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Humerus fracture
1. FRACTURE SHAFT
HUMERUS
Dr. RAMKISHAN
ASSISTANT PROFESSOR
DEPT. OF ORTHOPAEDICS AND
TRAUMATOLOGY
OSMANIA GENERAL HOSPITAL
HYDERABAD
2. FRACTURE SHAFT
HUMERUS
Introduction
History
Epidemiology
Mechanism of injury
Classification
Clinical features
Investigations
Treatment
Complications
3. INTRODUCTION
3% to 5% of all fractures
Most will heal with appropriate
conservative care, although a limited
number will require surgery for optimal
outcome.
Given the extensive range of motion of
the shoulder and elbow, and the minimal
effect from minor shortening, a wide
range of radiographic malunion can be
accepted with little functional deficit
4. GENERAL
CONSIDERATIONS
Current research -- decreasing the
surgical failure rate through
New implants and techniques,
Optimizing the postinjury rehabilitation
programs
Minimizing the duration and magnitude
of remaining disability.
10. EPIDEMIOLOGY
High energy trauma is more common in
the young males
Low energy trauma is more common in
the elderly female
11. AGE AND GENDER SPECIFIC
INCIDENCE OF SHAFT
HUMERUS FRACTURE
12. ANATOMY
Proximally, the humerus is roughly
cylindrical in cross section, tapering to a
triangular shape distally.
The medullary canal of the humerus
tapers to an end above the
supracondylar expansion.
The humerus is well enveloped in
muscle and soft tissue, hence there is a
good prognosis for healing in the
majority of uncomplicated fractures.
13. ANATOMY
Nutrient artery- enters the bone very
constantly at the junction of M/3- L/3 and
foramina of entry are concentrated in a
small area of the distal half of M/3 on
medial side
Radial nerve- it does not travel along the
spiral groove and it lies close to the inferior
lip of spiral groove but not in it
It is only for a short distance near the
lateral supracondylar ridge that the nerve is
direct contact with the humerus and
pierces lateral intermuscular septum
16. MECHANISM OF INJURY
Direct trauma is the most common especially
MVA
Indirect trauma such as fall on an outstretched
hand
Fracture pattern depends on stress applied
○ Compressive- proximal or distal humerus
○ Bending- transverse fracture of the shaft
○ Torsional- spiral fracture of the shaft
○ Torsion and bending- oblique fracture usually
associated with a butterfly fragment
17. CLINICAL FEATURES
HISTORY
Mode of injury
Velocity of injury
Alchoholic abuse, drugs ( prone for
repeated injuries )
Age and sex of the patient ( osteoporosis )
Comorbid conditions
Previous treatment( massages)
Previous bone pathology ( path # )
18. CLINICAL FEATURES
Pain.
Deformity.
Bruising.
Crepitus.
Abnormal mobility
Swelling.
Any neurovascular injury
19. CLINICAL FEATURES
Skin integrity .
Examine the shoulder
and elbow joints and
the forearm, hand,
and clavicle for
associated trauma.
Check the function of
the median, ulnar, and,
particularly, the radial
nerves.
Assess for the
presence of the radial
pulse.
21. IMAGING
AP and lateral views of the humerus,
including the joints below and above the injury.
Computed Tomographic (CT) scans of associated
intra-articular injuries proximally or distally.
CT scanning may also be indicated in the rare
situation where a significant rotational abnormality
exists as rotational alignment is difficult to judge from
plain radiographs of a diaphyseal long bone fracture.
A CT scan through the humeral condyles distally and
the humeral head proximally can provide exact
rotational alignment
MRI for pathological #
22. CLASSIFICATION
CLOSED
OPEN
LOCATION- proximal, middle, distal
FRACTURE PATTERN-tranverse, spiral,
oblique,comminuted segmental
SOFT TISSUE STATUS – Tscherene &
Gotzen
Gustilo &
Anderson
33. ASSOCIATED INJURIES
○ Radial Nerve injury = Wrist Drop =
Inability of extend wrist, fingers, thumb,
Loss of sensation over dorsal web
space of 1st digit
Neuropraxia at time of injury will often
resolve spontaneously
Nerve palsy after manipulation or
splinting is due to nerve entrapment
and must be immediately explored by
orthopedic surgery
○ Ulnar and Median nerve injury (less
common)
34. DIAGNOSIS
History
Clinical
examination
imaging
38. NON OPERATIVE
TREATMENT
INDICATIONS
Undisplaced closed simple
fractures
Displaced closed fractures with
less than 20 anterior angulation, 30
varus/ valgus angulation
Spiral fractures
Short oblique fractures
39. HUMERAL SHAFT
FRACTURES
Conservative Treatment
>90% of humeral shaft fractures
heal with nonsurgical
management
○ 20degrees of anterior
angulation, 30 degrees of varus
angulation and up to 3 cm of
shortening are acceptable
○ Most treatment begins with
application of a coaptation spint
or a hanging arm cast followed
by placement of a fracture brace
40. NON OPERATIVE
METHODS
Splinting:
Fractures are splinted with a hanging splint,
which is from the axilla, under the elbow,
postioned to the top of the shoulder .
The U splint.
The splinted extremity is supported by a
sling.
Immobilization by fracture bracing is
continued for at least 2 months or until
clinical and radiographic evidence of fracture
healing is observed.
41. FCB - INTRODUCTION
A closed method of treating fractures
based on the belief that continuing
function while a fracture is uniting ,
encourages osteogenesis, promotes the
healing of tissues and prevents the
development of joint stiffness, thus
accelerating rehabilitation
Not merely a technique but constitute a
positive attitude towards fracture
healing.
42. CONCEPT
The end to end bone contact is not
required for bony union and that rigid
immobilization of the fracture fragment
and immobilization of the joints above
and below a fracture as well as
prolonged rest are detrimental to
healing.
It complements rather than replaces
other forms of treatment.
43.
44. CONTRAINDICATIONS
Lack of co-operation by the pt.
Bed-ridden & mentally incompetent pts.
Deficient sensibility of the limb [D.M with
P.N]
When the brace cannot fitted closely
and accurately.
Fractures of both bones forearm when
reduction is difficult.
Intraarticular fractures.
45. TIME TO APPLY
Not at the time of injury.
Regular casts, time to correct any angular
or rotational deformity.
Compound # es , application to be
delayed.
Assess the # , when pain and swelling
subsided
1. Minor movts at # site should be pain free
2. Any deformity should disappear once
deforming forces are removed
3. Reasonable resistance to telescoping.
49. OPERATIVE TREATMENT
INDICATIONS
Fractures in which reduction is unable to be
achieved or maintained.
Fractures with nerve injuries after reduction
maneuvers.
Open fractures.
Intra articular extension injury.
Neurovascular injury.
Impending pathologic fractures.
Segmental fractures.
Multiple extremity fractures.
51. ANTERIOR APPROACH
SUPINEON
THE ARM
TABLE WITH
600
ABDUCTION AT
SHOULDER
52. ANTERO LATERAL
APPROACH
Incision
Proximal land mark
– coracoid process
Distal land mark-
anterior to lateral
supracondylar ridge
53. ANTERO LATERAL
APPROACH
Proximally, the plane
lies between the
deltoid laterally
(axillary nerve) and
the pectoralis major
medially(medial and
lateral pectoral
nerves).
54. ANTERO LATERAL
APPROACH
Distally, the plane
lies between the
medial fibers of the
brachialis
(musculocutaneous
nerve) medially and
the lateral fibers of
the brachialis (radial
nerve) laterally.
55. POSTERIOR APPROACH
Position of the
patient for the
approach to the
upper arm in either
the (A) lateral or (B)
prone position.
56. POSTERIOR APPROACH
Incision
Tip of olecranon
distally to postero
lateral corner of
acromion proximally
57. POSTERIOR APPROACH
Incise the deep
fascia of the arm in
line with the skin
incision.
58. POSTERIOR APPROACH
Identify the gap
between the lateral
and long heads of
the triceps muscle.
59. POSTERIOR APPROACH
Proximally develop the
interval between the two
heads by blunt
dissection, retracting the
lateral head laterally and
the long head medially.
Distally split their
common tendon along
the line of the skin
incision by sharp
dissection. Identify the
radial nerve and the
accompanying profunda
brachii artery.
62. PLATING
Plate osteosynthesis remains the criterion
standard of fixation of humeral shaft
fractures
high union rate, low complication rate, and
a rapid return to function
Complications are infrequent and include
radial nerve palsy, infection and refracture.
limited contact compression (LCD) plate
helps prevent longitudinal fracture or
fissuring of the humerus because the
screw holes in these plates are staggered.
63. PLATE OSTEOSYNTHESIS
There are several practical advantages
to the use of the LCD plates over
standard compression plates: they are
easier to contour, allow for wider angle
of screw insertion, and have
bidirectional compression holes.
Theoretical advantages include
decreased stress shielding and
improved bone blood flow due to limited
plate-bone contact.
64. PLATE OSTEOSYNTHESIS
Recently angle stable or locked plating
systems have gained wide popularity.
By locking the screws to the plate a
number of mechanical advantages are
gained, including a reduced risk for screw
loosening and a stronger mechanical
construct compared with conventional
screws and plates.
With locking plate systems, the pressure
exerted by the plate on the bone is minimal
as the need for exact anatomical
contouring of the plate is eliminated.
65. PLATE OSTEOSYNTHESIS
A theoretical advantage of this is less
impairment of the blood supply in the
cortical bone beneath the plate
compared to conventional plates.
For humeral shaft fractures,MIPO has
been considered too dangerous due to
the risk of neurovascular injuries,
particularly to the radial nerve.
73. PEARLS AND PITFALLS—
COMPRESSION PLATING
Use an anterolateral approach for midshaft or proximal
fractures, and a posterior approach for distal fractures.
Use a 4.5-mm compression plate in most patients, with
a minimum of 3 (and preferably 4) screws proximal and
distal. A 4.5-mm narrow plate is acceptable for smaller
individuals.
Insert a lag screw between major fracture fragments, if
possible.
Check the distal corner of the plate for radial nerve
entrapment prior to closure following the anterolateral
approach.
The intraoperative goal is to obtain sufficient stability to
allow immediate postoperative shoulder and elbow
74. INTRAMEDULLARY NAILING
Rush pins or Enders nails, while effective
in many cases with simple fracture
patterns, had significant drawbacks such
as poor or nonexistent axial or rotational
stability
With the newer generation of nails came a
number of locking mechanisms distally
including interference fits from expandable
bolts (Seidel nail) or ridged fins (Trueflex
nail), or interlocking screws (Russell-Taylor
nail, Synthes nail, Biomet nail)
75. INTRAMEDULLARY NAILING
Problems such as insertion site morbidity,
iatrogenic fracture comminution (especially
in small diameter canals), and nonunion
(and significant difficulty in its salvage)
have been reported
the use of locking nails is restricted to
widely separate segmental fractures,
pathologic fractures, fractures in patients
with morbid obesity, and fractures with poor
soft tissue over the fracture site (such as
burns).
76. INTRAMEDULLARY NAILING
One point emphasized in most series of
large-diameter nails is that the humerus
does not tolerate distraction. This is a
risk factor for delayed and nonunion.
Antegrade Technique
Retrograde Technique-best suited for
fractures in the middle and distal thirds
of the humerus
77. PEARLS AND PITFALLS—
INTRAMEDULLARY NAILING
Avoid antegrade nailing in patients with
pre-existing shoulder pathology or those
who will be permanent upper extremity
weight bearers (para- or quadriplegics).
Use a nail locked proximally and distally
with screws: use a miniopen technique
for distal locking for all screws.
78. PEARLS AND PITFALLS—
INTRAMEDULLARY NAILING
Avoid intramedullary nailing in narrow
diameter (<9 mm) canals: excessive
reaming is not desirable in the humerus.
Choose nail length carefully, erring on the
side of a shorter nail: do not distract the
fracture site by trying to impact a nail that is
excessively long.
Insertion site morbidity remains a concern:
choose your entry portal carefully and use
meticulous technique.
82. EXTERNAL FIXATION
Is a suboptimal form of fixation with a
significant complication rate and has
traditionally been used as a temporizing
method for fractures with contraindications
to plate or nail fixation.
These include extensively contaminated or
frankly infected fractures , fractures with
poor soft tissues (such as burns), or where
rapid stabilization with minimal physiologic
perturbation or operative time is required
(―damage-control orthopaedics‖)
83. EXTERNAL FIXATION
External fixation is cumbersome for the
humerus and the complication rate is high.
This is especially true for the pin sites,
where a thick envelope of muscle and soft
tissue between the bone and the skin and
constant motion of the elbow and shoulder
accentuate the risk of delayed union and
malunion, resulting in significant rates of
pin tract irritation, infection, and pin
breakage.
86. PLATE OR NAIL?
Plate Nail
Reliable, 96% Less incision
union required
Good Higher incidence
shoulder/elbow of complications?
function Lower union rate?
Soft tissue –
scars, radial
nerve, bleeding
87. WHAT IS THE ROLE FOR
NAILING?
Segmental fractures
Particularly with a very proximal fracture line
Pathologic fractures
? Cosmesis
88. COMPLICATIONS OF OPERATIVE
MANAGEMENT
Injury to the radial nerve.
Nonunion rates are higher when fractures
are treated with intramedullary nailing.
Malunion.
Shoulder pain -when fractures are treated
with nails and with plates .
Elbow or shoulder stiffness.