FRACTURE SHAFT HUMERUS
Dr. RAMKISHANASSISTANT PROFESSORDEPT. OF ORTHOPAEDICS AND TRAUMATOLOGYOSMANIA GENERAL HOSPITAL HYDERABAD
FRACTURE SHAFT HUMERUS Introduction History Epidemiology Mechanism of injury Classification Clinical features Investigations Treatment Complications
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
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.
GENERAL CONSIDERATIONS Successful treatment demands a
knowledge of : Anatomy, Biomechanics Techniques Patient Function and Expectations.
HISTORY
Sir JOHN CHARNLEY (1911-1982)
“It is perhaps the easiest of major lonf bones to treat by conservative methods”
SARMIENTO (February 15, 1811 – September 11, 1888)
RICHARD WATSON (1737- 1816)
EPIDEMIOLOGY
High energy trauma is more common in the young males
Low energy trauma is more common in the elderly female
AGE AND GENDER SPECIFIC INCIDENCE OF SHAFT HUMERUS FRACTURE
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.
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
ANATOMY
RELATIONSHIP OF NEUROVASCULAR STRUCTURES TO SHAFT HUMERUS
MECHANISM OF INJURYDirect trauma is the most common especially
MVAIndirect trauma such as fall on an outstretched
handFracture 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
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 # )
CLINICAL FEATURES
Pain. Deformity. Bruising. Crepitus. Abnormal mobility Swelling. Any neurovascular injury
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.
INVESTIGATIONS
Radiographs CT scan MRI scan Nerve conduction studies Routine investigations
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 #
CLASSIFICATION
CLOSED OPEN LOCATION- proximal, middle, distal FRACTURE PATTERN-tranverse, spiral,
oblique,comminuted segmental SOFT TISSUE STATUS – Tscherene &
Gotzen
Gustilo & Anderson
AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT
AO CLASSIFICATION
1 – HUMERUS 2--- DIAPHYSIS
A – SPIRAL– 1-PROXIMAL ZONE
2- MIDDLE ZONE
3- DISTAL ZONE
B- OBLIQUE
C- TRANSVERSE
AO CLASSIFICATION
AO CLASSIFICATION
A3
AO CLASSIFICATION
AO CLASSIFICATION
AO CLASSIFICATION
AO CLASSIFICATION
AO CLASSIFICATION
AO CLASSIFICATION
ASSOCIATED INJURIES
○ Radial Nerve injury = Wrist Drop = Inability of extend wrist, fingers, thumb, Loss of sensation over dorsal web space of 1st digitNeuropraxia at time of injury will
often resolve spontaneouslyNerve 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)
○ Brachial Artery Injury○ Clavicle, forearm, wrist & Chest injuries
DIAGNOSIS
History
Clinical examination
imaging
TREATMENT
Goal of treatment is to establish
union with acceptable alignment
TREATMENT OPTIONS
Non operative operative
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
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
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.
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.
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.
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.
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
subsided1. Minor movts at # site should be pain free2. Any deformity should disappear once
deforming forces are removed3. Reasonable resistance to telescoping.
OPERATIVE MANAGEMENT
OPERATIVE TREATMENT
INDICATIONSFractures 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.
METHODS OF SURGICAL MANAGEMENT Plating Nailing External fixation
ANTERIOR APPROACH
SUPINE ON THE ARM TABLE WITH 600 ABDUCTION AT SHOULDER
ANTERO LATERAL APPROACH
Incision Proximal land mark
– coracoid process Distal land mark-
anterior to lateral supracondylar ridge
ANTERO LATERAL APPROACH
Proximally, the plane lies between the deltoid laterally (axillary nerve) and the pectoralis major medially(medial and lateral pectoral nerves).
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.
POSTERIOR APPROACH Position of the
patient for the approach to the upper arm in either the (A) lateral or (B) prone position.
POSTERIOR APPROACH Incision Tip of olecranon
distally to postero lateral corner of acromion proximally
POSTERIOR APPROACH Incise the deep
fascia of the arm in line with the skin incision.
POSTERIOR APPROACH Identify the gap
between the lateral and long heads of the triceps muscle.
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.
INTRA OP PHOTO
PLATING - POSTERIOR APPROACH
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.
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.
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.
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.
DYNAMIC COMPRESSION PLATE
LIMITED CONTACT DCP
LOCKING PLATE
LOCKING PLATE HOLE
LOCKING PLATE
LAG SCREWS
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 motion.
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)
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).
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
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.
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.
ANTEGRADE TECHNIQUE
ANTEGRADE TECHNIQUE
RETROGRADE TECHNIQUE
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”)
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.
EXTERNAL FIXATION
EXTERNAL FIXATION
PLATE OR NAIL?
PlateReliable, 96%
unionGood
shoulder/elbow function
Soft tissue – scars, radial nerve, bleeding
NailLess incision
requiredHigher incidence
of complications? Lower union rate?
WHAT IS THE ROLE FOR NAILING? Segmental fractures
Particularly with a very proximal fracture line Pathologic fractures ? Cosmesis
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.
REHABILITATION
Allow early shoulder and elbow rom Weight bearing delayed till fracture is
united
CASE 1
IMPLANT FAILURE POST OP X RAY
CASE 2
IMPLANT FAILURE POST OP X RAY
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