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Closed Comminutive Fracture Left

Humerus With Radial Nerve Palsy

FAHRI DWI PERMANA

110 208 037

Advisor:

dr. Arnold

dr. Edwin

Supervisor:

dr. Henry Yurianto M. Phil PhD Sp.OT

Department of Orthopaedic dan Traumatology

Faculty of Medicine

Makassar

2014

CASE REPORT

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IDENTITY

Name : YT

Age : 55 years old / Male

Admission : December 2nd, 2014 at 20:10

Registration : 69 10 64

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AUTOANAMNESIS

Chief Complain : Pain in the Left Arm

Suffered since 3 days before admitted to WahidinGeneral Hospital due to traffic accident. Patient was

the passenger in an ambulance when the ambulancerolled over twice, ending upside-down.

History of loss of consciousness (-), vomit (-)

Patient is an engineers and right-hand dominant Prior Treatment at Palopo Hospital.

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GENERAL STATUS

Conscious / well-nourished

Vital Signs:

Blood pressure : 120/80 mmHgPulse rate : 84 x/min

Respiratory rate : 16 x/min

Temperature : 36,9 0CVAS : 6/10

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LOCAL STATUS

Left rm Region

Look : Deformity (+), Swelling (+), Wound (-), hematoma (-)

Feel : Tenderness (+)

Move : Active and passive motions of shoulder and elbowjoints are not evaluated due to pain

NVD : Sensibility is hypoesthesia along radial nervedistribution, pulsation of radial artery is palpable,extend thumb (-), Extend Wrist (-), OK Sign (+),abduction and adduction digiti (+), CRT

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CLINICAL FINDINGS

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RADIOLOGY FINDINGS

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LABORATORY FINDINGS

WBC : 10.830/ul

RBC : 4.300.000/ul

HBG : 13,4 g/dl

HCT : 37,1 %

PLT : 213.000/ul

CT : 300

BT : 700

HBsAg : Non-reactive

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Summary

A man 55 y.o came to the hospital with chief complaint of pain in

the left arm, suffered since 3 days before admitted to Wahidin

General Hospital. Patient was the passenger in an ambulance when

the ambulance rolled over. Patient is an engineers and right-hand

dominant. From physical examination, there is deformity, swelling, tenderness

at the left arm. Extend thumb (-), extend wrist (-), Sensibility is

hypoesthesia along radial nerve distribution, pulsation of radial

artery is palpable, CRT

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DIAGNOSIS

Closed Comminutive Fracture Left Humerus

Left Radial Nerve Palsy

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MANAGEMENT

IVFD RL

Analgetic

Apply Slab at Left Upper LimbORIF + Nerve exploration

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DISCUSSION

A t f H

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Anatomy of Humerus

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic Anatomy. 2nd ed.Philadelphia: Saunders; 2010.

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Nerves of Humerus

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic Anatomy. 2nd ed.Philadelphia: Saunders; 2010.

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Upper Arm Musle (anterior view)

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic Anatomy. 2nd ed.Philadelphia: Saunders; 2010.

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Upper Arm Musle (posterior view)

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic Anatomy. 2nd ed.Philadelphia: Saunders; 2010.

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MECHANISM OF HUMERUS INJURY

Fracture usually follows a fall on the out-stretched arm

A fall on the hand may twist the humerus, causing aspiral fracture

A fall on the elbow with the arm abducted exerts abending force, resulting in an oblique or transversefracture

A direct blow to the arm causes a fracture which iseither transverse or comminuted.

Fractures around the elbow in adultsespecially thoseof the distal humerusare often high-energy injurieswhich are associated with vascular and nerve damage.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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CLINICAL FEATURES

Pain.

Deformity.

Bruising. Crepitus.

Abnormal mobility

Swelling. Any neurovascular injury

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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CLINICAL FEATURES

Skin integrity .

Examine the shoulder andelbow joints and theforearm, hand, and

clavicle for associatedtrauma.

Check the function of themedian, ulnar, and,particularly, the radial

nerves. Assess for the presence of

the radial pulse.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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CLASSIFICATION

CLOSED

OPEN

LOCATION- proximal, middle, distal FRACTURE PATTERN-tranverse, spiral,

oblique,comminuted segmental

SOFT TISSUE STATUSTscherene & GotzenGustilo & Anderson

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

AO CLASSIFICATION OF HUMERAL

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AO CLASSIFICATION OF HUMERAL

DIAPHYSEAL FRACTURES Type A : Simple fracture

A1: Spiral

A2: Oblique (>30)

A3: Transverse (

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Type B : Wedge fracture

B1: Spiral wedge

B2: Bending wedgeB3: Fragmented wedge

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor. London: Springer; 2006.

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Type C : Complex fracture

C1: Spiral

C2: Segmented

C3: Irregular (significant comminution)

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor. London: Springer; 2006.

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ASSOCIATED INJURIES

Radial Nerve injury = Wrist Drop = Inability of

extend wrist, fingers, thumb, Loss of sensationover dorsal web space of 1stdigit

Neuropraxia at time of injury will oftenresolve spontaneously

Nerve palsy after manipulation or splintingis due to nerve entrapment and must beimmediately explored by orthopedic surgery

Ulnar and Median nerve injury (less common)

Brachial Artery Injury

Clavicle, forearm, wrist & Chest injuries

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures InAdults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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DIAGNOSIS

History

Clinical

examination

imaging

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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TREATMENTNON OPERATIVE TREATMENT

INDICATIONS

- Undisplaced closed simple fractures

- Spiral fractures

- Short oblique fractures

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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A humeral brace. The sling length can be altered to change the fractureposition.

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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OPERATIVE METHODS

Indication :

Absolut :

- associated vascular injury

- associated higher grade open wound

Fracture indication :- Failure to obtain and maintain adequate closed reductin

- Segmental fractures

- Pathologic fractures

- Intra-articular extension

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And Green's Fractures In

Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III PT, editors. USA: Wolters Kluwer; 2010.

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Lesion of radial nerve

1. Low Lession2. High Lession

3. Very High Lession

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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LESION IN THE UPPER ARM

Causes: Supracondylar # of the humerus.

Nerve damage

Callus bone formation following # cause delay

compression. Newborn : prolonged labour & forceps extraction

Clinical Features of high lesion: Inability to extend wrist, fingers & thumb.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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MANAGEMENT

Emergency surgery is required for brachial

plexus lesions associated with penetrating

wounds, vascular injury or severe (high-energy)

soft-tissue damage, whether open or closed;clean-cut nerves should be repaired or grafted.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G, editor2010.

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