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FRACTURE SHAFT HUMERUS
Edited by Abdelrahman youssif
HYDERABAD
Mansoura universityfaculty of medicineorthopedics department
Supervisor: Head of department:
Prof.Dr.hani.M.Elmowafy
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.
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.
Sir JOHN CHARNLEY (1911-1982)
“It is perhaps the easiest of major long bones to treat by conservative methods”
EPIDEMIOLOGY
High energy trauma is more common in the young males
Low energy trauma is more common in the elderly female
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
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
Inflammation
• Hematoma forms and provides source of hemopoieitic cells capable of secreting growth factors.
• Macrophages, neutrophils and platelets release several cytokines• this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12
• Fibroblasts and mesenchymal cells migrate to fracture site and granulation tissue forms around fracture ends
• Osteoblasts and fibroblasts proliferate• inhibition of COX-2 (ie NSAIDs) causes repression of runx-2/osterix, which are critical for differentiation of osteoblastic cells
Repair• Primary callus forms within two weeks. If the bone ends
are not touching, then bridging soft callus forms.
• Enchondral ossification converts soft callus to hard callus (woven bone). Medullary callus also supplements the bridging soft callus
• Type II collagen (cartilage) is produced early in fracture healing and then followed by type I collagen (bone) expression
• Amount of callus is inversely proportional to extent of immobilization • primary cortical healing occurs with rigid
immobilization (ie. compression plating)
Remodeling• Begins in middle of repair phase and continues
long after clinical union• chondrocytes undergo terminal differentiation
• signaling pathways including, indian hedgehog (Ihh), parathyroid hormone related peptide (PTHrP), FGF and BMP
• cartilaginous calcification takes place at the junction between the maturing chondrocytes and newly forming bone
• multiple factors are expressed including BMPs, TGF-Betas, IGFs, osteocalcin, collagen I, V and XI
• subsequently, VEGF production leads to new vessel invasion
• newly formed bone (woven bone) is remodeling via osteoblastic/osteoclastic activity
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.
IMAGING
AP and lateral views plain x-ray of the humerus,
including the joints below and above the injury.
CT scanning may also be indicated in the rare situation where a significant rotational abnormality exists. A CT scan through the humeral condyles distally and the humeral head proximally can provide exact rotational alignment
MRI for pathological cause
CLASSIFICATION
CLOSED OPEN LOCATION- proximal, middle, distal FRACTURE PATTERN-tranverse, spiral,
oblique,comminuted segmental SOFT TISSUE STATUS – Gustilo
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
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 splint 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.
HUMERUS BRACE- 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 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.
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.
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
Antegrade Technique
Retrograde Technique-best suited for fractures in the middle and distal thirds of the humerus
EXTERNAL FIXATION
External fixation is cumbersome for the humerus and the complication rate is high.
AS IT MAY accentuate the risk of delayed union and malunion, resulting in significant rates of pin tract irritation, infection, and pin breakage.
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.
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