M.E.Müller: Atlas: Fracture 12-A2

Humerus, Diaphysis,
simple fracture, oblique (>=30º) 0,25% of the total
3,52% of the humerus
15,92% of the segment

35 fractures 25,4% group 74%M, 26%F

78 fractures
56,5% group
69%M, 31%F

25 fractures 18,1% group
76%M, 24%F

Proximal section Middle section Distal section

These are simple fractures with an oblique fracture line, located at the proximal third and distal third of the humeral diaphysis. Ref. Manual of Internal Fixation:
232 - 251. 442 - 445.
Surgeon. MV, RO.

Subgroups A2.1 and A2.3 are discussed separate from the A2.2 subgroup because they usually are more displaced and unstable. Internal fixation is indicated because of the difficult reduction and stabilization by bloodless methods. The most proximal fractures require some kind of internal fixation with screws into the humeral head. The distal fractures, depending on their level, will need a straight plate or a reconstruction plate, placed either in the posterior or in the lateral aspect of the diaphysis and reaching the distal humeral zone.

In the oblique fractures, one interfragmentary lag screw must be placed whenever possible (it was not possible in the case illustrated in the superior half of the page). In the case illustrated in the inferior half of the page, the blown-up images show the reduction compressed by a lag screw. Since there is a small area of bone loss contra-lateral to the plate, it is substituted by cancellous bone graft that, once incorporated, guarantees the reconstruction of the cortex.

preoperative + 4 months

preoperative postoperative

+ 6 months + 6 months

These are simple diaphyseal fractures with an oblique fracture line (>=30º), located at the middle third of the humerus. Ref. Manual of Internal Fixation:
442 - 445. 448 - 449. 104 - 105 (2nd ed.)
Surgeon. RO, RO, RO.

A stable anatomic reduction is difficult to obtain by blood-less methods and this is why the conservative treatment leads to failures, either delayed unions or pseudoarthrosis. This type of fractures is more frequent than the A1.1 in young patients that, because of social, labor or sports reasons, require an early functional recovery. Several internal fixation methods have been tried. The classic method is the multiple intramedullary nailing proposed by Hackethal. The variability in the internal diameter of the diaphysis, the level of the fracture, the length and diameter of the nails as well as their proximal umbrella-like placement, the reduction, compressed or not, and other factors related to the cooperation of the patient, combine to yield only 50% of good results.

The salvage of a failure of Hackethal´s intramedullary nailing or the primary stable internal fixation is obtained with a compression plate (axial compression). The type of plate recommended in the AO Manual is the 4.5 mm. DCP or LC-DCP straight femoral plate, in order to be able to place the screws obliquely in the sagittal plane so as to avoid forming a row at their exit points, since this

could result in a long hairline fracture of the frail humeral cortex. As a mather of fact, the ideal plate size will depend on the humeral size and the thin diaphysis will require thinner plates. One important advance for the treatment of humeral fractures has been the low contact titanium plate (LC-DCP) which, because of its metallurgy, has the advantages of a better tolerance and malleability than the steel plates and their screw-hole design allows great divergence in the screw directions (40º).

In relation to the placement of the plate in the humerus, it has always been stated that the posterior aspect is the ideal in order for it to act as a tension band against the flexion of the elbow. In practice, both the postero-medial and the postero-lateral aspects can be used with the same success for the fractures of the upper and middle thirds, provided that the internal fixation has been well performed and that the elbow motion is free. One or two reconstruction plates, contoured to the posterior and lateral surfaces of the distal humerus, are used for the fractures of the distal third.

preoperative + 9 months

postoperative + 1 year

preoperative preoperative +8 months +8 months

preoperative preoperative 0 months 0 months

+6 months +6 months + 1 year + 1 year




						Humerus, Diaphysis, simple fracture, oblique (>=30º)	0,25% of the total 3,52% of the humerus 15,92% of the segment






These are simple fractures with an oblique fracture line, located at the proximal third and distal third of the humeral diaphysis.		Ref. Manual of Internal Fixation: 232 - 251. 442 - 445. Surgeon. MV, RO.

Subgroups A2.1 and A2.3 are discussed separate from the A2.2 subgroup because they usually are more displaced and unstable. Internal fixation is indicated because of the difficult reduction and stabilization by bloodless methods. The most proximal fractures require some kind of internal fixation with screws into the humeral head. The distal fractures, depending on their level, will need a straight plate or a reconstruction plate, placed either in the posterior or in the lateral aspect of the diaphysis and reaching the distal humeral zone.	In the oblique fractures, one interfragmentary lag screw must be placed whenever possible (it was not possible in the case illustrated in the superior half of the page). In the case illustrated in the inferior half of the page, the blown-up images show the reduction compressed by a lag screw. Since there is a small area of bone loss contra-lateral to the plate, it is substituted by cancellous bone graft that, once incorporated, guarantees the reconstruction of the cortex.






These are simple diaphyseal fractures with an oblique fracture line (>=30º), located at the middle third of the humerus.		Ref. Manual of Internal Fixation: 442 - 445. 448 - 449. 104 - 105 (2nd ed.) Surgeon. RO, RO, RO.

A stable anatomic reduction is difficult to obtain by blood-less methods and this is why the conservative treatment leads to failures, either delayed unions or pseudoarthrosis. This type of fractures is more frequent than the A1.1 in young patients that, because of social, labor or sports reasons, require an early functional recovery. Several internal fixation methods have been tried. The classic method is the multiple intramedullary nailing proposed by Hackethal. The variability in the internal diameter of the diaphysis, the level of the fracture, the length and diameter of the nails as well as their proximal umbrella-like placement, the reduction, compressed or not, and other factors related to the cooperation of the patient, combine to yield only 50% of good results. The salvage of a failure of Hackethal´s intramedullary nailing or the primary stable internal fixation is obtained with a compression plate (axial compression). The type of plate recommended in the AO Manual is the 4.5 mm. DCP or LC-DCP straight femoral plate, in order to be able to place the screws obliquely in the sagittal plane so as to avoid forming a row at their exit points, since this	could result in a long hairline fracture of the frail humeral cortex. As a mather of fact, the ideal plate size will depend on the humeral size and the thin diaphysis will require thinner plates. One important advance for the treatment of humeral fractures has been the low contact titanium plate (LC-DCP) which, because of its metallurgy, has the advantages of a better tolerance and malleability than the steel plates and their screw-hole design allows great divergence in the screw directions (40º). In relation to the placement of the plate in the humerus, it has always been stated that the posterior aspect is the ideal in order for it to act as a tension band against the flexion of the elbow. In practice, both the postero-medial and the postero-lateral aspects can be used with the same success for the fractures of the upper and middle thirds, provided that the internal fixation has been well performed and that the elbow motion is free. One or two reconstruction plates, contoured to the posterior and lateral surfaces of the distal humerus, are used for the fractures of the distal third.