Fracture humerus shaft in adults (AUDIT-KHOULA HOSPITAL)

1. FRACTURE HUMERUS SHAFT IN ADULTS
TEAM D AUDIT
KHOULA HOSPITAL
Supervised by
Dr. Ghassan Al YASSRI

2. Dr. Ahmed Al-Gazzar

3.  3-5 % of all fractures
 Bimodal distribution
 Males in 3rd decade
 Females in 7th decade

4.  Coaptation splint followed by functional brace
 Klenerman found that:-
•indicated in vast majority of humeral shaft fractures
•criteria for acceptable alignment includes
- anterior angulation < 20 *
- varus/valgus angulation <30*
- shortening < 3cm
•90 % union rate
•increased risk of non union with proximal third oblique or spiral fractures
•varus angulation is common but rarely has functional or cosmetic sequelae
**Klenerman L: Fractures of the shaft of the humerus. J Bone Joint Surg Br 1966; 48(1):105-
111.
I. Conservative:-

5. In the largest clinical analysis to date, Sarmiento et al reported on 922
patients treated with a functional brace for both closed and open
humeral shaft fractures:-
 98% of all closed injuries and 94% of all open fractures healed.
 Malunion, described as angular deformity greater than 16 degree in
any plane, 13% and 19%.
 Only 2% of patients reported loss of shoulder motion
**Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of fractures of
the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

6. **Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of
fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

7.  ABSOLUTE INDICATIONS :-
1. open fracture
2. vascular injury requiring repair
3. brachial plexus injury
4. ipsilateral forearm fracture (floating elbow)
5. compartment syndrome
 RELATIVE INDICATIONS:-
1. Bilateral humerus fracture
2. Polytrauma or ASSOCIATED lower extremity fracture
3. Pathological fractures
4. Burns or soft tissue injury
5. Long oblique or spiral proximal fracture
6. Intraarticular extension
II. Operative:

8.  RELATIVE INDICATIONS:-
1. pathologic fractures
2. segmental fractures
3. severe osteoporotic bone
4. overlying skin compromise limits open approach
5. polytrauma

9. AUDIT

12.  Outcome of the fracture
 Risk factors of associated injuries with ORIF , specially the
iatrogenic radial nerve injury.
PLAN

14.  We have analysed 57 consecutive fractures of the
humeral shaft treated over two-years period from July
2012 to July 2014
 The fractures were defined by their type “ closed
versus open and by AO morphology
 The data of the study is collected from khoula hospital
electronic system

16.  We have reviewed 57 patients with fracture humerus shaft
-43
-14
 55 cases with primary ORIF and 2 cases with revision fixation
 Male : Female is 3:1
 Age ranges from 16 – 72 years
 Average age 33.2

17. OLD
MIDDLE
Young
16 – 40 yrs
42 cases
41-60 yrs
12 cases
61- 72
3 CASES
Age groups of the patients

18.  Interval between the incidence of injury and surgery in primary
cases ranged from 0 day to 20 weeks.
 The 2 revision cases one done after 21 weeks due to re-fracture
and the other done after 3 years due to non union.

19. Types of Fractures
Closed fractures
• 54 cases
Open fractures
• 3 Cases

20.  A1 --- 6 cases
 A2 --- 6 cases
 A3 --- 19 cases
 B1 --- 8 cases
 B2 --- 7 cases
 B3 --- 3 cases
 C1 type --- 8 cases
Classification of fractures (AO)

21. Associated
Injuries
Radial nerve
injury
8 cases
Brachial artery
injury
2 cases
Multiple
nerve injury
1 case

22. 6 cases
4 primary fractures
2 revision fractures
51 cases
ORIF
by
plating
ORIF
by
plating +
bone graft
Operative Technique

23. Posterior 31 cases
Anterolateral 20 cases
Anterior 2 cases
Lateral 2 cases
Medial 1 case
Anteromedial
1 case
Approaches for surgery

24. Medical officer
1 case
Resident
1 case
Sr.consultant
2 cases specialist
25 cases
Sr.specialist
28 cases
Level of Surgeon

25. Supervision of surgery
supervised by Sr. consultant
•2 cases
Supervised by Sr. Specialist
•15 cases

26. 2
complications
10 cases
By specialist
Without
supervision
1 case
Deep SSI
1 case
Malunion
Supervision of surgery

27. Complications of the fracture
 9 cases with radial nerve injury 19 %
 8 cases initial isolated Radial nerve injury
 1 case with multiple upper limb nerve injury

28. Complications of surgery (ORIF)
1 case
Varus
angulation
1 case
Delayed
union
1 case
Deep SSI
2 cases
Non union
2 cases
Iatrogenic
radial n.
palsy
1.75 % 1.75 % 1.75 %
3.5% 3.5 %

29. Iatrogenic Radial Nerve Palsy

30. Iatrogenic Radial Nerve Palsy

31. NON UNION

32. Deep SSI

33. VARUS ANGULATION

34.  9 cases of initial radial nerve injury:-
 5 cases recovered completely
 2 cases recovered partially
 2 cases didn’t recover
 There was no proper documentation of the radial nerve deficit
regarding sensory and motor
Major morbidity of the fracture was the radial nerve injury

35.  2 cases of Iatrogenic radial nerve injury didn’t recover.
 Both cases were operated through anterolateral approach
 Both cases were operated by specialist and supervised by Sr.
Specialist .
 One case had shown radial nerve degeneration by EMG
study done after 1 year of injury .
 The other case was shown to the clinic only up to 4 months
after surgery with no recovery.

36.  Injury to the radial nerve with neuropraxia is the most frequently
encountered nerve deficit associated with humeral fractures and is
found in up to 18% of all patients.spontaneous recovery over a period
of 4 months occurs in 70% to 92% of patients managed with
observation; therefore, its presence is not an indication for open
management and nerve exploration.
Shao Y, Harwood P, Grotz M, Limb D, Giannoudis P. Radial nerve palsy associated with fractures of the
shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005;87:1647-52. doi:10.1302/0301
620X.87B12.16132

37. Compare Data
Khoula
(57)
USA
(213)
Singapore
(53)
Iatrogenic Radial n. palsy 3.5 % 8% 5.7%
Non union 3.5% 9% 3.7%
malunion 1.7% 1% ---
Deep SSI 1.7% 5% 3.7%
**Operative versus Nonoperative Treatment of Humeral Shaft Fractures: A Retrospective Review of 213 Patients from Two
Level I Trauma Centers Fri., Southeastern Fracture Consortium; Michael C. Tucker, MD1 (10-Southeastern Fracture
Consortium research grant); William T. Obremskey, MD2 (5A-Medtronic, Osteogenix; 7-Synthes); Mark Floyd,
BS3 (n); Anthony Denard, BS2 (n); 10/9/09 Upper Extremity, Paper #49, 11:45 am OTA-2009.
**Surgical Results of Open Reduction and Plating of Humeral Shaft Fractures. H T Hee,*MBBS, FRCS (Edin), FRCS (Glas), BY
Low,**FAMS, FRCS (Edin), FRCS (Glas), H F See,***FAMS, MBBS, FRCS (Glas). Ann Acad Med Singapore 1998; 27:772-5.

38.  The surgical approach used in the analysed cases with iatrogenic radial
nerve palsy was anterolateral approach That means the injury to the
nerve could happened due to over traction during reduction or during
putting the hardware.
 Surgeries done by specialist level with no supervision had a complication
rate of 20 %
Conclusion

39. Proper assessment of the neurologic deficit at the time of injury ,
pre operative and postoperative is of greatest importance.
Plan the proper approach prior to surgery according to type of
fracture , plan of fixation , associated injuries , skills of the
operating surgeon.
Where is the nerve
Length of observation for radial n. palsy remains a subject of debate.
During the observation period: Brace & aggressive ROM physiotherapy.
Recommendations

42. Thank
you