Fraktur Distal Humerus

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CASE PRESENTATIONCLOSED FRACTURE DISTAL OF THE LEFT HUMERUSPRESENTED BY :Agus durman|C11109001

advisor:dr. Naharuddin Imodr. Sebastian Mihardja

supervisor:dr. Zulfan Oktasatria Siregar, Sp.OTORTHOPHEDIC AND TRAUMATOLOGY DEPARTMENTMEDICAL FACULTY OF HASANUDDIN UNIVERSITYMAKASSAR, 2013Patient Identity Name: Mr. GGender: BoyDate of birth: June 11th 2011Medical Record: 635528Date of admission: November 4th 2013

History TakingChief Complaint : Pain at left arm History TakingSuffered since 5 days before admission to the hospital due to traffic accident. Mechanism of trauma :The patient was walking at roadside when suddenly got hit by a car from the back and the patient fell on the asphalt with the left side of the body. History of unconscious (-), nausea (-), vomit (-).Prior treatment in Hospital of Barru.

Physical ExaminationGeneral Status:Mild illness / conscious / well-nourished

Vital signs:BP : 100/60 mmHgHR : 88 x/minRR: 22 x/minT : 36,8C

Localized StatusLEFT ARM REGIONInspection: deformity (+), Swelling (+), hematoma (+), wound (-)Palpation: Tenderness (+)ROM : active and passive motion of shoulder and elbow joints were limited due to pain. NVD :Sensibility is difficult to be evaluated, extension thumb (+), apposition test (+), abduction and adduction fingers (+), radial artery is palpable, Capillary Refill Time 80% of all supracondylar fractures in adults.Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. 2006

Anatomy

Anatomi Anterior compartments: muscle : brachialis, biceps brachii, dan coracobrachialis. Neurovascular : brachial a., musculocutaneus n., media n., and radial n. Posterior compartments: muscle : triceps brachii. Neurovascular : radial n.and ulnar n.

Thompson JC. Arm. In: Netters Concise Orthopaedic Anatomy. Second edition.ClassificationThe AO-ASIF Group have defined three types of distal humeral fracture:Type A an extra-articular supracondylar fractureType B an intra-articular unicondylar fracture (one condyle sheared off)Type C bicondylar fractures with varying degrees of comminution.

Mechanism of injury Most low-energy distal humeral fractures result from a simple fall in middle-aged and elderly women in which the elbow is either struck directly or is axially loaded in a fall onto the outstretched hand.Motor vehicle and sporting accidents are more common causes of injury in younger individuals.Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

Clinical evaluationSigns and symptoms vary with degree of swelling and displacement; considerable swelling frequently occurs, rendering landmarks difficult to palpate. A careful neurovascular evaluation is essential because the sharp, fractured end of the proximal fragment may impale or contuse the brachial artery, median nerve, or radial nerveSerial neurovascular examinations with compartment pressure monitoring may be necessary

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

Radiological examinationStandard anteroposterior (AP) and lateral views of the elbow should be obtained. Oblique radiographs may be helpful for further fracture definition.Traction radiographs may better delineate the fracture pattern and may be useful for preoperative planning.Computed tomography may be utilized to delineate fracture fragments further.


Treatment General treatment principles :Anatomic articular reductionStable internal fixation of the articular surfaceRestoration of articular axial alignmentStable internal fixation of the articular segment to the metaphysis and diaphysisEarly range of elbow motion


Treatment Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

Thank youNonoperative The treatment principle is concervativeApply U slapApply hanging cast

Indication for surgeryMultiple fractureOpen fractureDisplaced intraarticular of the fractureNeurovascular compromiseInadequate closed reduction

TREATMENT

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.Applying a U-slab of plaster (after a few days in a shoulder-to-wrist hanging cast) is usually adequate. Ready-made braces are simpler and more comfortable, though not suitable for all cases. These conservative methods demand careful supervision if excessive angulation and malunion are to be prevented.TREATMENTNON OPERATIVEHanging castThis utilizes dependency traction by the weight of the cast and arm to effect fracture reduction.Indications include displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns. Transverse or short oblique fractures represent relative contraindications because of the potential for distraction and healing complications.Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENTNON OPERATIVECoaptation splint This utilizes dependency traction to effect fracture reduction, but with greater stabilization and less distraction than a hanging arm cast. The forearm is suspended in a collar and cuff.It is indicated for the acute treatment of humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns that may displace with a hanging arm castDisadvantages include irritation of the patients axilla and the potential for splint slippage.


TREATMENTNON OPERATIVEThoracobrachial immobilization (Velpeau dressing) This is used in elderly patients or children who are unable to tolerate other methods of treatment and in whom comfort is the primary concern.It is indicated for minimally displaced or nondisplaced fractures that do not require reduction.Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT NON OPERATIVE Shoulder spica castThis has limited application, because operative management is typically performed for the same indications.It is indicated when the fracture pattern necessitates significant abduction and external rotation of the upper extremity.Disadvantages include difficulty of cast application, cast weight and bulkiness, skin irritation, patient discomfort, and inconvenient upper extremity position.


TREATMENTNON OPERATIVEFunctional bracingThis utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints.It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a hanging arm cast or coaptation splint and swelling has subsided.Contraindications include massive soft tissue injury, an unreliable patient, and an inability to obtain or maintain acceptable fracture reduction.Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

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Fraktur Distal Humerus