Functional bracing of fractures of the shaft of the humerus

This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Functional bracing of fractures of the shaft of the humerus
A Sarmiento, PB Kinman, EG Galvin, RH Schmitt and JG Phillips
J Bone Joint Surg Am. 1977;59:596-601.
This information is current as of January 22, 2009
Reprints and Permissions
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
Publisher Information
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
Functional
Bracing
the Shaft
BY
AUGUSTO
SARMIENTO,
ROGER
H.
MD.I’.
SCHMITT,
i/ic
PHILIP
B.
KINMAN,
AND
JAMES
G.
of
Se/tool
?sfiai;ti
We treated
of the humerus
fifty-one
cases of fracture
of
with a functional
method
of
treatment
consisting
of a plastic
sleeve,
individually
molded or prefabricated.
It maintained
good alignment
of the fragments
and permitted
rapid and uninterrupted
osteogenesis.
The early introduction
of functional
activity to the entire
extremity
appears
to provide
a desirable
physiological
environment
conducive
to rapid healing.
Non-unions
have
not been
encountered
in nonpathological
fractures.
Healing time has been rapid, and
there has been consistent
restoration
of motion
of all
joints prior to the completion
of healing.
The morbidity
was minimum.
ABSTRACT:
the shaft
frequent
of the
and
usually
shaft
do
of the
humerus
not constitute
are
a major
relatively
in-
therapeutic
polypropylene
*
Read
thopaedic
*
596
P.O.
the
(middle
of
at the
functional
sleeves
and right).
Note
Annual
Surgeons,
Las
Box 520875.
Meeting
and
G.
Vegas.
Nevada,
Biscayne
Annex.
American
February
Miami,
Academy
6, 1977.
Florida
33152.
of Or-
M.D.t,
FLORIDA
Miami
Non-surgical
management
is preferred
because
healing
time is short,
and infection
is
uncommon
3,3.8.9.16i8
Even some of the most ardent
advocates of compression
osteosynthesis
recognize
that ‘ ‘better
results
after conservative
treatment
prove
that uncomplicated fractures
of the humeral
shaft should
not be primarily
non-union
is
approached
rare,
by open
However,
reduction”
non-surgical
19#{149}
management
of these
fractures
is associated
Non-union
with some morbidity
and undesirable
sequelae.
is not a frequent
complication
but it does occur
1 to 12 per cent of patients
i,2,11i4.16.20,3133
Loss of
in from
motion
of the shoulder
from adhesive
capsulitis
or from a
subluxation
of the shoulder
may cause an impordisability
during
healing
and afterward.
All types of
transient
conservative
therapy
Any
effective
have
disadvantages
device
even
-
as well
a hanging
as advan-
cast,
coapta-
I
used to stabilize
fracture
fragments.
The one made of Orthoplast
the Velcro
straps
that permit
removal
and reapplication
of the
of The
GALVIN,
MIAMI,
Re/iabilitatioii,
problem
tages.
FIG.
Photographs
EUGENE
C.O.1’,
()f Medicine,
tant
Fractures
M.D.t,
PHILLIPS,
of Ort/zopaedies
Departitent
U,tite,sitv
of
of the Humerus*
M.D.1’,
Front
of Fractures
tion
daily
needed
u-splints,
activities.
(left)
sleeve.
or a Velpeau
to restore
resembles
bandage
A long
period
motion
to the
THE
JOURNAL
of
that
made
limits
rehabilitation
-
immobilized
OF BONE
of prefabricated
a patient
may
joints3’6”0”2.
AND
JOINT
SURGERY
in
be
FUNCTIONAL
The
satisfactory
tibial,
the
results
femoral,
obtained
forearm,
University
BRACING
and
of Miami
by functional
Colles
School
us to extend
this method
shaft of the humerus.
OF
bracing
fractures
OF
of
developed
of Medicine2029
of treatment
FRACTURES
at
stimulated
to fractures
of
the
THE
tient
from
who
2.5
tial
cast,
sugar-tong
cation
splints,
of skeletal
sugar-tong
traction.
We
and
encouraged
splints
of-motion
exercises
FIG.
bandage
or a Velpeau
of
the
preferred
sleeve,
as
2-A
made
hanging
patients
shoulder
two
weeks
cast
to start
soon
as
the
from a point just below
the
the lateral
epicondyle.
During
of the humerus
the
initial
minor
of motion
permit
the
acute
brace
was
applied.
this
method
pain
and
As our
increased,
the
swelling
rangeimal
experience
brace
jury and presently
most patients
week ofinjury
(Fig. I). Originally
Johnson)
ence
a
sleeves
were
prefabricated
routine
appliance
simple
modifications
VOL.
59.A,
NO.
with
through
confidence
applied
earlier
a
can
1977
It is available
be made
after
sizes,
any
of the
allow
elbow.
of the
it
fragments
a complete
The
for personal
compression
A shoulder
portion
ofthe
harness
splint
range
Velcro
hygiene
soft
may
be
and looped
tissues
straps
and for adas the
edema
attached
around
to the proxthe neck to pre-
2-C
and lateral
roentgenograms
of the fragments.
vent
of
slippage
in patients
Following
in-
first
and
demonstrating
solid
union
fabricated
elbow
the
with
sleeve
downward.
large
and
the application
sleeve,
at 90 degrees
an
arm
This
flabby
is
likely
extremities.
of the custom-made
sling
of flexion.
was
to
applied
Patients
were
or preholding
the
encouraged
and
to do active
and passive
motion
exercises
for all joints
of
the fractured
extremity.
Extension
ofthe
elbow was gained
gradually
as the pain subsided.
Within
a few weeks
nearly
every patient
could
touch his face with his hand and activities
of daily
living
could
be performed
with
minimum
pa-
difficulty.
With experibecame
the
in two
to accommodate
and
of the splint
of the
must
Laterally,
acromion
to slightly
application
of the
alignment
sleeve
shoulder
humerus.
the
with
receive
it within
the
Orthoplast
(Johnson
molded
individually.
polypropylene
sleeve
we used.
5. JULY
was
of the
in the
The
Anteroposterior
and good alignment
the functional
and
out.
of the
FIG.
third
injury.
subsided,
correction
removal
occur
When
epicondyle
subsides.
possible.
fracture
of the middle
He was initially
treated
after
medial
be carried
justment
or
is hard to fit (Fig. I ). The sleeve extends
medially
centimeters
below
the axilla
to I .3 centimeters
2-B
FIG.
Fig. 2-A: Roentgenogram
of a transverse
of the humerus
in a fourteen-year-old
boy.
hanging
cast for seven
days.
Fig. 2-B: Anteroposterior
roentgenogram
Orthoplast
the
or by appli-
597
HUMERUS
extends
above
can
For all of the fifty-one
fractures
under review,
the mitreatment
was stabilization
either
by use of a hanging
THE
above
sleeve,
Technique
OF
SHAFT
Approximately
one
week
after
the
application
of
598
A.
the
sleeve,
sion
were
pendulum
begun.
formities
was
exercises.
of good
SARMIENTO,
P.
exercises
Spontaneous
observed
B.
with
the
correction
following
the
for periods
E.
G.
GALVIN,
elbow
in extenofangulatory
deinitiation
When
roentgenographic
and
callus formation
was demonstrated,
removed
KINMAN,
of
such
clinical
evidence
the splint was
of time.
Case
Material
We treated
forty-nine
patients
with fifty-one
humeral
shaft fractures
with the functional
brace
just described.
Twenty-eight
patients
were male and twenty-one
were fe-
R.
H.
SCHMITT,
AND
J.
fractures
were
breast).
the time
pathological
One patient
of the injury
had
(metastatic
, and
been
per
cent),
male.
second
One patient
had bilateral
fracture
below an already
of the patients
with
a
were
open
tures
involved
ranged
median
The fractures
nine instances
of
and
from
thirty-eight
thirty-eight,
the left humerus
occurred
(18 per
fracture
and
healed
fracture.
fourteen
years.
closed.
and
to seventy-five
Thirteen
Twenty-seven
twenty-four,
one had a
The ages
years,
fractures
fracthe right.
as a result of vehicular
accidents
in
cent);
twenty-eight
were the result
of the
chemotherapy
at
and
sixteen
of the distal
third
(32
per
cent).
The initial method
of immobilization
was traction
(6
per cent), a Velpeau
bandage
(6 per cent), a sugar-tong
(42
per
cent),
or a hanging
Roentgenograms
functional
sleeve
days
(average,
.
of the humerus
ten days after the
eleven
cast
ranged
1I.
fracture
carcinoma
receiving
a non-union
developed
that required
open reduction
and internal
fixation.
There were nine fractures
of the proximal
third of the
humerus
(18 per cent), twenty-six
of the middle third (50
time of this stabilization
of a comminuted
PHILLIPS
of falls (56 per cent); eleven
were gunshot
wounds
(22 per
cent);
and three
were twisting
injuries
(4 per cent).
Two
splint
Lateral
and anteroposterior
roentgenograms
of the distal
third of the humerus.
G.
days).
from
(46
per
cent).
The
four to ninety-seven
_
obtained
through
initial
insult.
The
arms
the
remained
Orthoplast
in the
sleeve
until the fractures
were clinically
and roentgenographically
healed.
Healing
was determined
on the basis of
absence
of pain and motion
at the fracture
site and good
callus
formation
as demonstrated
roentgenographically
(Figs.
2-A through
4-C).
The time from injury
to discontinuance
of the sleeve
with a median
of 8.5
THE
ranged
from three
weeks
and a mode
JOURNAL
OF BONE
to 22.5 weeks,
of seven
weeks.
AND
JOINT
SURGERY
FUNCTIONAL
BRACING
..
OF
rr.
,
FRACTURES
OF
THE
SHAFT
OF
THE
599
HUMERUS
. .
,-
Oblique
FIG.
Anteroposterior
and
fracture
with maintenance
The
only
occurred
in a patient
carcinoma
of the breast.
Follow-up
thirty months
after removal
of the
tation
of motion
mostly
a loss
was
of the
last
detected
few
union
with
at final
degrees
59-A,
NO.
5, JULY
1977
of the humerus.
4-B
FIG.
two to
limi-
Anteroposterior
sleeve
two weeks
gular
deformity.
roentgenogram
the initial
after
obtained
insult.
Note
through
the
the correction
Orthoplast
of the an-
-
rotation.
and shoulder
Those
nine
Three
patients
(6 per cent)
had
juries.
They were treated
initially
lar repair,
and skeletal
traction.
of the
was 4
and the most common
deformity
was yarns.
Eight
had 10 to 20 degrees
of angular
deformity.
The
patients
had less than 5 degrees
of angulation.
Six patients
(12 per cent) had an associated
initial
radialnerve
palsy from which
they recovered
spontaneously.
VOL.
third
of the
examination
of external
15 degrees
or less of abduction
or rotation
The average
angulation
of the fragments
degrees,
patients
remaining
of the proximal
metastatic
ranged
from
sleeve.
Minimum
All but nine of the patients
had full elbow
motion
at the time of removal
of the sleeve.
lacked
shoulder.
fracture
3-C
lateral
roentgenograms
illustrating
of satisfactory
alignment.
non-union
angulated
associated
vascular
by d#{233}bridement,
invascu-
Discussion
Our
functional
experience
during
bracing
for treatment
of the appendicular
immobilization
both
is not
skeleton
of fracture
a necessary
the past
thirteen
of fractures
leads
fragments,
prerequisite
years
of long
us to assert
adjacent
for fracture
with
bones
that rigid
joints,
or
healing.
It
600
A.
SARMJENTO,
P.
B.
KINMAN,
E.
G.
GALVIN,
R.
H.
SCHMITT,
AND
healing21’23’27.
Firm
rounding
the fractured
the brace
or sleeve
ments is maintained
terrupted
osteogenesis
have also indicated
maintained
J.
G.
PHILLIPS
compression
of the soft tissues
surbone is applied
by the rigid walls of
and
with
adequate
sufficient
Our own
21,27,28
that
during
the
alignment
stability
the
laboratory
functional
reparative
of the fragto permit
unin-
studies
activity
process
which
results
is
in large
periosteal
callus
callus of similar
of greater
mechanical
strength
than the
fractures
treated
by restricting
the activity
of the extremity
frequently
found
30
function
does
not
The bulkiness
in fractures
that
interfere
with
of the periosteal
callus
heal in the presence
of
joint
motion
and
remodel-
ing takes place in a consistently
rapid fashion.
Others have shown that up to 30 per cent of angulation
following
a humeral
fracture
is cosmetically
and
functionally
acceptable.
The bulk of the muscle
of the arm
and the wide ranges
of motion
of the shoulder
and elbow
tend to hide the bone
‘‘‘
The
rotatory
deformities
we found in our patients,
difficult
to measure,
did not result in limitation
tion or supination
of the forearm.
minimum
.
Just
distal
larly
FIG.
Antemposterior
of the fracture
appears
the
to
fracture
with
us
and lateral
restoration
that
site
a brace
that
in those
few days
roentgenograms
of adequate
the motion
when
4-C
after
demonstrating
alignment.
inevitably
is used
solid
takes
enhances
union
place
swelling
tremity
at
fracture
seems
the sleeve
to the sleeve
was
was
patients
who
of the injury.
a problem.
The
instituted
shortly
to
have
resulted
applied,
encountered
had
swelling
of the arm
on occasion,
the sleeve
In no instance,
applied
however,
active
and passive
after the application
in
although
of prona-
gradual
particuwithin
a
was the
use of the exof the sleeve
disappearance
of
the
edema.
References
1. CALDWLLL,
2. CAwwEI.L.
3. CARTNER,
4. CHARNLEY,
5.
6.
7.
8.
9.
10.
I I.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21
22.
23.
24.
25.
26.
27.
.
J. A.: Treatment
of Fractures
in the Cincinnati
General
Hospital.
Ann.
Surg..
97: 161-176,
1933.
J. A.: Treatment
of Fractures
of the Shaft of the Humerus
by Hanging
Cast.
Surg.,
Gynec.
and Obstet.,
70: 421-425,
1940.
M. J.: Immobilization
of Fractures
of the Shaft of the Humerus.
Injury,
5: 175-179.
1973.
JOHN:
The Closed
Treatment
of Common
Fractures.
Ed. 3. Edinburgh
and London,
E. and S. Livingstone,
1968.
CHRISTENsEN,
SrEEN:
Humeral
Shaft
Fractures,
Operative
and Conservative
Treatment.
Acta Chir.
Scandinavica,
133: 455-460,
1967.
COMFORT.
T. H.: The Sugartong
Splint
in Humeral
Shaft Fractures.
Minnesota
Med.,
56: 363-366,
1973.
EMMETt.
J. F., and BRECK.
L. W.: A Review
and Analysis
of 11,000
Fractures
Seen in a Private
Practice
ofOrthopaedic
Surgery
1936-1956.
J.
Bone
and
Joint
Surg.,
40-A:
I 169-1 175, Oct.
1958.
FENYri,
GY#{246}RGY: On Fractures
of the Shaft of the Humerus.
A Review
Covering
a 12-year
Period
with Special
Consideration
of the Surgically
Treated
Cases.
Acta Chir.
Scandinavica,
137: 221-226,
1971.
FISHER.
D. E.: Nonunions
of the Humeral
Shaft.
Minnesota
Med.,
55: 395-403,
1972.
GILHRI5T.
D. K.: A Stockinette-Velpeau
for Immobilization
of the Shoulder
Girdle.
J. Bone and Joint Surg.,
49-A:
750-751,
June
1967.
HOLM,
C. L.: Management
of Humeral
Shaft Fractures.
Fundamental
Nonoperative
Technics.
Clin. Orthop.,
71: 132-139,
1970.
HOSNER.
W.: Fractures
of the Shaft of the Humerus.
An Analysis
of 100 Consecutive
Cases.
Reconstr.
Surg.
Traumatol.
, 14: 38-64.
1974.
JoHNsoN,
E. W.. JR., and VESSER.
H. H., JR.: Humeral
Fractures
in Adults. Am. Fam. Physician,
5: 110-113.
Jan. 1972.
KENNkDY,
J. C. , and WYATT,
J. K.: An Evaluation
of the Management
of Fractures
through
the Middle
Third of the Humerus.
Canadian
J.
Surg..
I: 26-33,
1957.
KLENERMAN.
L.: Fractures
of the Shaft
of the Humerus.
J. Bone
and Joint Surg.,
48-B:
105-111,
Feb.
1966.
MANN,
R. J., and NEAL,
E. G.: Fractures
of the Shaft of the Humerus
in Adults.
Southern
Med.
J., 58: 264-268,
1965.
MNAYMNEH,
W. A.; SMITH-PETERSEN.
MoRtoN;
and AUFRANC,
0. E.: The Treatment
of Non-Union
of Humeral-Shaft
Fractures.
In Proceedings of The American
Academy
of Orthopaedic
Surgeons.
J. Bone and Joint Surg.,
45-A:
1548-1549,
Oct.
1963.
PENNSYLVANIA
ORTHOPAEDI
SoCIETY,
SCIENTIFIC
RESEARCH
COMMITTEE:
Fresh Midshaft
Fractures
ofthe
Humerus
in Adults.
Evaluation
of
Treatment
in Pennsylvania
during
1952-1956.
made
by the Scientific
Research
Committee,
Pennsylvania
Orthopaedic
Society.
Pennsylvania
Med.
J. . 62: 848-850.
1959.
R#{220}EDI. T.; MOSHFEGH.
A.: PFEIFFER,
K. M.; and ALLGOWER.
M.: Fresh Fractures
of the Shaft of the Humerus
Conservative
or Operative
Treatment?
Reconstr.
Surg.
Traumatol.
, 14: 65-74,
1974.
SARMIENTO,
AUGUSTO:
A Functional
Below-the-Knee
Cast for Tibial
Fractures.
J. Bone and Joint Surg.,
49-A:
855-875,
July 1967.
SARM1ENTO.
AuGusro:
A Functional
Below-the-Knee
Brace
forTibial
Fractures.
A Report
on Its Use in One Hundred
Thirty-five
Cases.
J. Bone
and Joint Surg..
52-A:
295-311,
March
1970.
SARMIENTO.
AUGUSTO:
Functional
Bracing
of Tibial
and Femoral
Shaft
Fractures.
Clin.
Orthop.,
82: 2-13,
1972.
SARMIENr0,
AUGUSTO:
Functional
Bracing
of Tibial
Fractures.
Clin.
Orthop.,
105: 202-219,
1974.
SARMIENTO.
AUGUSTO,
and
SINCLAIR.
W. F.: Application
of Prosthetics-Orthotics
Principles
to Treatment
of Fractures.
Artif.
Limbs,
11:
28-32,
Autumn
1967.
SARMiENTO.
AuGsTo,
and
SINCLAIR,
W. F.: Fracture
Orthoses.
In Atlas of Orthotics:
Biomechanical
Principles
and Applications,
pp. 245254. The American
Academy
of Orthopaedic
Surgeons.
St. Louis,
C. V. Mosby,
1975.
SARMIENTO,
AUGUSTO;
COOPER.
J. S.; and SINCLAIR,
W. F.: Forearm
Fractures.
Early Functional
Bracing
A Preliminary
Report.
J. Bone and
Joint Surg. , 57-A:
297-304,
April
1975.
SARMIENTO,
AuGusro;
LATTA,
LOREN;
and SINCLAIR,
W. F.: Functional
Bracing
ofFractures.
In Instructional
Course
Lectures,
The American
Academy
of Orthopaedic
Surgeons.
Vol. 25, pp. 184-239.
St. Louis,
C. V. Mosby,
1976.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
FUNCTIONAL
28.
Fractures.
29.
31
32.
.
33.
VOL.
OF
FRACTURES
OF
THE
SHAFT
OF
THE
HUMERUS
601
LOREN;
ZILI0LI,
ARMAND;
and SINCLAIR,
WILLIAM:
The Role of Soft Tissues
in the Stabilization
of Tibial
1 16- 129, 1974.
SARMIENTO,
AUGUSTO;
PRATT,
G. W.; BERRY,
N. C.; and SINCLAIR,
W. F.: Colles’
Fractures.
Functional
Bracing
in Supination.
J. Bone and
Joint Surg.,
57-A:
311-317,
April
1975.
SARMIENTO,
AUGUSTO;
SCHAEFFER,
J. F.; BECKERMAN,
LINDA;
LATTA,
L. L.; and ENIS, J. E.: Fracture
Healing
in Rat Femora
as Affected
by
Functional
Weight-Bearing.
J. Bone
and Joint
Surg. , 59-A:
369-375,
April 1977.
STEWART,
M. J.: Fractures
of the Humeral
Shaft.
Curr. Pract.
Orthop.
Surg.,
2: 140-162,
1964.
STEWART,
M. J., and HUNDLEY,
J. M.: Fractures
of the Humerus.
A Comparative
Study
in Methods
of Treatment.
J. Bone and Joint Surg.,
37-A:
681-692,
July 1955.
THOMPSON,
R. 0.; COMPERE,
E. L.; SCHNUTE,
W. J.; COMPERE,
C. L.; KERNAHAN,
W. T.; and KEAGY,
R. D.: The TreatmentofHumeral
Shaft
Fractures
by the Hanging
Cast Method.
J. Intemat.
CoIl. Surg. , 43: 52-60,
1975.
SARMIENTO,
30.
BRACING
59-A,
AUGUSTO;
Clin.
NO.
5,
LATTA,
Orthop.
JULY
1977
,
105: