measurement **Recognition:** - **Intraoperative**: Loss of wrist/finger extension during case - **Postoperative**: Wrist drop, finger/thumb extension weakness (EPL, EDC, EIP), thumb abduction weakness (APL, EPB) - **Preserved function**: Sensation over dorsal thumb/index web space, elbow extension (triceps innervated proximal to spiral groove) **Management:** - **Immediate post-operative palsy** (pre-operative function intact): - **Urgent re-exploration** (within 24-48 hours) - iatrogenic injury suspected - Identify nerve at lateral intermuscular septum - **Neurolysis** if nerve in continuity (free from scar, hematoma, or suture entrapment) - **Nerve repair** if laceration (primary end-to-end if tension-free, nerve graft if gap >1cm) - **Pre-operative palsy unchanged post-operatively**: - **Observation** for 3-4 months (70% spontaneous recovery - Shao 2005) - Serial EMG at 6-8 weeks (signs of reinnervation indicate recovery) - **Nerve exploration** if no recovery by 4-6 months - **Tendon transfers** if no recovery by 12 months: - PT to ECRB (wrist extension) - FCR to EDC (finger extension) - PL to EPL (thumb extension) **Outcome:** - Neurolysis (nerve in continuity): 80% recovery - Nerve repair (laceration): 40-60% recovery - Spontaneous recovery (observation): 70% (Shao 2005) ### Postoperative Complications **1. NONUNION (5-8%):** **Risk Factors:** - Inadequate fixation (<6 cortices proximal/distal to fracture) - Excessive periosteal stripping - Infection (deep infection 15-20% nonunion risk) - Smoking (5-10× increased nonunion risk) - Transverse fracture pattern **Management:** - **Hypertrophic nonunion**: Revision ORIF with larger plate, compression, NO bone graft needed - **Atrophic nonunion**: Revision ORIF with bone grafting (iliac crest autograft), larger plate, consider BMP-2 if high-risk - **Smoking cessation**: MANDATORY (10× reduced union rate if continued smoking) **2. INFECTION (2-3%):** **Management:** - **Superficial infection**: Oral antibiotics (flucloxacillin or cephalexin 500mg QDS for 10-14 days) - **Deep infection**: I&D + culture-guided IV antibiotics (6 weeks minimum) + hardware retention if fracture healing progressing **3. SHOULDER STIFFNESS (10-15%):** **Prevention:** - **Early ROM** at 2 weeks (pendulum exercises, passive ROM) - Minimize immobilization duration (coaptation splint for 7-10 days ONLY) **Management:** - Physical therapy: Progressive ROM exercises - Corticosteroid injection if adhesive capsulitis (triamcinolone 40mg + lidocaine) - Manipulation under anesthesia (MUA) if stiffness persists beyond 6 months {/* SECTION 10: VIVA SCENARIOS */} 20° varus/valgus or >30° AP angulation - these are RELATIVE indications for operative fixation", "Missing progressive displacement on serial X-rays - if fracture displaces AFTER functional brace application = operative indication", "Operating for isolated radial nerve palsy at presentation - 70% spontaneous recovery with observation (Shao 2005)", "Using IM nailing instead of plating - meta-analysis shows plating SUPERIOR (94% union vs 87%, less shoulder dysfunction)" ]} followUpQuestions={[ "The patient develops a radial nerve palsy 6 weeks after starting functional bracing. What is your management?", "Compare functional bracing to ORIF via anterior approach for this fracture. What are the risks/benefits?", "What would make you choose operative fixation for this patient?" ]} /> {/* SECTION 11: EXAM CHEAT SHEET */} 50% cortical destruction)", "**RELATIVE operative indications**: Failed closed reduction (>20° varus/valgus, >30° AP angulation, >3cm shortening), radial nerve palsy with manipulation (suggests entrapment), progressive displacement, segmental fractures", "**NON-OPERATIVE (functional bracing) - FIRST-LINE**: Closed, isolated fractures with acceptable alignment (<20° varus/valgus, <30° AP, <3cm shortening). Union rate 85-88% (Sarmiento 2000), NO surgery risks, immediate ROM", "**ANTERIOR approach best for**: Middle/distal 1/3 shaft (below deltoid insertion), polytrauma (supine positioning allows simultaneous procedures), distal shaft fractures", "**POSTERIOR approach best for**: Mid-shaft at spiral groove level (radial nerve DIRECTLY VISUALIZED - reduces iatrogenic injury from 5% to 1-3% - McKee 2004), radial nerve exploration (pre-op palsy), revision surgery" ] }, { title: "Complications and Management", items: [ "**Radial nerve injury (2-18%)**: Standard mid-shaft 2-5%, Holstein-Lewis 18%. Prevention: subperiosteal dissection only, proximal-to-distal exposure, identify nerve for Holstein-Lewis", "**Immediate post-op palsy (pre-op intact)**: IATROGENIC INJURY - urgent re-exploration within 24-48 hours for neurolysis (80% recovery) or nerve repair (60% recovery)", "**Primary fracture palsy (at injury)**: OBSERVE 3-4 months (70% spontaneous recovery - Shao 2005). Serial EMG at 6-8 weeks. Explore if no recovery by 4-6 months", "**Nonunion (5-8%)**: Risk factors: inadequate fixation (<6 cortices), smoking, infection. Management: Revision ORIF with bone grafting (iliac crest autograft), larger plate, smoking cessation MANDATORY", "**Infection (2-3%)**: Superficial = oral antibiotics. Deep = I&D + culture-guided IV antibiotics 6 weeks + hardware retention if healing progressing", "**Shoulder stiffness (10-15%)**: Prevention: early ROM at 2 weeks, minimize coaptation splint (7-10 days ONLY). Management: physiotherapy, corticosteroid injection, MUA if persists >6 months" ] }, { title: "Australian Clinical Context", items: [ "**Humeral shaft fractures**: 3-5% of all long bone fractures in Australian trauma systems (AIHW 2024). Bimodal distribution: young males (high-energy MVA, sports) and elderly females (osteoporotic falls)", "**Radial nerve palsy**: 11-12% incidence in humeral shaft fractures (matches international data 11.8% - Shao 2005). Most common at distal 1/3 spiral fractures (Holstein-Lewis pattern)", "**Management paradigm**: Functional bracing remains FIRST-LINE for closed, isolated fractures with acceptable alignment at major Australian trauma centers. Operative fixation reserved for polytrauma, failed bracing, unacceptable alignment", "**Antibiotic prophylaxis**: Cephazolin 2g IV pre-incision (eTG guidelines). Gentamicin 4mg/kg IV added for open fractures", "**Thromboprophylaxis**: Enoxaparin 40mg SC daily post-operatively (NOT typically used for isolated upper limb ORIF unless additional risk factors). Early mobilization is primary VTE prevention", "**Pain management**: Multimodal analgesia (paracetamol 1g QDS + oxycodone 5-10mg PRN). Interscalene brachial plexus block provides 12-18 hours perioperative analgesia. Avoid routine NSAIDs in first 6 weeks (nonunion risk)", "**WorkCover**: 25-30% of humeral shaft fractures in working-age adults are work-related. Return to work: light duties 6-8 weeks, heavy manual labor 12-16 weeks. Functional capacity evaluation required for WorkCover clearance", "**Nerve injury services**: Persistent radial nerve palsy beyond 6 months or iatrogenic nerve laceration requires peripheral nerve surgery referral (Royal North Shore Sydney, Austin Hospital Melbourne, Princess Alexandra Brisbane). Public waitlist 3-6 months elective, 2-4 weeks urgent", "**Smoking cessation**: CRITICAL for bone healing (10× increased nonunion risk with continued smoking). Quitline 13 7848 provides free telephone counseling. Nicotine replacement therapy PBS-subsidized" ] } ]} /> 1. Dabezies EJ, Banta CJ 2nd, Murphy CP, d'Ambrosia RD. Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop Trauma. 1984;6(1):10-13. 2. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996;78(11):1690-1695. 3. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87(12):1647-1652. 4. Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 1999;24(4):683-688. 5. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop. 2006;77(2):279-284. 6. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478-486. 7. McKee MD, Miranda MA, Riemer BL, et al. Management of humeral shaft fractures in the geriatric patient. J Orthop Trauma. 2004;18(9):549-554. 8. Rüedi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2nd ed. Stuttgart: Thieme; 2007.

Anterior Approach to Humeral Shaft (Henry)

Anterior Approach to Humeral Shaft (Henry)