Cast Brace for Humeral Frx : Wheeless' Textbook of Orthopaedics

- Discussion: (Humeral Shaft Frx)
- Forces Displacing the Fracture
- components of a well designed cast brace include an anterior component w/ a bicipital contour and a posterior component w/ a
              flat mold for the triceps;
- velcro straps maintain adequate compression;
- in closed humeral shaft fractures involving the middle or proximal thirds, about 95% of patients were satisfied w/ non operative
              treatment, but only about 2/3 will be pain free at work or w/ ADLs;
- non unions may occur in about 5% of patients;
- main indications:
      - closed humeral frx w/ spiral or oblique configuration which occur in the mid or proximal humerus;
- relative contra-indications:
      - open humeral frx;
      - distal 1/3 humeral frx
      - non compliant patients or patients who are demented;
      - morbid obesity;

- Treatment Protocol:
- reduce frx and apply cast padding;
- consider applying the brace on the day of injury, along w/ a sling;
   - some apply the cast brace at 4-5 days, at which time, some of the swelling to subsided and the patient is more comfortable;
- see the patient periodically to follow reduction and adjust brace;
- recognize that during the first 7-10 days there may be significant improvement in the fracture reduction due to the beneficial
             circumferential compression forces of cast brace and the benficial forces achieved from flexion and extension of the elbow;
- at one week postop, the patient begins pendulum ROM exercises;
- at two weeks the patient may begin active ROM exercises (while upright) as long as reduction is maintained;
- the frx should be re-manipulated w/ the ends lose contact;
- generally the cast brace is left on for about 9-11 weeks (range 4-17 weeks), until there is clinical and radiographic evidence
             of frx consolidation;

- Angular Deformities from Cast Brace:
- tends to occur in fractures which are more distal;
- angular deformities are varus and may be caused by the inappropriate application of the collar and cuff;
- at time of brace application, pt shrugs his shoulder so that length of collar and cuff is adjusted during shoulder elevation;
- as shoulder musculature relaxes, collar & cuff maintain their original adjusted length, & frx readily migrates into varus deformity;
- this can be corrected by lengthening the collar and cuff;
- Sarmiento A, et al (2000), researchers were able to follow 620 patients with humeral shaft frx that were treated with cast bracing;
- 465 (75 %) of the fractures were closed, and 155 (25 percent) were open;
- non-union: 9 (6 %) who had an open frx and seven (less than 2 %) who had a closed fracture had a nonunion after bracing;
- 87 % of the 565 patients for whom AP radiographs were available, the fracture healed in less than 16 deg of varus angulation,
and in 81 % of the 546 for whom lateral radiographs were available, it healed in less than 16 deg of anterior angulation;
- at the time of brace removal, 98 % of the patients had limitation of shoulder motion of 25 degrees or less
- Functional bracing for the treatment of fractures of the humeral diaphysis.