HUMERUS FRACTURES

Fahad zakwanMD5

• In evaluating humerus injuries, being able to classify the fracture and if necessary reduce, immobilize and know when to seek orthopaedic consultation is important.• 80% of proximal humeral fractures are non displaced or

minimally displaced and therefore can be managed nonoperatively.• Distal humeral fractures are associated with ipsilateral

proximal forearm fractures.• Rarely, vascular or nervous injuries are associated with

humeral fractures.

HUMERUS FRACTURES

ProximalMid shaftSupra condylar

1. PROXIMAL HUMERUS FRACTURES

Primarily older populationarm pronation limits abductionOlder pts #, while younger pts dislocateBoth if middle agedArm held close to body, mov’t limited by painTender, hematoma, bruising

Proximal Humerus Fractures

85% minimally displaced – conservative rxSeparation along old epiphyseal lines

Articular surface (anatomic neck)Greater and lesser tuberosity Humeral shaft (surgical neck)

Considered displaced if:> 1cm away> 45 degrees

HUMERAL HEAD:precarious blood supplyAVN

LESSER TUBEROSITY:subscapularis insertion

GREATER TUBEROSITY:supra/infraspinatus

insertion

SURGICAL NECK/SHAFT:deltoid/pectoralis major

largely dictates fx behaviorcompression: stable

shear: unstable

Anatomic PartsDeforming forces determine fracture displacement

Vascular Supply

• Lateral ascending branch of anterior humeral circumflex artery

•Damage may lead to AVN

Humeral Head Vascularity

Recent anatomic and clinical findings confirm that perfusion from the posterior

circumflex vessels alone may be adequate for head survival.

In the fractured humerus, the arcuate artery is generally interrupted.

Proximal Humeral FracturesNeer’s Classification

•The two main components of the classification are:1.number of fracture parts2.displacement

Neer Classification

Codman’s 4 parts

> 1 cm

45º

Parts

The Neer’s system divides the proxi-mal humerus into 4 parts and consid-ers not the fracture line, but the dis-placement as being significant in terms of classification. The four parts are:

1. humeral head2. greater tuberosity3. lesser tuberosity4. humeral shaft Codman’s

4 parts

One-part fracture

• fracture lines involve 1 - 4 parts•none of the parts are displaced

(i.e. <1cm and <45 degrees)•These undisplaced / minimally displaced frac-tures account for ~ 70 - 80% of all prox-imal humeral fractures and are almost al-ways treated conservatively.

Two-part fracture

fracture lines involve 2 - 4 partsone part is displaced (i.e. >1cm or >45 degrees)Four possible types of two-part fractures exist

(one for each part):1. surgical neck: most common2. greater tuberosity – frequently seen in the setting of anterior shoulder

dislocation a lower threshold of displacement (> 5mm) has been proposed3. anatomical neck 4. lesser tuberosity: uncommon

These fractures account for approximately 20% of proximal humeral fractures.

Three-part fracture

fracture lines involve 3 - 4 partstwo part are displaced (i.e. >1cm or >45 degrees)Two three-part fracture patterns are encountered

1. Greater tuberosity and shaft are displaced with respect to the lesser tuberosity and articular surface which remain together most common three part pattern

2. Lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together

These fractures account for approximately 5% of proximal humeral fractures.

Four – part fracture• fracture lines involve 4 parts•3 parts are displaced (i.e >1cm or >45 degrees) with respect to the 4th.•These #s are uncommon (<1% of proximal humeral #s)• It has a high incidence of osteonecrosis•These #s require operative mgt.

Proximal Humerus FracturesManagement

•Minimally displaced•# held together by capsule, periosteum, muscles•Analgesia, sling and swathe x 3-4/52

•2,3,4 part – ORIF•Fracture/dislocation – caution with force, don’t want to displace segments•Complications: adhesive capsulitis

Proximal Humeral Epiphysis #

RareUsually Males 11-17FOOSH# through zone of hypertrophy of epiphyseal plate

Arm held close to body, swelling

Classification: Salter Harris

Proximal Humeral EpiphysisManagement

•Potential for growth disturbance•<6 yo : usually Salter I, analgesia, sling and swathe•> 6 yo: usually Salter II• If > 20 deg need to reduce

MIDSHAFT HUMERUS FRACTURES

•Mechanism•Direct blow, severe twisting, FOOSH•Obvious deformity, crepitus•Shortened limb, rotated•Assess radial nerve•Exam shoulder and elbow

Midshaft Humerus Fractures

ManagementHanging arm cast (displaced) / Sugar tong (nondisplaced)

F/U with ortho in 24-48hoverriding #: accept up to 1 inch shortening

ORIFunacceptable alignment, radial nerve involvement, segmental #, other upper extremity injuries, pathological #, limited to bedrest

Midshaft Humerus Fractures

1 in prox to #

Midshaft Humerus Fractures

Midshaft Humerus FracturesChildren

Radial nerve injury is rareaccept 1-1.5cm shortening, 15-20 deg angulation

4-6 wks in modified Velpeau or sling and swathe (compliance difficult for hanging cast)

SUPRACONDYLAR FRACTURE

• Usually < 8yo

• Extension (95%) vs flexion

Supracondylar Fracture-clinically

•Mild swelling to gross deformity•arm held to side, immobile, extension•S-shaped configuration

Supracondylar Fracture-Classification

•Gartland• I - nondisplaced• II - displaced with intact posterior cortex• III - displaced fracture, no intact cortex• A: postermedial rotation of distal fragment• B: posterolateral rotation

Supracondylar Fracture-Management

• If NV compromise - urgent ortho consult• if no response in 60 min may attempt 1 reduction• watch brachial artery and median nerve• Gartland I - splint and ortho f/u 24h• Gartland II - controversy but most get pinned• Gartland III - closed reduction and pin

Supracondylar Fracture-Reduction

PEARL *** Physical examination

•Pain occurs with palpation or movement of shoulder or elbow.•Ecchymosis and Oedema are usually present•Perform careful neurovascular examination•Radial nerve injury following humeral shaft fractures is relatively common

Proximal #

• Patients presents with a painful shoulder and a very restricted ROM.•Obvious deformity is suggestive of glenohumeral dislocation.• Swelling and ecchymosis are common

examination findings

•Nerve damage with proximal humeral # is rare•Have risk of vascular injuries

Diaphyseal #

•Presents with painful deformed arm that may be associated with radial nerve palsy.•Usually the radial nerve palsy is reversible

•Crepitus may be observed•Shortening of the arm suggests displacement

Assessment of radial nerve

• The radial nerve primary motor function is to innervate the dorsal extrinsic muscles in the fore arm• Motor testing should include extension of the wrist and metacarpophalangeal (MCP) joints as well as abduction and extension of the thumb.• Proximal injury of the radial nerve causes wrist drop• On examination, the fingers are in flexion at the MCP

joints and thumb is adducted.

Treatment and management

•Prehospital care• Immobilization of the limb

•Hospital care•Minimize the patients movements and provide analgesia to make the patient comfortable in the acute care settings

Proximal humerus #

•Most minimally displaced proximal fractures can be managed non operatively.• Sling and swathe application is the primary treatment• Fractures of the anatomical neck should be referred to orthopedist due to the risk of avascular necrosis•Neers 2,3,4 - ORIF

Humerus shaft (diaphyseal) #

• Humerus shaft fractures should be stabilized using coaptation splint.• Wrap splinting material snugly from axilla to nape

of neck, creating a stirrup around the elbow.• Fracture reduction is usually not necessary

because reduction is usually difficult to maintain.• Because of the shoulders ability to compensate, 30

– 40 degrees angulation is acceptable

consultations• Most isolated proximal and diaphyseal humeral fractures

can be managed by an orthopedist in an outpatient setting.• Even patients with fractures that may eventually require surgery

generally may be discharged with early follow up care if fracture is otherwise uncomplicated.

• Fractures that can not be adequately reduced or when fracture reduction can not be controlled with functional bracing because of patient obesity, head trauma, or soft tissue injuries, surgical stabilization is indicated.

• Open fractures represent a surgical emergency, obtain an immediate orthopaedic consult.• Penetrating trauma requires particular

neurovascular scrutiny.• Glenohumeral dislocation in conjunction with a proximal humerus fracture requires orthopaedic evaluation.• Floating elbow (an ipsilateral humerus and

forearm fracture) requires operative repair.

medications

NSAIDS:

• Ibuprofen:• Usually DOC for treatment of mild to moderately severe pain, if no

contraindications.• Inhibits inflammatory reactions and pain, probably by decreasing activity

of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.• 300 – 800 mg 6 – 8 hrly

• Ketoprofen

• Naproxen

• Flurbiprofen**.

ANALGESICS• Acetaminophen:• DOC for treatment of pain in patients with documented

hypersensitivity to aspirin or NSAIDS and in those with upper GI disease or taking oral anticoagulants.

• Acetaminophen and codaine• Morphine sulphateANXIOLYTICS• lorazepam