Patient selection is important when functional bracing is chosen for the treatment of diaphyseal fractures of the humerus. When functional bracing is properly applied to well-selected patients, nonunion rates are low, and skin complications are almost nonexistent. We describe a patient with a closed diaphyseal humeral fracture who experienced skin breakdown and ulceration from the brace with protrusion of the proximal fracture spike, effectively converting a closed fracture into an open one.
The patient and her primary caregiver (her daughter) were informed that data concerning the case would be submitted for publication, and they consented.
Functional fracture bracing utilizes the principle of an incompressible soft-tissue sleeve to reduce shortening and angulation of long-bone fractures. This soft-tissue sheath encourages vascular invasion, which is ultimately responsible for osteogenesis4,5. When applied to the humerus, this technique has been associated with high rates of union and few complications1,4-8. As well as being more comfortable and lighter, the functional brace preserves greater range of motion at the unhindered elbow joint, unlike the traditional U-shaped plaster coaptation splint9.
The case of our patient illustrates one of the pitfalls of functional bracing that is uncommonly discussed in the literature: skin complications. Attention is usually focused on more common complications such as nonunion, radial nerve palsy, and variable degrees of malunion. Most authors have reported skin complications to be rare or nonexistent. The rates of each complication are presented in Table I.
When present, skin and soft-tissue complications are usually minor and resolve without extraordinary measures2,3,8,10,11. Rutgers and Ring10 reported skin breakdown in two (4%) of forty-nine patients, one of whom had cellulitis. They attributed the skin breakdown to excessive moisture during hot, humid summer months, and they noted that it resolved with the discontinuation of bracing in favor of a sling and the use of nonadherent dressings. Zagorski et al.11 reported major maceration in two (1%) of 170 patients. Both patients did not remove the brace and had poor hygiene. The maceration was amenable to standard skin cleansing, application of a drying lotion, and changing of the stockinette. Koch et al.3 reported that one (1%) of sixty-seven patients had development of dermatitis under the brace, but this was classified as a minor complication. Pehlivan8 reported that one (5%) of twenty-one patients had development of skin maceration, which resolved with skin care and ointments. In the study by Jawa et al.2, two of twenty-one patients had a rash with extensive desquamation, necessitating discontinuation of the brace. Both fractures ultimately united in a sling. All of those previous authors agreed that skin care and basic hygiene measures are important for the prevention of minor skin complications arising under a brace. This is especially so in regions with high humidity.
Erosion of the proximal fracture spike through its surrounding skin and soft-tissue envelope while the arm is enclosed within a functional brace is unusual and, to our knowledge, has not been reported previously. We believe that a few unique factors were responsible.
Proper patient selection is perhaps the most important factor for successful application of a functional brace. Our patient had dementia and therefore may have been a poor candidate for functional bracing. Although Rutgers and Ring10 stated that poor compliance is a contraindication to operative treatment because a failure to follow instructions could lead to serious complications following internal fixation as compared with the application of a simple brace, we believe that complications from bracing are an important consideration in this population4,8,12-14. In a review of this technique, Sarmiento and Latta concluded that compliance was the single most important issue associated with functional bracing4. Our patient removed the brace more often than at the recommended intervals, preferred the brace to be loose (releasing the Velcro straps regularly), and frequently attempted abduction of the arm when excited or agitated. Such a patient is less able to benefit from the "functional humeral sleeve" concept on which the principle of functional fracture bracing is based7. Although controlled motion at the fracture site is conducive to osteogenesis1,4,5, excessive motion fosters nonunion. A patient who is unable to comply with instructions to avoid shoulder abduction may be better served with internal fixation.
Our patient was a thin, elderly woman, with lax skin and little muscle mass or subcutaneous fat. These characteristics neutralize the intended sleeve-compression effect of surrounding soft tissue7.
Our patient remained supine for most of her waking hours. When seated, she tended to rest the elbow on the armrest of the chair for comfort. This runs contrary to one of the tenets of functional bracing, which is to allow gravity to restore alignment2,7.
Fracture characteristics may have played a role in this case as well. A long spiral diaphyseal fracture arising from a torsional force is displaced by muscle pull. With the fracture line exiting distal to the deltoid tuberosity, the deltoid displaces the proximal fragment laterally, and the triceps and biceps act in tandem to displace the distal fragment proximally and medially. In a study of thirty-two patients who were managed operatively because of a nonunion of a diaphyseal humeral fracture, Ring et al. noted that most patients (84%) had a spiral fracture15. Those authors believed the pull of the deltoid to be responsible, with invagination of the fracture spike through the circumferential muscle envelope also contributing to the nonunion.
We believe that post-reduction radiographs made with the patient wearing the functional brace are important and should be made regularly during the period of immobilization. In the case of our patient, post-reduction radiographs made following brace application (Fig. 3) showed acceptable anterior and varus angulation (<20° and <30°, respectively), rotation (<40°), and shortening (<3 cm)16. However, a careful retrospective examination of the initial (Fig. 1) and post-reduction radiographs (Fig. 3) revealed that some degree of buttonholing of the proximal fragment through a relatively thin biceps and brachialis muscle belly may have been present, allowing satisfactory alignment but preventing sufficient fragment apposition, in keeping with the hypothesis of Ring et al.15. Appreciation of this problem may have facilitated earlier internal fixation and avoided the resultant skin complication.
The case of our patient illustrates that successful functional bracing of long-bone fractures depends on a few factors, of which prudent patient selection is the most critical. Patients with dementia who are poorly compliant and immobile and have long, spiral fractures that tent the skin may be better served with open reduction and internal fixation.