3. Primary Survey
A : can speak , no limit ROM of neck, not tender along c-spine
B : trachea in midline, normal & equal breath sound, CCT
negative
C : BP 139/88 mmHg PR 95 bpm, not seen active bleeding,
cap. Refill<2 sec
D : E4V5M6, pupils 3 mm RTLBE
E : AW at both arm and dorsum of Lt. foot, Rt. Arm deformity,
not seen active bleeding
4. Secondary Survey
A : no food/drug allergy
M : no current medication
P : no U/D
L : NPO time 7.00 am
E : ขี่รถจักรยานยนต์ล้มเอง ไม่สวมหมวกกันน๊อค เกิดเหตุบริเวณ
ถนน
5. Physical Examination
General appearance : A Thai boy, good consciousness,
look painful
V/S : BP 139/88 mmHg, PR 98 bpm, RR22/min, T 36.6oC
HEENT : not pale conjunctivae, anicteric sclerae
Heart&Lung : WNL
Abdomen : WNL, pelvic compression test negative
6. Extremities : Rt. Arm varus deformity, marked tender
Rt. Elbow not tender, radial a. 2+, cap.refil < 2 sec
Sensory : intact pinprick sensation
Can extend wrist, can opponens/adduct/extend thumb
Physical Examination
7.
8.
9. Extremities : Rt. Arm deformity, marked tender
Rt. Elbow not tender, radial a. 2+, cap.refil < 2 sec
Sensory : intact pinprick sensation
Can extend wrist, can opponens/adduct/extend thumb
Physical Examination
13. 1. Pethidine 40 mg IV stat
2. Close Reduction
3. Immobilization with U-slab Rt. Arm
& on Rt. Arm sling
4. Repeat Film Rt. Humerus AP,Lateral
5. Discharge นัด F/U 1 week
6. Home medication :
Paracetamol (500) 1 tab PO prn q 6 hr
Management
17. Introduction
1. Incidence3-5% of all fractures
2. bimodal age distribution
•young patients with high-energy trauma
•elderly, osteopenic patients with low-
energy injuries
18. Classification
1. OTA
• bone number: 1
• fracture location: 2
• fracture pattern: simple:A, wedge:B, complex:C
2. Descriptive
• fracture location: proximal, middle or distal third
• fracture pattern: spiral, transverse, comminuted
3. Holstein-Lewis fracture
19. Holstein-Lewis fracture
• A spiral fracture of the distal
one-third of the humeral shaft
• Commonly associated with
neurapraxia of the radial nerve
(22% incidence)
20. Presentation
Symptoms
• pain
• extremity weakness
Physical exam
• examine overall limb alignment
will often present with shortening and in varus
• preoperative or pre-reduction neurovascular exam is critical
examine and document status of radial nerve pre
and post-reduction
21. Imaging
Radiographs
• Views
• AP and lateral
• be sure to include joint above and below the site of
injury
• transthoracic lateral
• traction views not routinely indicated
• Rotating the patient prevents rotation of the distal fragment
avoiding further nerve or soft tissue injury
27. Treatment
• Relative indications
• bilateral humerus fracture
• polytrauma or associated lower extremity fracture
• allows early weight bearing through humerus
• pathologic fractures
• burns or soft tissue injury that precludes bracing
• intraarticular extension
28. Treatment
2. Closed Intramedullary Nailing (IMN)
• relative indications
• pathologic fractures
• segmental fractures
• severe osteoporotic bone
• overlying skin compromise limits open approach
• polytrauma
29. Complications
1. Nonunion
2. Malunion
3. Radial nerve palsy
• Incidence : seen in 8-15% of closed fractures
• increased incidence distal one-third fractures
• neuropraxia most common injury in closed fractures and
neurotomesis in open fractures
• 85-90% of improve with observation over 3 months
• spontaneous recovery found at an average of 7 weeks, with full
recovery at an average of 6 months
30. Radial nerve palsy
Treatment
1. observation
• Indicated as initial treatment in closed humerus fractures
• obtain EMG at 3-4 months
• wrist extension in radial deviation is expected to be regained first
• brachioradialis first to recover, extensor indicis is the last
31. Radial nerve palsy
Treatment
2. surgical exploration
indications
1. open fracture with radial nerve palsy
(likely injury to the radial nerve)
2. closed fracture that fails to improve over ~ 3-6 months
3. fibrillations (denervation) seen at 3-4 months on EMG
