Humerus fracture

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2. FRACTURE SHAFTHUMERUS Introduction History Epidemiology Mechanism of injury Classification Clinical features Investigations Treatment Complications 3. INTRODUCTION 3% to 5% of all fractures Most will heal with appropriateconservative care, although a limitednumber will require surgery for optimaloutcome. Given the extensive range of motion ofthe shoulder and elbow, and the minimaleffect from minor shortening, a widerange of radiographic malunion can beaccepted with little functional deficit 4. GENERALCONSIDERATIONS Current research -- decreasing thesurgical failure rate through New implants and techniques, Optimizing the postinjury rehabilitationprograms Minimizing the duration and magnitudeof remaining disability. 5. GENERALCONSIDERATIONSSuccessful treatment demands aknowledge of : Anatomy, Biomechanics Techniques Patient Function and Expectations. 6. HISTORY 7. Sir JOHN CHARNLEY (1911-1982) It is perhaps theeasiest of major lonfbones to treat byconservativemethods 8. SARMIENTO (February 15,1811 September 11, 1888) 9. RICHARD WATSON (1737-1816) 10. EPIDEMIOLOGY High energy trauma is more common inthe young males Low energy trauma is more common inthe elderly female 11. AGE AND GENDER SPECIFICINCIDENCE OF SHAFTHUMERUS FRACTURE 12. ANATOMY Proximally, the humerus is roughlycylindrical in cross section, tapering to atriangular shape distally. The medullary canal of the humerustapers to an end above thesupracondylar expansion. The humerus is well enveloped inmuscle and soft tissue, hence there is agood prognosis for healing in themajority of uncomplicated fractures. 13. ANATOMY Nutrient artery- enters the bone veryconstantly at the junction of M/3- L/3 andforamina of entry are concentrated in asmall area of the distal half of M/3 onmedial side Radial nerve- it does not travel along thespiral groove and it lies close to the inferiorlip of spiral groove but not in it It is only for a short distance near thelateral supracondylar ridge that the nerve isdirect contact with the humerus andpierces lateral intermuscular septum 14. ANATOMY 15. RELATIONSHIP OFNEUROVASCULARSTRUCTURES TO SHAFTHUMERUS 16. MECHANISM OF INJURY Direct trauma is the most common especially MVA Indirect trauma such as fall on an outstretched hand Fracture 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 17. CLINICAL FEATURES HISTORY Mode of injury Velocity of injury Alchoholic abuse, drugs ( prone forrepeated injuries ) Age and sex of the patient ( osteoporosis ) Comorbid conditions Previous treatment( massages) Previous bone pathology ( path # ) 18. CLINICAL FEATURES Pain. Deformity. Bruising. Crepitus. Abnormal mobility Swelling. Any neurovascular injury 19. CLINICAL FEATURES Skin integrity . Examine the shoulderand elbow joints andthe forearm, hand,and clavicle forassociated trauma. Check the function ofthe median, ulnar, and,particularly, the radialnerves. Assess for thepresence of the radialpulse. 20. INVESTIGATIONS Radiographs CT scan MRI scan Nerve conduction studies Routine investigations 21. IMAGINGAP and lateral views of the humerus, including the joints below and above the injury. Computed Tomographic (CT) scans of associatedintra-articular injuries proximally or distally. CT scanning may also be indicated in the raresituation where a significant rotational abnormalityexists as rotational alignment is difficult to judge fromplain radiographs of a diaphyseal long bone fracture.A CT scan through the humeral condyles distally andthe humeral head proximally can provide exactrotational alignment MRI for pathological # 22. CLASSIFICATION CLOSED OPEN LOCATION- proximal, middle, distal FRACTURE PATTERN-tranverse, spiral,oblique,comminuted segmental SOFT TISSUE STATUS Tscherene &Gotzen Gustilo &Anderson 23. AO CLASSIFICATION OF THEHUMERUS FRACTURESHAFT 24. AO CLASSIFICATION 1 HUMERUS 2--- DIAPHYSIS A SPIRAL 1-PROXIMAL ZONE2- MIDDLE ZONE3- DISTAL ZONEB- OBLIQUEC- TRANSVERSE 25. AO CLASSIFICATION 26. AO CLASSIFICATIONA3 27. AO CLASSIFICATION 28. AO CLASSIFICATION 29. AO CLASSIFICATION 30. AO CLASSIFICATION 31. AO CLASSIFICATION 32. AO CLASSIFICATION 33. ASSOCIATED INJURIES Radial Nerve injury = Wrist Drop =Inability of extend wrist, fingers, thumb,Loss of sensation over dorsal webspace of 1st digit Neuropraxia at time of injury will oftenresolve spontaneously Nerve palsy after manipulation orsplinting is due to nerve entrapmentand must be immediately explored byorthopedic surgery Ulnar and Median nerve injury (lesscommon) 34. DIAGNOSISHistoryClinicalexamination imaging 35. TREATMENTGoal of treatment is to establishunion with acceptable alignment 36. TREATMENT OPTIONSNon operative operative 37. NON OPERATIVETREATMENT INDICATIONSUndisplaced closed simplefracturesDisplaced closed fractures withless than 20 anterior angulation, 30varus/ valgus angulation Spiral fractures Short oblique fractures 38. HUMERAL SHAFTFRACTURES 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 39. NON OPERATIVEMETHODS 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 asling. Immobilization by fracture bracing iscontinued for at least 2 months or untilclinical and radiographic evidence of fracturehealing is observed. 40. FCB - INTRODUCTION A closed method of treating fracturesbased on the belief that continuingfunction while a fracture is uniting ,encourages osteogenesis, promotes thehealing of tissues and prevents thedevelopment of joint stiffness, thusaccelerating rehabilitation Not merely a technique but constitute apositive attitude towards fracturehealing. 41. CONCEPT The end to end bone contact is notrequired for bony union and that rigidimmobilization of the fracture fragmentand immobilization of the joints aboveand below a fracture as well asprolonged rest are detrimental tohealing. It complements rather than replacesother forms of treatment. 42. CONTRAINDICATIONS Lack of co-operation by the pt. Bed-ridden & mentally incompetent pts. Deficient sensibility of the limb [D.M withP.N] When the brace cannot fitted closelyand accurately. Fractures of both bones forearm whenreduction is difficult. Intraarticular fractures. 43. TIME TO APPLYNot 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. 44. OPERATIVE MANAGEMENT 45. OPERATIVE TREATMENT INDICATIONS Fractures 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. 46. METHODS OF SURGICALMANAGEMENT Plating Nailing External fixation 47. ANTERIOR APPROACH SUPINEON THE ARM TABLE WITH 600 ABDUCTION AT SHOULDER 48. ANTERO LATERALAPPROACH Incision Proximal land mark coracoid process Distal land mark-anterior to lateralsupracondylar ridge 49. ANTERO LATERALAPPROACH Proximally, the planelies between thedeltoid laterally(axillary nerve) andthe pectoralis majormedially(medial andlateral pectoralnerves). 50. ANTERO LATERALAPPROACH Distally, the planelies between themedial fibers of thebrachialis(musculocutaneousnerve) medially andthe lateral fibers ofthe brachialis (radialnerve) laterally. 51. POSTERIOR APPROACH Position of thepatient for theapproach to theupper arm in eitherthe (A) lateral or (B)prone position. 52. POSTERIOR APPROACH Incision Tip of olecranondistally to posterolateral corner ofacromion proximally 53. POSTERIOR APPROACH Incise the deepfascia of the arm inline with the skinincision. 54. POSTERIOR APPROACH Identify the gapbetween the lateraland long heads ofthe triceps muscle. 55. POSTERIOR APPROACH Proximally develop theinterval between the twoheads by bluntdissection, retracting thelateral head laterally andthe long head medially.Distally split theircommon tendon alongthe line of the skinincision by sharpdissection. Identify theradial nerve and theaccompanying profundabrachii artery. 56. INTRA OP PHOTO 57. PLATING - POSTERIORAPPROACH 58. PLATING Plate osteosynthesis remains the criterionstandard of fixation of humeral shaftfractures high union rate, low complication rate, anda rapid return to function Complications are infrequent and includeradial nerve palsy, infection and refracture. limited contact compression (LCD) platehelps prevent longitudinal fracture orfissuring of the humerus because thescrew holes in these plates are staggered. 59. PLATE OSTEOSYNTHESIS There are several practical advantagesto the use of the LCD plates overstandard compression plates: they areeasier to contour, allow for wider angleof screw insertion, and havebidirectional compression holes. Theoretical advantages includedecreased stress shielding andimproved bone blood flow due to limitedplate-bone contact. 60. PLATE OSTEOSYNTHESIS Recently angle stable or locked platingsystems have gained wide popularity. By locking the screws to the plate anumber of mechanical advantages aregained, including a reduced risk for screwloosening and a stronger mechanicalconstruct compared with conve