J Korean Fracture Soc. 2000 Oct;13(4):982-991. Korea

Reprint of article in Injury on Orthofix website

eMedicine Lawless 2004

Pathologic Humerus Fracture Reuben Gobezie MD, Brent A. Ponce MD, John Ready MD DEPARTMENT OF ORTHOPAEDICS, BRIGHAM AND WOMEN'S HOSPITAL, BOSTON MA Introduction Bony lesions may result in pathologic fractures. These lesions, when not of mesenchymal origin, commonly include myeloma, lymphoma, and most commonly metastastic carcinoma. The axial skeleton is the third most common site of bony metastasis, after the lung and liver. Of the 1.2 million new cases of cancer each year in the United States, one half will metastasize to the skeleton1. The tumors most likely to metastasize to bone are prostate (32%), breast (22%), kidney (16%), lung and thyroid1. Metastatic disease to the axial skeleton occurs much more frequently in the spine, pelvis, ribs, and lower extremities than in the humerus. Yet, metastasis to the humerus accounts for 20% of osseous metastasis. The humerus is the second most common site for long bone metastases, behind only the femur in its frequency of involvment. In multiple myeloma, the majority of patients have pathologic fractures at the time of diagnosis, and up to 30% of patients present with non-vertebral fractures2. Metastasis to the long bones usually reflects an advanced disease state. It has been recommended that the majority of patients with metastatic bone tumors receive multidisciplinary care from a team including orthopaedic oncologists, radiotherapists, and oncologists.

Wheeless'in children, supracondylar frxs typically remains extra-articular & involves thin bone between coronoid fossa & olecranon fossa of distal humerus; - frx line angles from anterior distal point to posterior prox site; - in adults, supracondylar frx of humerus may be intra-articular; - frx occurs most often around age 6-7 years; Textbook of Orthopaedics

Medscape 2000 Report on presentation on Polaris Humeral Intramedullary Nailing

OTA e-Poster 2001

OTA paper 2004

Abstract OTA paper 2004
Conclusion/Significance: Plating of humeral shaft fractures has traditionally been performed with 4.5-mm dynamic compression plates, broad or narrow, with good results, and this method is treated as our control group in this study. The smaller 3.5-mm plate offers the theoretical advantage of more holes per unit length, especially useful in complex comminuted fractures or periarticular fractures, particularly of the distal third of the humeral shaft. They are generally more easily contoured and are more easily positioned on the humerus. Decreased need for dissection resulting in fewer traumas to the radial nerve may also be an advantage. The advent of locked-plating technology makes these implants even more attractive for routine use in fixation of the humeral shaft. In our series, no failures occurred in the locked-plating group, even with weight-bearing. Although the larger plates remain the likely implant of choice for nonunion of the humerus, we believe that these results support the use of 3.5-mm plates, particularly the locking-compression plates, for the routine operative treatment of humeral shaft fractures.

2 Cases Report. J Korean Fracture Soc. 2000 Oct;13(4):978-98 Spiral fractures of the middle or distal shaft of the humerus that occur during attempts to throw a variety of objects are not common. Many authors have reported that the cause of fracture was the results of uncoordinated muscle violence. We experienced two cases of throwing fractures of humerus, one is baseball player(catcher) preceded by arm pain during throwing motion, the other is recreational hand grenade player without prodromal arm pain. 1. Korean (Abstract)

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #64, 10:16 AM Treatment of High-Energy Supracondylar/Intercondylar Fractures of the Distal Humerus Lisa K. Cannada, MD , Mary B. Zadnik, OTR/L; Walter Andrew Eglseder, MD; University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA Purpose: High-energy intraarticular fractures of the distal humerus seen at major trauma centers are often open, and the patients may have multiple injuries. The literature does not specifically address the long-term outcomes of the surgical decision-making protocol. Our technique involves the use of a staged capsulectomy, no routine transposition of the ulnar nerve, and olecranon osteotomy fixation with a 6.5 partially threaded cancellous screw and tension band wiring. The purpose of this study was to review the results of our protocol to provide trauma surgeons with guidelines to assist in the surgical decision making and treatment of these complex injuries to provide for an optimal functional outcome. Methods: After obtaining IRB approval, the Trauma Registry was used to identify our study population. Between 1997 and 2001, 70 patients with 71 fractures were treated. There were 41 men and 29 women with an average age of 42 years (range, 16 to 85). Fifty-five percent of fractures were open (grade I, 6; II,19; IIIA, 9; IIIB, 5). Twenty-two patients had isolated injuries, and 25 (36%) had ipsilateral associated upper extremity trauma. Sixty-nine percent of patients had associated injuries, including 15 closed head injuries. The mechanism of injury was a motor vehicle accident (28), a fall >from a height (17), a pedestrian struck by an auto (8), a gun shot wound (5), industrial (4), and miscellaneous (8). According to the OTA classification, there were 28 13C-2 and 43 13C-3 fractures. The majority of operations were performed by a single surgeon through a posterior, triceps-sparing approach. The ulnar nerve was meticulously dissected and mobilized with the avoidance of traction or devascularization. Fracture fixation was with a combination of pelvic reconstruction plates or LCDC plates or both in addition to supplemental screw and K-wire fixation. Capsulectomy was completed in those patients with significant limitations (less than 60° of flexion/extension arc) of motion after an average of 10 months of follow-up. Clinical follow-up consisted of a physical examination, radiographs, and completion of the DASH. Results: Sixteen patients were lost to follow-up. The average follow-up was 14 months (range, 3 to 67). Complications included five nonunions of the humerus, three nonunions of the olecranon, four ulnar nerve neurolyses, four superficial and three deep infections. Adapted Cassebaum ratings of results were 70% good to excellent, 20% fair, and 10% poor. Patients with isolated fractures had 81% good-to-excellent results; those who had polytrauma had 65% good-to-excellent results. Seventeen patients (25%) had capsulectomies, and 14 of them had good-to-excellent results, 2 had a fair result, and 1 was lost to follow-up. With use of our olecranon osteotomy fixation technique, there was only a 4% nonunion rate and two reports of painful hardware. Five patients had ulnar nerve symptoms at follow-up. The overall DASH score was 72. Discussion: Supracondylar/intercondylar fractures of the distal humerus are among the most challenging fractures for the orthopaedic surgeon to treat. Our study population involved high-energy fractures; 55% of these were open injuries and 69% of patients had polytrauma. With these patients, operative stabilization can be of significant value in their care. However, early mobilization and rehabilitation may be difficult. The majority of capsulectomies were performed in this population, with 82% having a good-to-excellent result. We found only five patients (7%) with ulnar nerve symptoms at follow-up; therefore, we do not recommend routine transposition. Use of the long intramedullary screw for olecranon osteotomy fixation appears to minimize the risk of complications after osteotomy. In the largest series to date, our results demonstrate that our approach to the OTA C2 and C3 fractures of the distal humerus should help with the surgical decision-making and treatment of these fractures to provide for optimal functional outcome.