We generally wait for 4 months and decide if healing occurs and we monitor:
1. Pain
2. Motion at the fracture side
3. X-rays of the fracture with Sarmiento brace on and with the brace off at 4 months. A key radiograph is an abducted view of the humerus with the Xray beam perpendicular to the plane of the scapula (similar inclination to the Grashey view). If motion at the fracture site is detected on X-ray then we start the workup for nonunion of the fracture.
In this case the 4 month followup X-rays did not reveal union, there was motion at the fracture site and for that reason operative fixation was decided with a long 4.5mm plate. We routinely avoid placement of two plates or more than 4 screws on each site of the fracture to avoid disturbance in the blood flow of the humeral bone. If possible a lag screw is used to achieve compression. In this case cancellous bone graft with DBM was added to the construct.
Of particular importance is the protection of the radial nerve which crosses the posterior mid shaft area at 20cm proximal to the medial epicondyle and pierces the IM septum at approximately 10-14cm proximal to the lateral epicondyle. The plate needs to be visualized in its entirety to avoid plating of the nerve, and the placement of the lag screw(s) needs to be performed in way that does not endanger the radial nerve (posterior mid shaft area and spiral groove). Up to 20% radial nerve palsies have been reported with this type of surgery.
The case is illustrated below:
initial X-rays
initial X-rays
Reduction with Sarmiento
Reduction with Sarmiento
4 months post injury
4 months post injury with Sarmiento brace off
4 months after surgery the fracture is healed as demonstrated by the X-rays below:
