Midshaft Humerus Fractures Treatment & Management
- Author: Matthew Lawless, MD; Chief Editor: Harris Gellman, MD more...
Surgical treatment of humeral shaft fractures should be considered for multiple reasons. One indication for surgery is an inability to maintain the fracture in adequate alignment using closed methods. Factors that can account for this inability include the following:
Fracture pattern - Displaced, comminuted, or segmental (segmental fractures are at risk of nonunion at one fracture site or at both of them) 
Prolonged recumbency or an inability to maintain a semisitting or reclined position, as in a patient with multiple traumatic injuries
Ipsilateral fracture of the ulna or radius is another indication for surgery, necessitating stabilization of the humeral and forearm fractures to allow early range of motion (ROM).[1, 11, 15] If the patient has bilateral humeral fractures, one or both should be fixed to allow patient self-care. Operative indications also include open fractures, existing or impending pathologic fractures, and fractures associated with a vascular injury that requires repair.
An area of controversy is the occurrence of new-onset radial nerve injuries after closed manipulation. Such injuries were once thought to be indications for surgery; however, this assumption has been called into question. Spinal cord or brachial plexus injuries are indications for surgery. Surgery is also indicated for fractures of the humeral shaft that are associated with displaced intra-articular fracture extension.
There are few, if any, absolute contraindications for surgical treatment of a midshaft humeral fracture.
The best operative treatment modality has not yet been fully determined. An association between fractures treated with antegrade intramedullary nailing and a higher number of shoulder complaints is likely, but cases involving newer nails, such as the Synthes flexible humeral nail (with a starting point lateral to cuff insertion), have not yet been monitored adequately.
Most closed fractures of the humeral shaft can be successfully treated with closed methods; union rates higher than 90% are often reported.[2, 17, 18] Multiple closed techniques are available, including the following[2, 17] :
Hanging arm cast
Abduction humeral/shoulder spica cast
All of these techniques have been used successfully, but closed humeral shaft fractures are usually treated with a hanging arm cast or a coaptation splint for 1-3 weeks, after which period they are placed in a functional brace.[2, 1, 11, 18]
No recommendations have been made regarding the use of the hanging arm cast versus the coaptation splint, though Rockwood recommended using hanging arm casts initially for oblique or spiral fractures with shortening, when the cast can extend at least 2 cm proximal to the fracture site. When a hanging arm cast is used, it should be replaced, once reduction is adequate, with another treatment or should be monitored closely to look for fracture distraction and nonunion. In some cases, a functional arm brace can also serve as initial treatment.
The functional brace, first used by Sarmiento et al in 1977, consists of anterior and posterior plastic shells that are held together with Velcro straps. The fracture is kept in position through soft-tissue compression, and the brace is tightened as the swelling decreases. Over-the-shoulder extensions are available but are rarely necessary. A functional brace should not be used when massive soft-tissue injury or bone loss has occurred, when an acceptable fracture alignment cannot be maintained, or when the patient is unreliable or uncooperative.
For many of the nonoperative treatments (eg, functional bracing, hanging arm casts, and coaptation splinting) to work most effectively, the patient should remain upright, either standing or sitting, and should avoid leaning on the elbow for support. This allows gravitational force to assist in fracture reduction. The patient should begin ROM exercises of the fingers, wrist, elbow, and shoulder as soon as these can be tolerated.
A Velpeau dressing or a sling-and-swathe (similar to the Velpeau dressing but less restrictive) is typically used in nondisplaced or minimally displaced fractures in children younger than 8 years, as well as in elderly patients who are unable to tolerate other treatment methods. Pads can be placed in the axilla to control fracture angulation.
Acceptable alignment of humeral shaft fractures is considered to be 3 cm of shortening, 30º of varus/valgus angulation, and 20º of anterior/posterior angulation.[1, 21] Varus/valgus angulation is tolerated better proximally, and more angulation may be tolerated better in patients with obesity. Patients with large, pendulous breasts who are treated nonsurgically are at increased risk for varus angulation. No set values for acceptable malrotation exist, but compensatory shoulder motion allows for considerable tolerance of rotational deformity.
Low-velocity gunshot wounds act as closed injuries after initial treatment (debridement of skin at the entry and exit sites and a single dose of prophylactic antibiotics).
The patient's position for surgery is determined by the method chosen for fixation. Antegrade nailing of the humerus is performed with the arm draped free and the patient in either a beach chair or a supine position. For the placement of distal locking screws, the C-arm can be rotated 180º so that the top can be used as a table to support the arm. Retrograde nailing is performed with the patient in the prone position and the arm supported on a radiolucent arm board.
Positioning for placement of plates and screws is again determined by the approach chosen. During a posterior approach, the patient is positioned prone, with the arm over an arm board. The patient is positioned supine for an anterior approach, with the extremity placed in about 60º of abduction on an arm board.
External fixation is performed with the patient supine and the arm on an arm board.
Surgical fixation using plates and screws
Open reduction and internal fixation (ORIF) with direct fracture exposure often yield near-anatomic alignment. The rates of nonunion and hardware failure necessitating revision range from 0% to 7%.[14, 22] The ROM of the elbow and shoulder predictably returns after plate fixation; when complete motion is not obtained, it is often the case that other associated skeletal or neurologic injuries exist.
Evidence also suggests that immediate weightbearing on an upper extremity that has been treated with ORIF has little or no deleterious effect. The most common complications associated with plating procedures are iatrogenic nerve palsy (0-5%, with most cases being a transient problem that requires no further intervention) and infection (0-6%).[14, 22, 24]
The two approaches most commonly used for fracture exposure and plate application are the posterior approach and the anterolateral approach. Either is adequate for fractures in the midthird and distal third, but fractures in the proximal third often require the anterolateral approach.[2, 1, 15, 18] The medial approach has also been described, though less commonly.
The posterior approach exploits the interval between the lateral and long heads of the triceps (best found proximally). The medial head of the triceps is then incised down the midline to expose the posterior aspect of the humeral shaft.
If additional proximal exposure is required, the extensile posterior approach can be used. This approach involves identifying the lower lateral brachial cutaneous nerve and radial nerve distally and then resecting the distal 3 cm of the lateral septum. This allows medial retraction of the radial nerve. The medial and lateral heads of the triceps then can be elevated off the lateral intermuscular septum and bone.
This extensile posterior approach allows exposure of the shaft proximally to the axillary nerve. The radial nerve crosses the posterior aspect of the humerus, where it is, on average, 20.7 (±1.2) cm proximal to the medial epicondyle and 14.2 (±0.6) cm proximal to the lateral condyle.
In the anterolateral approach, two different internervous planes are used. Proximally, the plane is between the deltoid and the pectoralis major. Distally, the plane lies between the medial fibers of the brachialis (ie, the musculocutaneous nerve) and its lateral fibers (ie, the radial nerve).
Care should be taken to avoid excessive soft-tissue stripping and devitalization of butterfly fragments. A 4.5-mm–broad dynamic compression plate (or a narrow plate in smaller individuals) is typically selected. Lag screws should be inserted when possible, and five to 10 cortices of fixation (proximal and distal to the fracture site) should be obtained. Fracture stability should then be assessed.[2, 1, 11, 17, 18]
The need for additional bone grafting is determined at the time of surgery. A low threshold for the addition of cancellous bone grafting should be maintained.
In certain situations (eg, where humeral size is limited), however, dual small-fragment locking plate constructs may be an alternative to a single large-fragment plate. A study by Kosmopoulos and Nana suggested that in such situations, orthogonal (90º) plates may be preferable to side-by-side plates.
Some surgeons prefer not to plate humeral shaft fractures, because of the difficulties of dealing with fracture exposure, the technical aspects of plating, and complex fracture patterns, as well as because of concerns about radial nerve injury.[15, 29]
Modified techniques for minimally invasive plating have been reported.[30, 31] Although minimally invasive plate osteosynthesis (MIPO) is a difficult procedure, satisfactory outcomes have been achieved by skilled surgeons with an understanding of neurovascular anatomy.[31, 32, 33, 34]
Surgical fixation with intramedullary implants
Intramedullary fixation has gained popularity in this setting. Initial reports found there to be a higher nonunion rate with such fixation than with conservative treatment or with ORIF with plates and screws. However, several subsequent reports demonstrated that with newer implants and improved techniques, locked intramedullary nailing could achieve a success rate as high as that of the other methods.[3, 24, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44] In these studies, the incidence of nonunion was approximately 6%, the incidence of infection was 2%, and the incidence of radial nerve palsies was 3%.
Intramedullary nailing can be used to stabilize fractures that are 2 cm below the surgical neck to 3 cm proximal to the olecranon fossa. Results comparing ORIF with locked intramedullary nailing have failed to demonstrate any difference in blood loss or operating room time.[15, 24]
Intramedullary nails have certain potential advantages over plates and screws. The intramedullary nail is closer to the normal mechanical axis and can act as a load-sharing device if there is cortical contact. The nails are subjected to lower bending forces and thus are less likely to fail through fatigue. Intramedullary nails can be placed without direct fracture exposure and with much less soft-tissue dissection. Additionally, cortical osteopenia caused by stress shielding (as is seen with plates and screws) is less likely.
Standard locked intramedullary humeral nails can also be inserted via either an antegrade or a retrograde approach. The antegrade approach typically involves a starting point at the proximal humerus; this point can be through the rotator cuff, where the tissue is less vascular, or just lateral to the articular surface, where the blood flow is higher.
The procedure can be started with a small incision made with the aid of fluoroscopy or with a larger incision in which the cuff is identified and purposefully incised. No evidence has indicated that either method is superior.[45, 46, 47] The nail can be placed with or without reaming (no evidence suggests that either method is superior with regard to healing time and complication rate), then locked proximally and distally.
Care must be exercised in the placement of the proximal locking screws because the axillary nerve lies 5-6 cm distal to the edge of the acromion. The distal locking screw can often be placed by means of a lateromedial or an anteroposterior approach. The lateromedial technique puts the radial nerve at risk, and the anteroposterior method places the musculocutaneous nerve at risk. An alternative and possibly safer method involves placing the screw posteroanteriorly.
Retrograde insertion of intramedullary humeral nails requires a distal triceps-splitting approach and the use of a hole, 1 cm wide and 2 cm long, that is placed 2.5 cm proximal to the olecranon fossa. The starting hole must be beveled along the path of the nail insertion. The nail can be locked proximally, either lateromedially (placing the axillary nerve at risk) or anteroposteriorly (placing the biceps tendon at risk).
If any resistance is met during attempted passage of the nail, either antegrade or retrograde, consideration should be given to making a small incision to ensure that the radial nerve is not entrapped in the fracture site.
The use of flexible nails (often Ender nails with a 3.5-mm diameter) has become limited to isolated cases of transverse or short oblique fractures with a canal larger than 7 mm. These nails can be inserted either retrograde (the more common approach, accomplished through triceps splitting with an entry portal just above the olecranon fossa) or antegrade.
These nails can be locked at the end with wire or 3.5-mm cortical screws to prevent migration, but no method of statically locking the nails exists. Therefore, bending and angulation can still occur in spiral or comminuted fractures. Furthermore, a canal of less than 7 mm only allows insertion of one nail.
Studies of the outcome of humeral fractures treated with flexible intramedullary nailing (Ender nails) reveal that antegrade insertion is associated with shoulder dysfunction (pain and decreased ROM) in 5-10% of patients and that hardware removal is not entirely effective in relieving symptoms.[48, 49, 50] A starting point outside the rotator cuff may help decrease these numbers. Reports on the use of Rush rod fixation have demonstrated unacceptably high rates of nonunion, delayed union, and shoulder pain.
With retrograde nailing, union rates range from 91% to 98%, and rates of infection (which is mostly associated with open fractures) range from 0% to 2%. With the use of multiple nails, hardware failure is reported to be rare, and the rate of iatrogenic radial nerve injury, which is usually temporary, is placed at 3%.
Locked intramedullary nailing in an antegrade fashion has resulted in loss of shoulder motion in 6-37% of cases.[45, 47] It has also been reported that retrograde nailing is not associated with shoulder pain and that the return of elbow motion is not a problem unless other associated injuries are located in the fractured extremity. A concern also exists that once the retrograde nail has been placed, the starting hole just distal to this may act as a stress riser.
Biomechanical studies have shown that for midshaft fractures, retrograde and antegrade nailing showed similar initial stability, bending, and torsional stiffness. In proximal fractures (10 cm distal to the greater tuberosity tip), the antegrade nails have demonstrated significantly more initial stability and higher bending and torsional stiffness, as has been true for distal fractures with retrograde nailing.
Nonunions in humeral fractures after treatment with plate and screws typically respond well to replating with the addition of bone graft. This is not the case when nonunions follow treatment with humeral nails. If a humeral nonunion treated with an intramedullary nail is treated with exchange nailing, the success rate can be as low as 40-60%.[47, 53] However, if the nail is removed and ORIF with bone grafting is performed, the union rate is again very high. However, this is a more technically difficult scenario.
Surgical fixation with external fixators
Traditionally, external fixation of humeral shaft fractures has been limited to open fractures. The open wound should be treated in an appropriate manner and, for Gustilo grade I or II wounds, followed by ORIF or unreamed intramedullary nailing. For grade III wounds, external fixation is the treatment of choice. Debridement is performed every 48 hours until the wound is clean. Then, at the final debridement, bone grafting may be used if needed. Treatment of humeral shaft fractures with an external fixator carries a high complication rate.
Radial nerve injury occurs in as many as 18% of humeral shaft fractures. Although the oblique distal third humeral fracture (Holstein-Lewis) is better known for an association with radial nerve palsy than other humeral shaft fractures are, such palsy most commonly occurs with middle third humeral fractures. Most of these nerve injuries are neurapraxic or axonotmetic types, 90% of which resolve to at least grade IV strength in 3-4 months.[14, 56]
Indications for early nerve exploration include a palsy associated with an open wound or penetrating injury. The question of whether it is best to explore a radial nerve when function decreases after closed manipulation is controversial. Some authors recommend waiting to perform exploration if no return of function is observed after 3-4 months, stating that the results of secondary repair of radial nerve injuries are as good as those of primary repair and that the situation has been made easier because the fracture has had time to heal.
Brachial artery injuries that are associated with humeral shaft fractures are uncommon. At risk fractures are those in the proximal and distal thirds of the arm. Surgical stabilization of fractures associated with arterial injury is mandatory at the time of vascular repair.
A period of 4 months has been noted to be adequate to allow humeral shaft fractures to heal. The nonunion rate reportedly ranges from 1% to 15%. A higher nonunion rate for humeral shaft fractures has been associated with transverse fractures, as well as with such factors as fracture distraction, soft-tissue interposition, inadequate shoulder immobilization, and decreased shoulder motion.[58, 59, 60]
Medical factors that decrease the union rate include diabetes mellitus, corticosteroid use, older age, poor nutritional status, obesity, fractures underlying a burn, and previous radiation.[61, 62] Functional bracing has little role in nonunion. Electrical stimulation may be beneficial but should not be used when infection, a gap of more than 1 cm, or a synovial pseudarthrosis is present.
ORIF with compression plates and screws, with or without the aid of bone grafting, is considered to be the treatment of choice for most established nonunions. Some reports describe nonunions being treated with retrograde intramedullary nails and antegrade nails, with a union rate similar to that associated with ORIF.[24, 63]
Beaty JH. Humeral shaft fractures. Orthopaedic Knowledge Update. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999. 278-86.
Zuckerman JD, Koval KJ. Fractures of the shaft of the humerus. Rockwood CA, Green DP, Bucholz RW, et al, eds. Rockwood and Greens’ Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996. 1025-53.
Lin J, Hou SM, Hang YS, et al. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res. 1997 Sep. (342):147-55. [Medline].
Persad IJ, Kommu S. U cast or functional bracing following fractures of the shaft of humerus. Emerg Med J. 2007 May. 24(5):361. [Medline].
Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006 Nov. 88(11):1469-73. [Medline].
Williams PL, Warwick R, Dyson M, et al, eds. Gray’s Anatomy. 37th ed. New York, NY: Churchill Livingstone; 1989. 406-10.
Mahabier KC, Vogels LM, Punt BJ, Roukema GR, Patka P, Van Lieshout EM. Humeral shaft fractures: Retrospective results of non-operative and operative treatment of 186 patients. Injury. 2012 Aug 28. [Medline].
Connolly S, McKee MD, Zdero R, Waddell JP, Schemitsch EH. Immediate Plate Osteosynthesis of Open Fractures of the Humeral Shaft. J Trauma. 2010 Jan 8. [Medline].
Heineman DJ, Poolman RW, Nork Sean SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop. 2010 Apr. 81(2):218-25. [Medline].
Pretell J, Rodriguez J, Blanco D, Zafra A, Resines C. Treatment of pathological humeral shaft fractures with intramedullary nailing. A retrospective study. Int Orthop. 2010 Apr. 34(4):559-63. [Medline].
Hartsock LA. Humeral shaft fractures. Levine AM, eds. Orthopaedic Knowledge Update, Trauma. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999. 23-32.
Garcia A Jr, Maeck BH. Radial nerve injuries in fractures of the shaft of the humerus. Am J Surg. 1960 May. 99:625-7. [Medline].
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 Dec. 87(12):1647-52. [Medline].
Foster RJ, Dixon GL Jr, Bach AW, et al. Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study. J Bone Joint Surg Am. 1985 Jul. 67(6):857-64. [Medline].
Gregory PR, Sanders RW. Compression plating versus intramedullary fixation of humeral shaft fractures. J Am Acad Orthop Surg. 1997 Jul. 5(4):215-23. [Medline].
Schatzker J. Fractures of the humerus. Schatzker J, Tile M, eds. The Rationale of Operative Fracture Care. New York, NY: Springer-Verlag; 1987. 61-70.
Crenshaw AH. Shaft of humerus. Canale ST, ed. Campbell’s Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby; 1998. 2296-309.
Ward EF, Savoie FH, Hughes JL. Fractures of the diaphyseal humerus. Browner BD, Jupiter JB, Levine AM, et al, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2nd ed. Philadelphia, Pa: WB Saunders; 1998. 1523-47.
Sarmiento A, Kinman PB, Galvin EG, et al. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977 Jul. 59(5):596-601. [Medline].
Naver L, Aalberg JR. Humeral shaft fractures treated with a ready-made fracture brace. Arch Orthop Trauma Surg. 1986. 106(1):20-2. [Medline].
Klenerman L. Fractures of the shaft of the humerus. J Bone Joint Surg Br. 1966 Feb. 48(1):105-11. [Medline]. [Full Text].
Heim D, Herkert F, Hess P, et al. Surgical treatment of humeral shaft fractures--the Basel experience. J Trauma. 1993 Aug. 35(2):226-32. [Medline].
Tingstad EM, Wolinsky PR, Shyr Y, et al. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000 Aug. 49(2):278-80. [Medline].
Rodriguez-Merchan EC. Compression plating versus hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma. 1995 Jun. 9(3):194-7. [Medline].
Lu S, Wu J, Xu S, Fu B, Dong J, Yang Y, et al. Medial approach to treat humeral mid-shaft fractures: a retrospective study. J Orthop Surg Res. 2016 Mar 17. 11:32. [Medline]. [Full Text].
Hoppenfeld S, deBoer P. The humerus. Hannon BC, ed. Surgical Exposures in Orthopaedics: The Anatomic Approach. 2nd ed. Philadelphia, Pa: JB Lippincott; 1984. 52-65.
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 Nov. 78(11):1690-5. [Medline].
Kosmopoulos V, Nana AD. Dual plating of humeral shaft fractures: orthogonal plates biomechanically outperform side-by-side plates. Clin Orthop Relat Res. 2014 Apr. 472(4):1310-7. [Medline]. [Full Text].
Farragos AF, Schemitsch EH, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma. 1999 May. 13(4):258-67. [Medline].
Tan JC, Kagda FH, Murphy D, Thambiah JS, Khong KS. Minimally invasive helical plating for shaft of humerus fractures: technique and outcome. Open Orthop J. 2012. 6:184-8. [Medline]. [Full Text].
Shin SJ, Sohn HS, Do NH. Minimally invasive plate osteosynthesis of humeral shaft fractures: a technique to aid fracture reduction and minimize complications. J Orthop Trauma. 2012 Oct. 26(10):585-9. [Medline].
Kim JW, Oh CW, Byun YS, Kim JJ, Park KC. A Prospective Randomized Study of Operative Treatment for Non-comminuted, Humeral Shaft Fractures: Conventional Open Plating versus Minimal Invasive Plate Osteosynthesis. J Orthop Trauma. 2014 Sep 10. [Medline].
Lee HJ, Oh CW, Oh JK, Apivatthakakul T, Kim JW, Yoon JP, et al. Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator. Arch Orthop Trauma Surg. 2013 May. 133(5):649-57. [Medline].
Esmailiejah AA, Abbasian MR, Safdari F, Ashoori K. Treatment of Humeral Shaft Fractures: Minimally Invasive Plate Osteosynthesis Versus Open Reduction and Internal Fixation. Trauma Mon. 2015 Aug. 20 (3):e26271. [Medline]. [Full Text].
Sims SH, Smith SE. Intramedullary nailing of humeral shaft fractures. J South Orthop Assoc. 1995 Spring. 4(1):24-31. [Medline].
Achecar F, Whittle AP. Unreamed vs reamed interlocking nailing of humeral shaft fractures. Orthop Trans. 1997. 21:1166.
Brumback RJ. The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res. 1996 Mar. (324):292-320. [Medline].
Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res. 1998 May. (350):40-50. [Medline].
Ingman AM, Waters DA. Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results. J Bone Joint Surg Br. 1994 Jan. 76(1):23-9. [Medline]. [Full Text].
Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am. 1996 Jun. 78(6):891-6. [Medline].
Rommens PM, Verbruggen J, Broos PL. Retrograde locked nailing of humeral shaft fractures. A review of 39 patients. J Bone Joint Surg Br. 1995 Jan. 77(1):84-9. [Medline]. [Full Text].
Shazar N, Brumback RJ, Vanco B. Treatment of humeral fractures by closed reduction and retrograde intramedullary Ender nails. Orthopedics. 1998 Jun. 21(6):641-6. [Medline].
Tomé J, Carsi B, García-Fernández C, et al. Treatment of pathologic fractures of the humerus with Seidel nailing. Clin Orthop Relat Res. 1998 May. (350):51-5. [Medline].
Mückley T, Diefenbeck M, Sorkin AT, et al. Results of the T2 humeral nailing system with special focus on compression interlocking. Injury. 2007 Dec 27. [Medline].
Riemer BL, Foglesong ME, Burke CJ 3rd. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopedics. 1994 Jan. 17(1):19-29. [Medline].
Riemer BL, Butterfield SL, D'Ambrosia R, et al. Seidel intramedullary nailing of humeral diaphyseal fractures: a preliminary report. Orthopedics. 1991 Mar. 14(3):239-46. [Medline].
Robinson CM, Bell KM, Court-Brown CM, et al. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br. 1992 Jul. 74(4):558-62. [Medline]. [Full Text].
Brumback RJ, Bosse MJ, Poka A, et al. Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma. J Bone Joint Surg Am. 1986 Sep. 68(7):960-70. [Medline].
Hall RF Jr, Pankovich AM. Ender nailing of acute fractures of the humerus. A study of closed fixation by intramedullary nails without reaming. J Bone Joint Surg Am. 1987 Apr. 69(4):558-67. [Medline].
O'Donnell TM, McKenna JV, Kenny P, et al. Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus. J Bone Joint Surg Br. 2008 Jan. 90(1):61-5. [Medline].
Stern PJ, Mattingly DA, Pomeroy DL, et al. Intramedullary fixation of humeral shaft fractures. J Bone Joint Surg Am. 1984 Jun. 66(5):639-46. [Medline].
Lin J, Inoue N, Valdevit A, et al. Biomechanical comparison of antegrade and retrograde nailing of humeral shaft fracture. Clin Orthop Relat Res. 1998 Jun. (351):203-13. [Medline].
McKee MD, Miranda MA, Riemer BL, et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma. 1996. 10(7):492-9. [Medline].
Mostafavi HR, Tornetta P 3rd. Open fractures of the humerus treated with external fixation. Clin Orthop Relat Res. 1997 Apr. (337):187-97. [Medline].
Pollock FH, Drake D, Bovill EG, et al. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am. 1981 Feb. 63(2):239-43. [Medline].
Kettelkamp DB, Alexander H. Clinical review of radial nerve injury. J Trauma. 1967 May. 7(3):424-32. [Medline].
Verga M, Peri Di Caprio A, Bocchiotti MA, et al. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: review and evaluation of the long-term results of 52 cases. J Hand Surg Eur Vol. 2007 Oct. 32(5):529-33. [Medline].
Boyd HB. The treatment of difficult and unusual nonunions. J Bone Joint Surg. 1943. 25:535.
Mast JW, Spiegel PG, Harvey JP Jr, et al. Fractures of the humeral shaft: a retrospective study of 240 adult fractures. Clin Orthop Relat Res. 1975 Oct. (112):254-62. [Medline].
Urist MR, Mazet R, McLean FC. The pathogenesis and treatment of delayed union and nonunion. J Bone Joint Surg. 1954. 36A:931.
Healy WL, White GM, Mick CA, et al. Nonunion of the humeral shaft. Clin Orthop Relat Res. 1987 Jun. (219):206-13. [Medline].
Green E, Lubahn JD, Evans J. Risk factors, treatment, and outcomes associated with nonunion of the midshaft humerus fracture. J Surg Orthop Adv. 2005. 14(2):64-72. [Medline].
Wu CC, Shih CH. Treatment for nonunion of the shaft of the humerus: comparison of plates and Seidel interlocking nails. Can J Surg. 1992 Dec. 35(6):661-5. [Medline].