2. FRACTURESHAFT HUMERUS
• Introduction
• History
• Epidemiology
• Mechanism of injury
• Classification
• Clinical features
• Investigations
• Treatment
• Complications
3. INTRODUCTION
• 3%to 5%ofall fractures
• Most will heal with appropriate conservative care, although alimited 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, awide range of radiographic malunion can be accepted with little functional
deficit
5. EPIDEMIOLOGY
• High energy trauma is more common in the young males
• Low energy trauma is more common in the elderly female
6. ANATOMY
• Proximally, the humerus is roughly cylindrical in cross section, tapering to a
triangular shapedistally.
• 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.
7. 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 medialside
• 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
10. MECHANISMOFINJURY
• Direct trauma is the most common especially MVA
• Indirect trauma such asfall on an outstretched hand
• Fracture pattern depends on stress applied
• Compressive- proximal or distalhumerus
• Bending- transverse fracture of the shaft
• Torsional- spiral fracture of the shaft
• Torsion and bending- oblique fracture usually associated
with abutterflyfragment
11. CLINICALFEATURES
• 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 # )
13. CLINICALFEATURES
• 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.
• Assessfor the presence of the radial
pulse.
15. IMAGING
APand lateral views of the humerus,
including the joints below and above the injury.
• Computed Tomographic (CT)scans ofassociated intra-articular injuries proximally or distally.
• CTscanningmay also be indicated in the rare situation where a significant rotational
abnormality exists asrotational alignment is difficult to judge from plain radiographs of a
diaphyseal long bone fracture. ACTscan through the humeral condyles distally and the humeral
head proximally can provide exact rotational alignment
• MRI for pathological#
27. IIrRadial nerveinjury=wristdrop=inabilityof extend wrist,
fingers, thumb, Loss of sensation over dorsal web
space of 1st digit
•Neuropraxia at time of injury will often resolve
spontaneously
•Nerve 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)
• BrachialArtery Injury
• Clavicle, forearm, wrist &Chest injuries
ASSOCIATEDINJURIES
31. 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
32. HUMERALSHAFTFRACTURES
• Conservative Treatment
• >90%of humeral shaftfractures
heal with nonsurgicalmanagement
• 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
33. NONOPERATIVEMETHODS
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.
34. 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.
35. 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.
36.
37. 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.
38. TIMETOAPPLY
1.
2.
3.
• 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 subsided
Minor movts at # site should be pain free
Any deformity should disappear once deforming forces are
removed
Reasonable resistance to telescoping.
42. OPERATIVETREATMENT
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. ANTEROLATERALAPPROACH
• Proximally, the plane liesbetween
the deltoid laterally (axillary nerve)
and the pectoralis major
medially(medial and lateral pectoral
nerves).
47. ANTEROLATERALAPPROACH
• Distally, the plane lies between
the medial fibers of the brachialis
(musculocutaneous nerve)
medially and the lateral fibers of
the brachialis (radial nerve)
laterally.
48. POSTERIORAPPROACH
• Position of the patient for
the approach to the
upper arm in either the
(A) lateral or (B) prone
position.
52. POSTERIORAPPROACH
• 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
brachiiartery.
55. 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.
56. PLATEOSTEOSYNTHESIS
• 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.
57. PLATEOSTEOSYNTHESIS
• 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.
58. PLATEOSTEOSYNTHESIS
• Atheoretical 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.
66. PEARLS AND PITFALLS – COMPRESSION PLATING
• Useananterolateralapproachformidshaftorproximalfractures, and a
posterior approach for distal fractures.
• Use a4.5-mm compression plate in most patients, with a minimum of 3(and
preferably 4) screws proximal and distal. A4.5-mm narrow plate is acceptable
for smaller individuals.
• Insert alag 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.
67. 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)
68. 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).
69. 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
70. PEARLSAND PITFALLS—INTRAMEDULLARYNAILING
• 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.
71. PEARLSAND 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 meticuloustechnique.
75. EXTERNALFIXATION
• 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”)
76. EXTERNALFIXATION
• 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.
81. COMPLICATIONSOFOPERATIVE
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 shoulderstiffness.
86. Simple elbow dislocation is one in which there are
no associated fractures
The elbow joint is the second most commonly
dislocated joint in the adult population
Adolescent males are the highest-risk group
87. GROSS ANATOMY
Articulations
The elbow joint is made up of three articulations
Radiohumeral: capitellum of the humerus with the radial
head
Ulnohumeral: trochlea of the humerus with the trochlear
notch (with separate olecranon and coronoid process
articular facets) of the ulna
Radioulnar: radial head with the radial notch of the
ulna (proximal radioulnar joint)
88. MOVEMENTS
The elbow is a trochoginglymoid (combination hinge and pivot) joint
the hinge component (allowing flexion-extension) is formed by the
ulnohumeral articulation
the pivot component (allowing pronation-supination) is formed by the
radiohumeral articulation and the proximal radioulnar joint
89. LIGAMENTS
medial (ulnar) collateral ligament complex
lateral (radial) collateral ligament complex
oblique cord
inconstant thickening of supinator muscle fascia and
functionally insignificant
runs from tuberosity of the ulna to just distal to radial tuberosity
quadrate ligament (of Denuce)
thickening of the inferior aspect of the joint capsule
runs from just inferior to the radial notch of the ulna to insert
to the medial surface of the radial neck
90. PATHOANATOMY AND APPLIED
ANATOMY
soft tissue restraints can be divided into both static
and dynamic stabilizers
static stabilizers joint capsule and the LCLs and MCLs
91. LCL
Primary varus and posterolateral rotational stabilizer
LCLhas three components-
The radial collateral ligament
annular ligament
The lateral ulnar collateral ligament
92. The radial head is surrounded by the annular ligament which attaches to
the anterior and posterior margins of the radial notch of the proximalulna
The radial collateral ligament arises from the lateral epicondyle and blends
with the annular ligament
The lateral ulnar collateral ligament is posterior to the radial collateral
ligament
93. MCL consists of the anterior and posterior bundles
The anterior bundle is the key valgus stabilizer of the elbow, arising from
the anteriorinferior aspect of the medial epicondyle to insert on the
sublime tubercle of the proximal ulna
The posterior bundle provides a secondary restraint to valgus load and
also resists ulnar rotation
96. Patients with simple elbow dislocations routinely have disruption of both
the MCL and LCLand the elbow capsule
The muscular origins may be disrupted aswell; typically the injury to the
lateral common extensor origin is more extensive than the medial common
flexor origin
Most activities of daily living exert a varus force on the elbow than a valgus
force, residual instability is usually due to incompetence of the LCLin the
majority of patients
97. The radial head causes an impression
fracture of the posterior capitellum which
can contribute to recurrent instability
98. Mechanisms of Injury
Fall on an outstretched hand
The soft tissue injury is thought to begin on the lateral side of
the elbow with disruption of the lateral collateral ligament
(LCL) and then proceeds through the capsule to the medial
side with the medial collateral ligament (MCL) being injured
last
99.
100. Associated Injuries
Simple elbow dislocations are not associated with fractures
Disruption of the collateral ligaments, elbow capsule, and forearm flexor
and extensor muscle origins
Injury to the brachial artery has been described in closed simple
dislocations and nerve palsies are possible
The ulnar nerve is the most commonly injured nerve following elbow
dislocation
101. Signs and Symptoms
Obvious deformity and pain about the affected elbow
Elbow flexed to 90 degrees, the medial and lateral epicondyles and the
olecranon process should form an isosceles triangle
Complete peripheral neurologic examination should be performed
102. Imaging and Other Diagnostic Studies
Anteroposterior, lateral, and oblique radiographs
are used to diagnose elbow dislocation and help
to rule out associated fractures
Although rarely required in practice, a line drawn
along the anterior margin of the humerus (anterior
humeral line) and one along the long axis of the
radius should intersect near the centre of the
capitellum
103. Computed tomography (CT) scanning is rarely
needed but can be useful if there is a questionable
associated fracture
104. MRI is not needed unless there is concern
for ulnar nerve entrapment in the joint
since the pathology of the soft tissue injury
associated with elbow dislocations has
been well established
105. CLASSIFICATION
Based on the direction of dislocation
Simple versus complex
displacement of the ulna relative to the humerus
Posterior ■ Posterolateral ■ Posteromedial ■ Lateral ■ Medial ■ Anterior
110. INJURY PATTERNS
Posterior dislocation with a fracture of the radial head
Posterior dislocation with fractures of the radial head and coronoid
process—the so-called “terrible triad” injury
Varus posteromedial rotational instability pattern injuries associated with
anteromedial facet of the coronoid fractures
Anterior olecranon fracture-dislocations
Posterior olecranon fracture-dislocations
111. TYPESOFELBOW INSTABILITY
Posterolateral rotatory instability (elbow dislocations with or without
associated fractures)
Varus posteromedial rotational instability (anteromedial coronoid facet
fractures)
Olecranon fracture-dislocations
113. NONOPERATIVE TREATMENT
The majority of simple elbow dislocations can be treated nonoperatively
with closed manipulative reduction evaluation of stability and an early
rehabilitation program
114. TECHNIQUES-PARVINS METHOD
The medial and lateral epicondyles are palpated and their relationship to
the olecranon is determined in order to first correct and medial/lateral
displacement in the coronal plane
The elbow is typically flexed to approximately 30 degrees, and traction is
placed through the forearm while stabilizing the humerus
Direct pressure over the olecranon may help to guide it over the distal
humerus and into joint
Supination of the forearm may be helpful to gain thereduction
115.
116. After reduction-the elbow is taken through an arc of flexion– extension in
pronation, neutral, and supination in order to evaluate for residual
instability
The elbow redislocates when flexed to less than 30 degrees, operative
treatment should be considered
Most patients will have varus–valgus instability
117. The elbow is then immobilized in a light plaster splint with the forearm in
pronation, neutral, or supination (depending on the position of maximal
stability) and the elbow at 90 degrees of flexion
Radiographs are performed to ensure a congruous reduction has been
achieved and to evaluate for the presence of fractures not visualized on the
prereduction radiographs
118. Immobilization greater than 3 weeks should be
avoided as this has been demonstrated to cause
an increased incidence of stiffness and poorer
functional outcomes
119. OUTCOMES
Several studies have reported good to excellent outcomes in the majority
of patients after simple elbow dislocation
Prolonged immobilization after injury was associated with a worse result
with increasing duration of immobilization leading to increased flexion
contracture and more severe residual pain: In general, prolonged
immobilization is to be avoided in this setting
120. OPERATIVE TREATMENT
The main indication for operative management of simple elbow
dislocations is an inability to maintain a concentric elbow joint after closed
reduction or a recurrent dislocation
irreducible dislocations are also indications for operative treatment but
these are rare injuries
121. SURGICAL PROCEDURE
Patient is placed supine on the operating table with a radiolucent arm
table on the affected side
Preoperative examination of the shoulder should be performed to besure
that there is adequate external rotation of the shoulder in order to
approach the medial side of the elbow
122. Surgical Approach-posterior midline incision is employed and a full
thickness lateral flap is elevated on the deep fascia
If the medial structures require repair, full thickness elevation of the medial
flap is performed
123. Soft Tissue Repair
Vast majority of cases,a medial ligament repair is not required and the
surgery is complete
The lcl can be repaired using transosseous bone tunnels or suture anchors
Locking krackow stitches are placed in the lcl while a second suture is
placed in the extensor fascia
124.
125. In the unusual setting that the elbow remains unstable in spite of repair of
the lateral structures, the medial side of the elbow is approached with care
taken to protect the ulnar nerve
The flexor–pronator muscles are also repaired if they have been avulsed
elbow is still unstable, then a static or hinged external fixator should be
placed or, asa last resort, the elbow should be transfixed with a screw or
robust Steinman pin
126. EXTERNAL FIXATION
A hinged fixator will allow for range of motion exercises to beperformed
while the external fixator is in place and should be considered if the
surgeon has access to this and the experience to apply it
Static fixators are easier to apply and are more widely available
The key to all hinged devices is an understanding of the axis of elbow
rotation
Two pins are placed in the humeral shaft laterally and two pins are placed
in the ulnar shaft laterally in a position that allows for forearm rotation
127. Open pin placement is recommended to avoid injury to the radialnerve
A static frame is assembled with the elbow joint reduced
The external fixator is left in place for approximately 4 weeks and then a
range of motion protocol is initiated asoutlined above for closed
treatment
128.
129. Bridge Plate
Indications are conditions where maintenance of
reduction is challenging such as morbid obesity and
patients with neurologic injuries such as spasticity or
flaccid paralysis
triceps-splitting approach
Three to four locking screws are placed in the ulna
and the distal humerus avoiding the articulation and
fossae
130. The plate is removed at 4 weeks, and a posterior
capsulectomy and an elbow manipulation can be
considered at the time of plate removal to increase the
recovery of motion
133. COMPLICATIONS
Loss of motion (stiffness): Stiffness
following complicated or
uncomplicated elbow dislocation is
usually the rule. Immobilization of the
elbow should generally not go beyond
2 weeks
135. Persistent instability/redislocation:
This is rare after isolated, traumatic posterior elbow
dislocation; the incidence is increased in the presence of
an associated coronoid process and radial head fracture
(terrible triad of the elbow)
