Orthopedic Surgery Expert Opines on Malunion Stemming From Humerus Injury

This case involves a cyclist who suffered a humerus injury while competing in an event. He passed over a large rock and fell off his bike, fracturing his humerus. The cyclist’s orthopedic surgeon treated him with a brace and monitored him closely for several months. Eventually, the orthopedist cleared the cyclist to remove the brace, claiming that his bones were in proper alignment. The cyclist experienced persistent pain in his humerus following the removal of the brace and decided to see another orthopedist. The second orthopedist discovered that the cyclist’s bones had not realigned properly and that had several splinters in his humerus. The cyclists required a number of surgeries to correct these issues. An orthopedic expert was sought to review the records and opine on whether there was a deviation in the standard of care.

Question(s) For Expert Witness

1. How would you treat patients like the one described above?

2. What are the indications for operative repair of a humerus fracture?

Expert Witness Response E-017978

I routinely treat patients with fractures similar to this patient's injury. These fractures are most commonly sustained in conjunction with a fall. Indications for operative repair of a humerus fracture must take into consideration the patient, the fracture itself, and surgeon-specific variables. Fracture issues include fracture reduction, adequate stability, fracture healing, and joint mobility. Patient issues include bone quality, general health/comorbidities, and functional demand/occupational requirements. Surgeon-specific variables include surgical skill and available equipment.

Complex humeral shaft fractures are classified by the Müller AO classification system as either simple, wedge, or complex fracture patterns. The description noted appears to be a complex pattern with either a spiral, segmental or irregular fragment composition. Operative stabilization would be indicated for an open fracture, in a patient unable to sit or stand, for irreducible displacement, obesity, or nerve injury. Delayed surgery is always possible. External fixation is usually indicated for unstable fractures as temporizing fixation or for loss of reduction. Closed reduction with nailing (intramedullary antegrade or retrograde) is indicated for unacceptable reduction, loss of reduction and failure to heal to name a few. Open or closed reduction with plating (plate and screws) is indicated for open fractures, unacceptable reduction, failure of fracture healing, vascular injury, radial nerve palsy, ipsilateral brachial plexus injury, obesity or large breast, and a requirement for early load bearing.