Shar hospital activity

1. Humeral Shaft Fracture and
Principles of Management
Presented by :
(
Ismael Othman Mahmood (KBMS trainee – 2nd stage
Supervised by :
Dr. Aso Ali Bakir

2. Are common
fractures of the
diaphysis of the
humerus , which
may be
associated with
radial nerve
injury.

3. Epidemiology
• Incidence : 3-5 % of all fractures
•
• Demographics :
Bimodal age distribution
Young pt. ; high energy
Elderly pt. ; low energy

4. Anatomy
• extends from the surgical neck proximally to
the humeral condyles distally.
• Cylindrical shape proximally
• conical in its middle 1/3
• Flattened dramatically in the coronal plane
distally .

8. • muscles are divided into anterior flexor and
posterior extensor compartments .

11. Radial Nerve Anatomy
• Largest branch of the brachial plexus
• Arises from posterior cord ( C5 – T1 )
• Motor and Sensory ( mixed )

16. Radial n.
Courses along spiral groove
14 cm proximal to the lateral epicondyle and 20
cm proximal to the medial epicondyle .

17. Radial nerve
At the junction of the middle and distal third of
the humerus, about a handbreadth above the
lateral epicondyle, the radial nerve perforates
the lateral intermuscular septum.
Here the nerve is less mobile and more
vulnerable when displacement of fragments
occurs.

18. Radial nerve palsy
High Radial nerve palsy :
• Elbow extension spared
• Lost: Wrist , thumb and
finger extension ; Sensation
over 1st web space

22. Mechanism of injury
*A fall on the hand may twist the humerus, causing a spiral fracture .
*A fall on the elbow with the arm abducted
exerts a bending force, resulting in an oblique or transverse fracture.
*A direct blow to the arm causes a fracture which is either transverse
or comminuted.
*Fracture of the shaft in an elderly patient may be due to a metastasis
(Pathological ).

23. Pathological anatomy
• With fractures above the deltoid insertion- the
proximal fragment is adducted by pectoralis major and
the distal fragment laterally displaced .
• With fractures lower down- the proximal fragment is
abducted by the deltoid.
• Fractures proximal to the Brachioradialis and
extensor muscles, the distal fragment rotated laterally.
• Distal fractures tend to fall into varus.

25. Clinical features:
1-pain
2- bruise
3-swelling
4- weakness

26. Physical examination :
Examine overall
limb alignment ;
often present with
shortening and in
varus.

27. Radial nerve function test:
( pre- and post-
reduction )
assessment is very
important.
How to do ?
- by assessing active
extension of the MCP
joints.

28. Active extension of
the wrist can be
misleading.
Why ?
Extensor carpi radialis
longus is sometimes
supplied by a branch
arising proximal to the
injury.

29. Radiographs:
AP and Lateral
( joint above and below )
Shows:
1- site of fracture
2- pattern ;
Transverse
Spiral
Oblique
Comminuted
3-Displacement

30. USG of ARM:
To detect the
radial continuity
or entrapment.

31. Transthoracic lateral
*Sagittal plane
deformity
*avoiding further
nerve or soft tissue
injury.

32. Traction view:
•not routinely
indicated
Better Delineates
the fracture lines
and extent of joint
injury .

33. Classification
OTA
• Bone number : 1
• Location : 2
• Pattern :
*Simple A
*Wedge B
*Complex C

34. Classification
Descreptive
1- Location :
Proximal 1/3
Middle 1/3
Distal 1/3
2- Pattern :
Spiral
Transverse
Comminuted

35. Treatment
*Non-Operative ;
1- Coaptation splint followed by functional brace
*Operative :
1-ORIF
2-IMN
3- EF

36. Non-Operative mx:
• Fracture of the humerus heals readily.
• The weight of the arm with an external cast is
usually enough to pull the fragments into
alignment.

37. Hanging Cast
• applied from shoulder to wrist with the elbow
flexed 90 degrees.
• the forearm section is suspended by a sling
around the patient’s neck.
• may be replaced by a short (shoulder to elbow)
cast or a functional polypropylene brace after 2–3
weeks which is worn for a further 6 weeks .

38. Hanging Cast

39. functional polypropylene brace Short Cast
Sarmiento brace ( U – Shaped )

40. Coaptation Splint

41. Advantages of non-operative Mx:
• The wrist and fingers exercises can be done
from the start easily .
• Pendulum exercises of the shoulder are
begun within a week .

43. Operative vs. non-operative mx:
• (1) the complication rate after internal fixation
of the humerus is high
• (2) that the great majority of humeral
fractures unite with non-operative treatment
• (3) there is no good evidence that the union
rate is higher with fixation (and the rate may
be lower if there is distraction with nailing or
periosteal stripping with plating).

44. Operative treatment
indications for surgery:
1- severe multiple injuries
2- an open fracture
3- segmental fractures
4- displaced intra-articular extension
5- a pathological fracture
6- a ‘floating elbow’
7- radial nerve palsy after manipulation
8- non-union
9- problems with nursing care in a dependent person

45. Methods
Fixation can be achieved with:
(1) a compression plate and screws
(2) an interlocking intramedullary nail or semi-
flexible pins
(3) an external fixator

46. Compression plate and screw
Advantage :
1-excellent reduction and
fixation.
2-does not interfere with
shoulder or elbow function.
Disadvantage:
1- Radial nerve injury
2- too much periosteal
stripping >> non- union

47. Interlocking intramedullary nail
Advantage :
1- Minimal dissection
Disadvantage:
1-Rotator cuff injury
2- Distract the fracture

48. External Fixation
Advantage :
1- Segmental fracture
2- Open fracture
Disadvantage :
1- Radial nerve injury

49. Complications
Early :
Vascular injury – Brachial
Artery
Nerve injury; Radial nerve
( Particularly in Holstein-Lewis
fracture
Holstein-Lewis fracture

50. Complications
LATE:
1-Delayed union and non-union
( typical in segmental high energy fracture and
open fracture )
2-Joint stiffness

51. Holstein-Lewis Fracture
A spiral fracture of the distal 1/3
of the humeral shaft commonly
associated with injury to radial
nerve ( 22% ).

52. Special features in children
• Uncommon .
• in under 3 years of age
possibility of child abuse to
be considered and tactful
examination needed for
other injuries .

53. Special features in children
Mx:
Conservative :
* can usually be treated by
applying a collar and cuff
bandage for 3–4 weeks.
*manipulation may be needed, If
there is gross shortening.
*Older children may require a
short plaster splint.

54. Special features in children
Operative :
ORIF with flexible
intramedullary nail fixation

55. References:
• Apley and Solomon’s Concise system of
Orthopaedics and Trauma 10th Edition
• AO Principles of fracture Management 3rd Edition
• www.orthobullets.com
• www.slideshare.net