Fr Humerus

  • View
    222

  • Download
    0

Embed Size (px)

Text of Fr Humerus

  • Therapy operatif Fracture Indications Associated Injuries Patient Indications

  • Fracture Indications

    Failure to obtain and maintain adequate closed reductionShortening >3 cmRotation >30 degrees Angulation >20 degreesSegmental fracturePathological fractureIntraarticular extension Shoulder jointElbow joint

  • Associated Injuries Open woundVascular injuryBrachial plexus injuryIpsilateral forearm fractureIpsilateral shoulder or elbow fractureBilateral humeral fracturesLower extremity fracture requiring upper extremity weight bearingBurnsHigh-velocity gunshot injuryChronic associated joint stiffness of elbow or shoulder

  • Patient Indications Multiple injuries, polytraumaHead injury (Glasgow Coma Scale score = 8)Chest traumaPoor patient tolerance, complianceUnfavorable body habitus Morbid obesityLarge breasts

  • Approach Fractures of the middle / proximal thirdAnterolateral (brachialis-spliting approach)Midshaft or extend into the the distal third humerus Posterior approach ( triceps splitting or modified posterior approach )w

    Gerwin, Hotchkiss, and Weiland described a modified posterior approach in which the triceps is reflected medially off the lateral intermuscular septum*

  • Place the patient in a lateral decubitus position.Use a wide proximal preparation and drape to allow for the use of a sterile tourniquet.Make an incision from the tourniquet to the tip of the olecranon in line with the humerus

  • Carry dissection down to the triceps fascia, incise the fascia, and carry the dissection laterally to the intermuscular septum.Identify the lower lateral brachial cutaneous nerve, and follow it proximally where it meets the radial nerve as it pierces the septum. This usually is at the level of the tourniquet. Release the tourniquet.Identify the radial nerve.Dissect the triceps muscle proximally off the intermuscular septum.Free the radial nerve proximally, distally, anteriorly, and posteriorly, including incision of the lateral intermuscular septum for 3 cm to allow mobilization of the nerve.Incise the triceps off the periosteum to expose the humerus; preserve as much of the periosteum as possible.Proximally, reflect the posterior border of the deltoid anteriorly if needed for exposure.Place a single bone clamp proximal and distal to control the fragments and reflect the triceps . Avoid circumferential stripping of the soft tissues with the clamp.

  • After dbridement of the fracture site, insert a lag screw for provisional fixation. Alternatively, for transverse fractures where lag screw fixation is difficult, a compression plating technique can be used, or a minifragment plate (Eglseder technique) can be used for provisional fixation, followed by plate fixation.Perform large-fragment plating in neutralization, compression, or bridge-plating mode.Confirm alignment of the humerus and reduction of the fragments with fluoroscopy.Perform routine skin closure over a drain.

  • A, Incision. B, Incision of fascia to expose intramuscular septum. C, Identification of lateral brachial cutaneous nerve. D, Mobilization of radial nerve*

  • E, Bone clamp used to control fragments. F, After dbridement, fixation with lag screw. G, After plate application.

    *

  • Postoperative Care Postoperatively, range of motion of the shoulder and elbow is begun within the first week, and weight bearing usually is allowed if fixation is stable.

  • Complications Radial nerve palsyInfection refractures

    Gerwin, Hotchkiss, and Weiland described a modified posterior approach in which the triceps is reflected medially off the lateral intermuscular septum*A, Incision. B, Incision of fascia to expose intramuscular septum. C, Identification of lateral brachial cutaneous nerve. D, Mobilization of radial nerve*E, Bone clamp used to control fragments. F, After dbridement, fixation with lag screw. G, After plate application.

    *