Fractures of the humerus have tremendous capacity to heal with closed treatment. Infrequently, however, operative treatment of humeral diaphyseal fractures may be required. Multiple methods of operative treatment are currently available in these situations, including open reduction internal fixation (ORIF) with dynamic compression plates (DCP), external fixation, and intramedullary (IM) stabilization. Another older method is lateral humeral tension band wiring, based on an idea advocated by Bigelow in 1867, for treatment of nonunion in long bones.¹ This is a limited open procedure with minimal soft tissue stripping and good healing rates in non-unions of the humerus, radius and femur. We report here the use of this technique in a meromelic 14-year-old skeletally immature female with an open transverse right humerus fracture.

The humerus is approached laterally with a small single incision made through the skin and subcutaneous tissue down to the bone, avoiding the radial nerve by careful dissection. In the case of a non-union, the non-union site is often covered by fibrous tissue interspersed with callus that is subsequently debrided. With help from an assistant, the denuded ends of the nonunion are flexed gently into view. The irregularities of the fracture fragments and inflamed tissues are removed. Minimal periosteal stripping over the area of bone to be excised (usually 1.5-2 cm) is undertaken. Tissue protectors are crucial in avoiding unnecessary local soft tissue injury as the roughened edges are finished with a straight cut using a mini saw. The length of bone resected determines the amount of periosteum that is stripped (usually 1.5-2 cm). A unicortical drill hole is then placed into the proximal fragment approximately 1.5 cm from the fractured end, and a #10 wire is passed through the drill hole into the intramedullary (IM) canal. The wire is then passed from the IM canal through another drill hole 1.5 cm from the fracture on the distal fragment, and the fractured ends are brought into apposition. The wire ends are then pulled slightly off the surface of the bone to compress the fracture site, are twisted tightly into place and buried. Wound closure is undertaken in a meticulous manner. Post-operatively, the humerus is placed in a concave coaptation splint with an axillary pad to increase the compression of the fracture site and immobilize the limb. The position of immobilization is at 90 degrees of flexion at the elbow with neutral rotation at the wrist. The post-operative splint is continued for several weeks until there are clinical signs of union. At that time, range of motion of the elbow and shoulder is initiated. The wire is left in place until clinical healing is complete and is only removed if irritation persists.

The patient is a 14-year-old female who was crossing the street when an oncoming car at moderate speed hit her. She had transient loss of consciousness but was easily aroused at the scene. Glascow coma score (GCS) was 15. Her injuries included abrasions over the right eye, periorbital edema with ecchymosis, Grade III liver laceration, diffuse pain localizations, and a grade I open midshaft humerus fracture of her right meromelic limb. Neurovascular status was completely intact.

She was evaluated by all services, and cleared for an irrigation and debridement of the open fracture within six hours of injury. The 1cm laceration was posteromedial, and was surgically extended by 1cm proximally and distally for complete exposure of the bone ends and thoroughly irrigated with saline under pulsatile lavage. It was a transverse midshaft fracture that could be manipulated with direct intraoperative pressure to maintain alignment (Figure 1). Because of the open fracture in an already shortened limb, it was decided to internally stabilize her fracture. A tension wire construct was chosen, and placed as lateral as possible using the technique closely approximating the fracture ends, as described by Bigelow¹ (Figure 2). Post-operatively, she was placed into a long arm cast.

Figure 1 Pre-operative x-ray of a 14-year-old female with an open midshaft humerus fracture that is transverse and shortened.

Figure 2 The technique of limited open reduction and wire fixation is demonstrated.

Because of the posteromedial nature of the tension band, mild varus drift occurred in the loosened cast, but no shortening resulted (Figure 3). She also missed initial follow-up appointments. She was then placed into a functional brace until complete consolidation of the bone was appreciated (Figure 4). She was then released to regular activities. She only complained of mild irritation at the wire site because of her thin arm. The discomfort was not enough to want hardware removal. She is now active and able to carry out activities of daily living (Figure 5).

Figure 3 Because the wire was not directly lateral (due to the open laceration on the posteromedial humerus), direct tensioning effects could not be maintained with external immobilization and the fracture angulated at the next followup (left). The fracture was (more ...)

Figure 4 Final radiograph taken at seven months after complete healing. No significant problems are encountered, except occasional mild irritation from the wire tips.

Figure 5 Clinical photographs showing the small incision and the excellent alignment of the limb.

For isolated fractures of the humeral shaft, non-operative methods are the accepted form of treatment, especially in shaft fractures not associated with neurovascular injuries.² The majority of these fractures heal rapidly, without significant residual disability. The humeral functional brace further improves conservative closed treatment, providing effective stabilization while minimizing upper extremity joint stiffness associated with other immobilization techniques.³ Surgical intervention in the acute setting is generally reserved for fractures with neurovascular injuries, open fractures, multiple fractures with associated ipsilateral extremity injuries, bilateral fractures and pathologic fractures.^4,5

In our current case, the open fracture was stabilized with the lateral wire after thorough irrigation and debridement. No further periosteal stripping was necessary to place the wire and the fracture remained more stable. She was able to mobilize the shoulder and elbow early (within four weeks).

In 1867, Bigelow first published a series of long-bone non-unions treated through this limited approach and insertion of a lateral longitudinal wire. This is essentially the first description of the modern tension-band wiring technique.¹ In his series of 11 non-united fractures (nine humeri, one radius and one femur), all healed except for one patient with a pathologic fracture who desired an above-elbow amputation five months after wire fixation. The success of Bigelow's technique is based on the understanding that delayed unions and nonunions are more probable to occur with more severe local soft tissue injury with altered vascularity. The Bigelow operative procedure, at the time of its inception, was successful at positively affecting healing because it involved minimal violation of soft tissue and periosteum, and provided bone-to-bone apposition as along as the extremity was further stabilized with an external post-operative splint.

Another factor underlying Bigelow's successful procedure for non-unions resides in the inherent anatomy and biomechanics of the arm. The musculature around the humerus, including the powerful deltoid and pectoralis major, tends to place a varus deforming force on mid-diaphyseal fractures. With this lateral angulation, the medial side of the fracture experiences compressive forces, while strong tensile forces are created on the lateral side. By inserting a lateral wire on the convex side of the fracture, the wire directs an eccentric load on the bone and acts as a tension band. Consequently, the wire in this system absorbs all of the tensile forces and affects dynamic compression across the fracture site. Pauwels was one of the first authors to demonstrate the success of tension-band wiring in a series of fractures, osteotomies and pseudarthroses⁶. It has now become the standard of treatment in fractures of the patella⁷ and olecranon,⁸ areas where the inherent fracture stability is compromised by excessive tensile forces. Unlike the olecranon and patella, where normal range of motion further induces dynamic compression of the tension band, the humerus fracture relies on the muscular pull and support from an external splint to affect its compression.

Even in Bigelow's period, despite the lack of radiographs, antisepsis and antibiotics, ten out of 11 chronic non-unions healed in his series including a femur fracture. The only failure occurred in a patient with pathologic bone who did not allow sufficient time for complete union before desiring an amputation.