AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Although most fractures of the humeral shaft are inherently unstable, nonoperative treatment remains the criterion standard.¹ For operative candidates, the role of surgery, as well as which type of surgery is appropriate, is dependent on the patient and the fracture characteristics.^{2, 3}

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Arm.

See also the following related topics in eMedicine:
Distal Humerus Fractures
Fractures, Humerus
Proximal Humerus Fractures

See also the following related topics in Medscape:
Interventions for treating proximal humeral fractures in adults
Imaging of Elbow Pathology

Problem

No classification scheme for humeral shaft fractures has gained universal acceptance. The Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF) classification is based on the amount of comminution, as follows:

• Type A fractures - No comminution has occurred.
• Type B fractures - A butterfly fragment is present.
• Type C fractures - Comminution has occurred.

Traditionally, humeral shaft fractures have been described according to the following features⁴:

• Location - For example, proximal, middle, or distal
• Type of fracture line - Such as transverse, oblique, spiral, comminuted, or segmental
• Opened or closed status

See also the following related eMedicine article:
General Principles of Fracture Care

Frequency

Fractures of the humeral shaft account for approximately 3% of all fractures.^{5, 4}

Clinical

Patients with humeral shaft fractures present with arm pain, deformity, and swelling. The arm is shortened, with motion and crepitus on manipulation. A careful neurovascular evaluation of the limb must be documented, because the incidence of radial nerve injuries is approximately 16%.⁶ If indicated, Doppler pulse and compartment pressures should be checked.^{5, 7, 8}

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The 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 1 fracture site or at both of them)⁹
• Prolonged recumbency or an inability to maintain a semisitting or reclined position, as in a patient with multiple traumatic injuries
• Noncompliance

Ipsilateral fracture of the ulna and/or radius is another indication for surgery, requiring stabilization of the humeral and forearm fractures to allow early range of motion (ROM).^{5, 6, 10} If the patient has bilateral humeral fractures, 1 or both should be fixed to allow patient self-care.⁴ 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 following closed manipulation. Such injuries were once thought to be indications for surgery; however, this assumption has now been called into question.⁵ Spinal cord or brachial plexus injuries are indications for surgery.¹⁰ Surgery is also indicated for fractures of the humeral shaft that are associated with displaced intra-articular fracture extension.¹¹

See also the following related topics in eMedicine:
Floating Elbow
General Principles of Internal Fixation

See also the following related topic in Medscape:
Resource Center Spinal Disorders

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The humeral shaft is the area extending from the upper border of the pectoralis major tendon to the supracondylar ridge. The proximal half is almost cylindrical, while distally, the anteroposterior diameter narrows into a prismatic shape. The posterior surface (between the medial and lateral borders) is the largest. The radial sulcus, which contains the radial nerve and, at its midpoint, the nutrient foramen, crosses the posterior middle third of the humerus.

The large muscles that surround the humerus prevent direct palpation. The arm is divided into anterior and posterior compartments by 2 intermuscular septa: medial and lateral. The anterior compartment contains the biceps brachii, coracobrachialis, and brachialis muscles; the brachial artery and vein; and the median, musculocutaneous, and ulnar nerves. The triceps muscle and the radial nerve are contained in the posterior compartment.¹²

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

There are limited, if any, absolute contraindications to surgery for a midshaft humeral fracture.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Imaging Studies

• Anteroposterior and lateral radiographs should be obtained first. These should be taken at 90° angles to each other. To obtain these radiographs, move the patient rather than rotate the injured limb through the fracture site. The shoulder and elbow should be included on each radiograph. Traction radiographs may be helpful with comminuted or severely displaced fractures, and comparison radiographs of the contralateral side may be helpful for determining preoperative length.^{4, 5}
• Computed tomography (CT) scanning is rarely indicated.⁴

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Medical Therapy

Most closed fractures of the humeral shaft can be treated successfully with closed methods; union rates of more than 90% are often reported.^{4, 13, 14} Multiple closed techniques are available, including the employment of traction, as well as the use of the hanging arm cast, co-aptation splint, Velpeau dressing, abduction humeral/shoulder spica cast, or functional brace.^{4, 13} All of these techniques have been used successfully, but closed humeral shaft fractures are usually treated with a hanging arm cast or a co-aptation splint for 1-3 weeks, after which they are placed in a functional brace.^{4, 5, 6, 14}

No recommendations have been reported regarding the use of the hanging arm cast versus the co-aptation splint, although Rockwood recommends using hanging arm casts initially for oblique or spiral fractures with shortening, when the cast is able to extend at least 2 cm proximal to the fracture site.⁴ When a hanging arm cast is employed, it should be replaced, once reduction is adequate, with another treatment method or should be monitored very closely to look for fracture distraction and nonunion.¹⁴ In some cases, a functional arm brace also can be applied as the initial treatment.

Sarmiento and colleagues first used the functional brace in 1977.¹⁵ This device 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 if the patient is unreliable or uncooperative.¹⁶

For many of the nonoperative treatments (eg, functional bracing, hanging arm casts, co-aptation 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 (which is similar to the Velpeau dressing but is 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.¹⁴

Acceptable alignment of humeral shaft fractures is considered to be 3 cm of shortening, 30° of varus/valgus angulation, and 20° of anterior/posterior angulation.^{5, 17} 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 of varus angulation. No set values for acceptable malrotation exist, but compensatory shoulder motion allows for considerable tolerance of rotational deformity.⁵

Low-velocity gunshot wounds act as closed injuries after initial treatment (debridement of skin at the entry and exit sites and a single dose prophylactic antibiotics).⁵

Surgical Therapy

Surgical fixation using plates and screws

Open reduction and internal fixation (ORIF) with direct fracture exposure often yields near anatomic alignment. The rates of nonunion and hardware failure requiring revision range from 0-7%.^{9, 18} 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.¹⁰ Evidence also suggests that immediate weight bearing on an upper extremity that has been treated with ORIF has little or no deleterious effect.¹⁹ 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%).^{9, 18, 20}

The 2 approaches that are used for fracture exposure and plate application are the posterior approach and the anterolateral approach. Either approach is adequate for fractures in the midthird and distal third, but fractures in the proximal third often require the anterolateral approach.^{4, 5, 10, 14}

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.²¹

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.²² The radial nerve crosses the posterior aspect of the humerus, where it is, on average, 20.7 cm (±1.2 cm) proximal to the medial epicondyle and 14.2 cm (±0.6 cm) proximal to the lateral condyle.²²

In the anterolateral approach, 2 different internervous planes are used. Proximally, the plane is between the deltoid and pectoralis major. Distally, the plane lies between brachialis' medial fibers (ie, the musculocutaneous nerve) and its lateral fibers (ie, the radial nerve).²¹

Care should be taken to avoid excessive soft-tissue stripping and the 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 5-10 cortices of fixation (proximal and distal to the fracture site) should be obtained. Fracture stability should then be assessed.^{4, 5, 6, 13, 14}

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.⁴

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.^{10, 23}

Surgical fixation with intramedullary implants

Intramedullary (IM) fixation has gained popularity over the last several years. Initial reports revealed that there was a higher nonunion rate following such fixation than there was with conservative treatment or with ORIF with plates and screws. However, several reports have demonstrated that with newer implants and improved techniques, locked IM nailing can achieve a success rate as high as that of the other methods.^{1, 20, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33} In these studies, the incidence of nonunion is approximately 6%, the incidence of infection is 2%, and the incidence of radial nerve palsies is 3%. IM nailing can be used to stabilize fractures that are 2 cm below the surgical neck to 3 cm proximal to the olecranon fossa.⁵ Results comparing ORIF with locked IM nailing have failed to demonstrate any difference in blood loss or operating room time.^{10, 20}

IM nails have certain potential advantages over plates and screws. The IM 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, making failure by fatigue less likely to occur.⁵ IM nails can be placed without direct fracture exposure and with much less soft-tissue dissection. Additionally, cortical osteopenia caused by stress shielding (as seen with plates and screws) is less likely.

Standard locked intramedullary humeral nails can also be inserted either antegrade or retrograde. 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, where the cuff is identified and purposefully incised. No evidence has indicated that either method is superior.^{34, 35, 36} 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) and then be locked proximally and distally.¹⁰ Care must be exercised when placing the proximal locking screws because the axillary nerve lies 5-6 cm distal to the edge of the acromion.²³ The distal locking screw can often be placed lateromedial or anteroposterior. 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.⁶

Retrograde insertion requires a distal triceps splitting approach and a hole placed 2.5 cm proximal to the olecranon fossa, measuring 1 cm in width and 2 cm in length.¹⁰ The starting hole must be beveled along the path of the nail insertion.⁶ 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 while attempting to pass 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 (more common, 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 these 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 1 nail.¹⁰

The outcome of humeral fractures treated with flexible IM nailing (Ender nails) reveals 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.^{37, 38, 39} A starting point outside the rotator cuff may help to decrease these numbers. Reports on the use of Rush rod fixation have demonstrated unacceptably high rates of nonunion, delayed union, and shoulder pain.⁴⁰ With retrograde nailing, union rates vary from 91-98%, and infection (which is mostly associated with open fractures) varies from 0-2%. 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%.¹⁰

Locked IM nailing in an antegrade fashion has resulted in loss of shoulder motion in 6-37% of cases.^{34, 36} 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.¹⁰ 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.²³ 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.⁴¹

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 IM nail is treated with exchange nailing, the success rate can be as low as 40-60%.^{36, 42} 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.²³

Surgical fixation with external fixators

Traditionally, the 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, be followed by ORIF or unreamed IM nailing. For grade III wounds, external fixation is the treatment of choice. Debridements are performed every 48 hours until the wound is clean. Then, at the final debridement, bone grafting may be used if needed.¹⁴ A high complication rate has been associated with the treatment of humeral shaft fractures with an external fixator.⁴³

Preoperative Details

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 180° 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 60° of abduction on an arm board.

External fixation is performed with the patient supine and the arm on an arm board.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Radial nerve injury occurs in up to 18% of humeral shaft fractures.⁴⁴ Although the oblique distal third humeral fracture (Holstein-Lewis) is better known than are other humeral shaft fractures for an association with radial nerve palsy, such palsy most commonly occurs with middle third humeral fractures.⁴⁵ Most of these nerve injuries are neurapraxic or axonotmetic types, 90% of which resolve to at least grade IV strength in 3-4 months.^{9, 45}

Indications for early nerve exploration include a palsy associated with an open wound or penetrating injury.⁵ Whether or not it is best to explore a radial nerve after function decreases following closed manipulation has sparked controversy. Some authors recommend waiting to perform exploration if no return of function is observed after 3-4 months.⁴⁶ The proponents of this argument state 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.⁴

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.⁴ Surgical stabilization of fractures associated with arterial injury is mandatory at the time of vascular repair.

Four months has been noted to be an adequate period for humeral shaft fractures to heal. The nonunion rate reportedly varies from 1-15%. 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.^{47, 48, 49}

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.^{50, 51} 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.⁵ Some reports describe nonunions being treated with retrograde IM nails and antegrade nails, with a union rate similar to that associated with ORIF.^{20, 52}

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

Each method of humeral shaft fracture treatment is associated with a union rate of higher than 90%. Each fracture must be considered separately and treated accordingly.

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

The best operative treatment modality has still not been fully determined. An association between fractures treated with antegrade IM 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 still not been monitored adequately.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• References

1. Lin J, Hou SM, Hang YS, et al. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res. Sep 1997;(342):147-55. [Medline].
2. Persad IJ, Kommu S. U cast or functional bracing following fractures of the shaft of humerus. Emerg Med J. May 2007;24(5):361. [Medline].
3. 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. Nov 2006;88(11):1469-73. [Medline].
4. Zuckerman JD, Koval KJ. Fractures of the shaft of the humerus. In: Rockwood CA, Green DP, Bucholz RW, et al, eds. Rockwood and Greens' Fractures in Adults. 4^th ed. Philadelphia, Pa: Lippincott-Raven; 1996:1025-53.
5. Beaty JH. Humeral shaft fractures. In: Orthopaedic Knowledge Update. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:278-86.
6. Hartsock LA. Humeral shaft fractures. In: Levine AM, eds. Orthopaedic Knowledge Update, Trauma. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:23-32.
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12. Williams PL, Warwick R, Dyson M, et al, eds. Gray's Anatomy. 37^th ed. New York, NY: Churchill Livingstone; 1989:406-10.
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14. Ward EF, Savoie FH, Hughes JL. Fractures of the diaphyseal humerus. In: Browner BD, Jupiter JB, Levine AM, et al, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. 2^nd ed. Philadelphia, Pa: WB Saunders; 1998:1523-47.
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19. Tingstad EM, Wolinsky PR, Shyr Y, et al. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. Aug 2000;49(2):278-80. [Medline].
20. Rodriguez-Merchan EC. Compression plating versus hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma. Jun 1995;9(3):194-7. [Medline].
21. Hoppenfeld S, deBoer P. The humerus. In: Hannon BC, ed. Surgical Exposures in Orthopaedics: The Anatomic Approach. 2^nd ed. Philadelphia, Pa: JB Lippincott; 1984:52-65.
22. 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. Nov 1996;78(11):1690-5. [Medline].
23. Farragos AF, Schemitsch EH, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma. May 1999;13(4):258-67. [Medline].
24. Sims SH, Smith SE. Intramedullary nailing of humeral shaft fractures. J South Orthop Assoc. Spring 1995;4(1):24-31. [Medline].
25. Achecar F, Whittle AP. Unreamed vs reamed interlocking nailing of humeral shaft fractures. Orthop Trans. 1997;21:1166.
26. Brumback RJ. The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res. Mar 1996;(324):292-320. [Medline].
27. Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res. May 1998;(350):40-50. [Medline].
28. Ingman AM, Waters DA. Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results. J Bone Joint Surg Br. Jan 1994;76(1):23-9. [Medline]. [Full Text].
29. Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am. Jun 1996;78(6):891-6. [Medline].
30. Rommens PM, Verbruggen J, Broos PL. Retrograde locked nailing of humeral shaft fractures. A review of 39 patients. J Bone Joint Surg Br. Jan 1995;77(1):84-9. [Medline]. [Full Text].
31. Shazar N, Brumback RJ, Vanco B. Treatment of humeral fractures by closed reduction and retrograde intramedullary Ender nails. Orthopedics. Jun 1998;21(6):641-6. [Medline].
32. Tomé J, Carsi B, García-Fernández C, et al. Treatment of pathologic fractures of the humerus with Seidel nailing. Clin Orthop Relat Res. May 1998;(350):51-5. [Medline].
33. Mückley T, Diefenbeck M, Sorkin AT, et al. Results of the T2 humeral nailing system with special focus on compression interlocking. Injury. Dec 27 2007;[Medline].
34. Riemer BL, Foglesong ME, Burke CJ 3rd. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopedics. Jan 1994;17(1):19-29. [Medline].
35. Riemer BL, Butterfield SL, D'Ambrosia R, et al. Seidel intramedullary nailing of humeral diaphyseal fractures: a preliminary report. Orthopedics. Mar 1991;14(3):239-46. [Medline].
36. 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. Jul 1992;74(4):558-62. [Medline]. [Full Text].
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Article Last Updated: Jan 8, 2008