The approaches for plating in the humeral shaft can be either anterolateral or dorsal. The proximal trains deltoid and the distal dorsal approaches are followed for nailing. The patient has positioned supine or semi-seated with the chest elevated about 30°for the antegrade approach. But for the dorsal approach. The patient is made to lie on the table with the fractured side close to its edge and the head facing away. The fractured upper armrests on a radiolucent side table with the forearm hanging down.
Transdeltoid approach
This approach is applied to the antegrade intramedullary nail.
Anterolateral approach
An anterolateral approach may be used for the plating of proximal humeral shaft fractures. This may be extended down the shaft for middle-third fractures. One needs to be careful while using this approach in distal-third fractures as the radial nerve clings to the lateral cortex and may be trapped below the distal corner of the plate.
Dorsal approach
This approach is commonly used for the distal half fractures of the humerus. Once the radial nerve is identified, it can be easily extended for more proximal fractures. Access for nailing needs approximately 8 cm. incision over the distal part.
Reduction tools and techniques
In order to restore length, the reduction is achieved by careful traction which is afterward maintained with pointed reduction forceps in spiral or oblique fractures. Reduction for plating must be atraumatic. Transverse fractures can be reduced properly by using the plate. The plate is positioned extraperiosteally.
The reduction is done with the nail partially inserted in case of closed nailing. Then, it is used as a reduction tool, the opposing fragment is taken up and engaged. Additional external manipulation will facilitate the process. The usual tools can be applied for open reduction.
Implant Selection
Earlier the broad DCP 4.5 was recommended for plating. But nowadays the narrow LC-DCP 4.5 is preferred for plating. This plate will fit properly on either the posterior or lateral surface. But to lessen the risk of fatigue fractures by the rotational load, the screws must be inserted in an offset pattern rather than a parallel sequence.
The solid humeral nail is available in three diameters: 6.7, 7.5, and 9.5 mm. Its length varies from 190–325 mm. Both variables should be determined before nail insertion. A radiographic ruler is used to measure length and diameter intraoperatively. The 7.5 mm nail is a standard nail.
Surgical treatment— tricks and hints
To achieve proper fixation of the plate, the screws should engage six to eight cortices generally with three to four holes both up and down the fracture. If possible, inter-fragmentary compression should be either by placing a lag screw through the plate or by applying axial load with the help of the articulated tension device or DC holes. Periosteal stripping must be done neither for plate fixation nor for screw placement. The application of a nerve stimulator during surgery is very helpful in finding the radial nerve. Though, it will be much safer to check out the nerve and ensure it is not below the plate specifically at the ends of the plate.
For the purpose of nailing two different systems of nail assembling are available. To add inter-fragmentary compression and to increase rotational stability, a specific compression device is applied in transverse or short oblique fractures. From the beginning, this device is used combinedly with the insertion handle and the nail. If no extra compression is to be applied then only the insertion handle is combined with the nail. Only minimal force is applied for nail insertion.
The nail is advanced by hand to the fracture gap and beyond with careful rotational movements without using a hammer, after fracture reduction. Proximal interlocking is carried out through the targeting device. But the distal interlocking is executed freehand in the anteroposterior direction.
