2. FRACTURE SHAFT HUMERUS
• Introduction
• History
• Epidemiology
• Surgical anatomy
• Mechanism of injury
• Classification
• Clinical features
• Investigations
• Treatment
• Complications
3. INTRODUCTION
• 3% to 5% of all fractures
• 14% of all fractures of humerus
• 60%- middle third, 30%- proximal third ,10%- distal third of diaphysis
• 2 to 10% are open fracture
• Most will heal with appropriate conservative care, although a limited
number will require surgery for optimal outcome.
• Given the extensive range of motion of the shoulder and elbow,
5. SIR JOHN CHARNLEY (1911-1982)
• “It is perhaps the easiest of major
long bones to treat by
conservative methods”
6. EPIDEMIOLOGY
Bimodal age distribution
• High energy trauma is more common in the youngmales- third
decade
• Low energy trauma is more common in the elderly female- seventh
decade
• .
7. AGE AND GENDER SPECIFIC INCIDENCE OF SHAFT
HUMERUS FRACTURE
8. Anatomy of shaft humerus
• Shaft of humerus: It is cylindrical in upper half and
triangular in lower half. It has three borders and three
surfaces.
• Borders
• Anterior border : continuation of lateral lip of bicipital
groove.
• Medial border: continuation of Medial lip of bicipital groove
continues
downwards as medial border which then continues as medial
supracondylar ridge.
• Lateral border: Is well defined only in lower half, continues
downwards as lateral supracondylar ridge.
• Surfaces
• Anteromedial surface: between anterior and medial border.
• Anterolateral surface: between anterior and lateral border.
Just above the middle shows ‘V’ shaped tuberosity called
‘Deltoid tuberosity‘.
• Posterior surface: between medial and lateral border. In its
middle 1/3rd has a shallow groove called ‘Radial groove’.
9. ANATOMY
• Humeral shaft is the area extending from upper border of the pectoralis
major tendon to supracondylar ridge.
• Nutrient artery- enters the bone very constantly at the junction of M/3-
L/3 .
• Radial nerve- it does not travel along the spiral groove and it lies close
to the inferior lip of spiral groove .
• 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
16. Holstein–Lewis fracture:
simple spiral fracture of the distal
third of the shaft of humerus with
distal bone fragment displaced and
the proximal end deviated toward the
radial side with an increased risk of
acute radial nerve palsy
The Holstein-Lewis humeral shaft
fracture constitutes 7.5% of all
humeral shaft fractures and was
associated with an increased risk of
acute radial nerve palsy compared
with other types of humeral shaft
fractures
17. MECHANISM OF INJURY
• Direct trauma is the most common especially MVA
• Indirect trauma such as fall on an outstretched hand
• Extreme muscle contraction
• Fracture 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
18. CLINICAL FEATURES
• HISTORY
• Mode of injury –fall on out stretched hand ,MVA,
direct load on arm, extreme muscle contraction .
• Alchoholic abuse, drugs ( prone for repeated injuries )
• Age and sex of the patient ( osteoporosis)
• Comorbid conditions
• Previous treatment( massages)
• Previous bone pathology ( path # )
19. CLINICAL FEATURES
• Pain.
• Deformity.
• Bruising.
• Crepitus.
• Abnormal mobility
• Swelling.
• Any neurovascular injury
20. 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 ofthe
radial pulse.
21. ASSOCIATED INJURIES
• Radial nerve injury –wrist drop-Inability of 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
• Brachial Artery Injury
• Clavicle, forearm, wrist & Chest injuries
• Ulnar and Median nerve injury (less common)
23. IMAGING
• AP and lateral views of the humerus – these should be taken at 90
degree angles to each other .
including the joints below and above the injury.
• Traction radiographs may be helpful with comminuted or severely
displaced fractures and contralateral determining pre operative length
• CT scanning may also be indicated in the rare situation where a
significant rotational abnormality exists as rotational alignment is difficult
to judge from plain radiographs of a diaphyseal long bone fracture. A CT
scan through the humeral condyles distally and the humeral head
proximally can provide exact rotational alignment
• MRI for pathological #
27. NON OPERATIVE TREATMENT
STRONG INDICATIONS
• Acute /closed/isolated fracture in a cooperative and ambulatory patients
RELATIVE INDICATIONS
• Displaced closed fractures with less than 20 anterior angulation,
• 30 varus/ valgus angulation
• Spiral fractures / Short oblique fractures
• Open fracture without neurovascular injury
• Non compliant patients
28. CONTRAINDICATIONS NON
OPERATIVE TREATMENT
• Multiple injuries
• Vascular injury
• Additional injuries to ipsilateral arm
nerve dysfunction
• Bilateral fracture
• Pathologic fracture
• Nonunited fracture
29. 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
spint or a hanging arm cast followed by placement of a
functional brace
30. NON OPERATIVE METHODS
• Coaptation Splinting/ u slab
• Fractures are splinted with a hanging splint, which is from the axilla, under the
elbow, postioned to the top of the shoulder .
• The splinted extremity is supported by a sling.
• Disadvantages – elbow stiffness , axillary irritation, patient discomfort
Bulkiness of cast
• Immobilization by fracture bracing is continued for at least 2 months or until
clinical and radiographic evidence of fracture healing is observed.
31. HANGING ARM CAST
Traction provided by the weight of the cast to
effect fracture reduction
Indications; mid shaft fracture with shortening,
oblique or spiral fractures
Contraindications ; undisplaced transverse
fractures
Things to consider while applying;
Patient must remain upright
Cast should be light
Applied with elbow 90degree flexion and forearm
neutral position
Cast should extend atleast 2cm proximal to
fracture site
3 plaster/ wire loops are applied of distal fore arm
Dorsal ,neutral , volar.
32. THORACOBRACHIAL IMMOBILIZATION
/ VALPAUE DRESSING
• Most useful in undisplaced and minimally
displaced fracture in children and elderly
• Advantages; inexpensive , comfortable, easy
application.
33. SHOULDER SPICA CAST
INDICATION
When closed reduction of fracture
require significant abduction and
external rotation of upper extrimities.
DISADVANTAGE
Difficulty to apply, cast weight bulkiness,
skin irritation, patient discomfort,
avoided in patient with pulmonary
problems.
34. FUNCTIONAL CAST BRACING -
INTRODUCTION
• Principle; functional brace is an orthosis that
affects the fracture reduction through soft tissue
compression
• 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
• Currently braces are prefabricated and consist of
anterior and posterior shell
• These shells are circulated with Velcro straps
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.
ADVANTAGES
• Union rates with functional bracing are 96 to 100%
• Considered as GOLD STANDARD for non operative treatment because
• Easy application,
• Adjustability, allowance of shoulder and elbow motion
• Low cost ,reproducible results
• Success depends on ; upright patient ,tightening daily, cannot lean on
elbow .
36.
37.
38. CONTRAINDICATIONS
• Lack of co-operation by the patients
• Bed-ridden & mentally incompetent patients
• 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.
• Massive soft tissue injury or bone loss .
39. TIME TO APPLY
•
•
•
•
1.
2.
3.
time to correct any angular or rotational deformity.
Compound # es , application to be delayed.
Assess the # , when pain and swellingsubsided
Minor movts at # site should be pain free
Any deformity should disappear once deforming forces are removed
Reasonable resistance to telescoping.
41. OPERATIVE TREATMENT
INDICATIONS
• Fractures in which reduction is unable to be achieved or maintained.
• Fractures with nerve injuries after reduction maneuvers.
• Intra articular extension injury.
• Neurovascular injury.
pathologic fractures.
• Multiple extremity fractures.
• Floating elbow
• Nonunion
• Bilateral fractures
RELATIVE INDICATIONS
• Open fractures obesity
• Segmental fractures periprosthetic fractures
• Non complaint patients type A fracture in the middle third humerus
44. ANTERO LATERAL APPROACH
• Incision
• Proximal land mark – tipof
coracoid process
• Distal land mark- anterior to
lateral supracondylar ridge
45. ANTERO LATERAL APPROACH
• Proximally, the plane lies between
the deltoid laterally (axillary
nerve) and the pectoralis major
medially(medial and lateral
pectoral nerves).
46. ANTERO LATERAL APPROACH
• Distally, the plane lies between
the medial fibers of the brachialis
(musculocutaneous nerve)
medially and the lateral fibers of
the brachialis (radial nerve)
laterally.
47.
48. POSTERIOR APPROACH
• Position of the patient for the
approach to the upper arm in
either the (A) lateral or (B) prone
position.
52. POSTERIOR APPROACH
• 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 lineof
the skin incision by sharp
dissection. Identify the radial
nerve and the accompanying
profunda brachii artery.
55. SURGICAL STEPS FOR ORIF OF DIAPHYSEAL HUMERUS
FRACTURE
• Expose the humerus diaphysis through the selected approach.
• Identify and protect neurovascular structure that are nearby or
Cross the surgical field.
• Avoid soft tissue or periosteal stripping.
• Reduce the fracture manually by traction.
• Apply external fixator or distractor across the fracture to maintain
Reduction if required.
• Reduce the fracture and provisionally stabilize with the reduction
Forceps or k-wire. Use the plate as indirect reduction tool.
• Avoid iatrogenic damage to nerves and vessels with the reduction
forceps.
• Implant of choice is the 4.5mm narrow dynamic compression plate
Or the 4.5mm low contact plate or LC DCP .
56. • Secure the plate provisionally with one or two screws in each
Main fragment, check reduction and alignment, then proceed to
Insert the remainder of the screws.
• Avoid screws in area of communication
• Confirm fracture reduction and plate/screws length with image
Intensifier prior to wound closure.
57. 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.
58.
59. PLATE OSTEOSYNTHESIS
• There are several practical advantages to the use of the LC DCP 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.
60. PLATE OSTEOSYNTHESIS
• A theoretical advantage of this is less impairment of the blood supply inthe
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.
61.
62. • use an anterolateral approach for mid shaft or proximal
fractures, and a posterior approach for distal fractures.
• Use a 4.5-mm compression plate in most patients, with a
minimum of 3 (and preferably 4) screws proximal and distal.
A 4.5-mm narrow plate is acceptable for smaller individuals.
• Insert a lag 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.
63.
64. SURGICAL STEPS FOR MINIMALLY INVASIVE PLATE
OSTEOSYNTHESIS OF DIAPHYSEAL FRACTURE
• Expose the proximal and distal “windows” through the selected
Approach(anterior/lateral)
• Identify and protect neurovascular structures that are nearby or cross
The surgical field( musculocutaneous nerve anteriorly, radial nerve
Laterally.
• Reduce the fractur manually by traction
• Apply external fixator or distractor across the fracture to maintain
Reduction
• Create an extra periosteal tunnel alongside the surface of the
humerus
• Avoid iatrogenic damage to the nerve and vessels with the tunnelling
Instruments or the plate
• Secure the plate provisionally with one screw in one main fragment,
Reduce fracture, and secure the plate with a screw to the other main
65. Fragment. Check reduction and alignment, then proceed to insertion of
The screws.
• Check screw insertion and screw length withh the image intensifier
Regularly.
• Avoid screws in area of comminution.
• Confirm fracture reduction and plate/screw length with image
Intensifier prior to wound closure.
66.
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 asburns).
69. INTRAMEDULLARY NAILING
• Antegrade Technique
• Retrograde Technique-best suited for fractures in the middle and distal
thirds of the humerus
70. PEARLS AND PITFALLS—INTRAMEDULLARY NAILING
• 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. PEARLS AND 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 excessivelylong.
• Insertion site morbidity remains a concern: choose your entryportal
carefully and use meticulous technique.
77. SURGICAL STEPS FOR RETROGRADE
INGTRAMEDULLARY NAILING OF DIAPHYSEAL
HUMERAL FRACTURE
• Expose the posterior supracondylar humeral cortex.
• Open 1x2 cm entry portal by connecting multiple drill holes with an
Osteotome
• Reduce the fracture under image intensifier control
• Pass the guide wire through the fracture to the distal fragment.
• Ream the canal, if necessary
• Take care not to create a fracture at the supracondylar area with
The reamers. Hand reaming is the preferred
• Avoid injury to radial nerve with the reamer whenever the fracture
Is located at the middle/distal humeral diaphysis
• Meticulous washing out of the reaming by products
• Introduce the selected nail to its final position
78. • Take care not to create a fracture at the supracondylar area
• Maintain fracture reduction during the insertion of the nail
• Do no allow destruction at the fracture site
• Lock the nail distally with the use of a targeting device and proximally
According to the type of the nail.(fixed or bio)
• Long targeting device are not reliable
• Never leave a nail unlocked.
• Avoid neurologic injury from the use of locking screws.
79.
80. EXTERNAL FIXATION
• External fixator of humeral shaft fracture has been limited to open
Fractures.
• The open wound should be treated in an appropriate manner and
for gustilo grade 1 or 2 wounds, followed by orif or unreamed intramed
-ullary nailing.
• For grade 3 wounds, external fixator is the treatment of choice.
• Debridement is performed every 48 hours until the wound is clean
• Then, at the final debridement, bone grafting may be used if needed.
• Treatment of humeral shaft fracture with an external fixator carries
a high complication rate.
• the placement of skeletal pins in the humerus varies with anatomic
Site. The variable relationship of the neurovascular bundle to the done
Dictates different pin placement for the proximal, middle, and distal third
81. • Proximal third: insert a half pin from the lateral side of the bone.
Take care not to penetrate the medial cortex too far to avoid damage
To the neurovascular bundle(brachial artery and median nerve)
• Middle third: place a half pin anteriorly. Take care not to penetrate
The far cortex too deeply to avoid damage to the radial nerve,
Which courses in a medial to lateral direction on the posterior aspect
Of the middle third of bone.
• Distal third: insert transfixation pins from lateral to medial point
Take care to avoid ulnar nerve as it runs in the groove on back of
Medial humeral epicondyle.
85. 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.
87. RADIAL NERVE INJURY
• Radial nerve injury occurs in as many as 18% of humeral shaft fracture
• Although the oblique distal third humeral fracture(Holstein-lewis)
Is better known for an association for radial nerve palsy than other
Humeral shaft fracture are, such palsy most commonly with middle third
Humeral fracture.
• Most of these nerve injuries are neurapraxic or axonotmetic types,
90% which resolve to at least grade 4 strength in 3-4 months.
• Indications for early nerve exploration include a palsy associated
With an open wound or penetrating injury.
• The question of whether it is best to explore a radial nerve when
Function decreases after closed manipulation is controversial.
• Some authors recommend waiting to perform exploration if no return
Of function is observed after 3-4 months.
• Stating that the results of secondary repair of radial nerve injuries
Are as good as those of primary repair and that the situation has been
Made easier because the fracture has had time to heal.
88. RADIAL NERVE INJURY
A period of 4 months has been noted to be adequate to allow humeral shaft
fractures to heal
ADVANTAGES OF LATE Vs EARLY NERVE EXPLORATION
• Enough time will have passed for recovery from neuropraxia or neurotmesis
• Precise evaluation of nerve lesion is possible
• The associated fracture will may have to unite
• Secondary repair as good as primary repair
89. VASCULAR INJURY
• Although uncommon injury ,a laceration of brachial artery
• At risk fracture those in the proximal and distal thirds of arm.
MECHANISMS
• gunshot ,stab wound
• Vessel entrapment by fracture fragments
• Occlusion of hematoma or swelling in a tight compartment
• Arterial inflow should be established within 6 hours
• If limb viability is not in jeopardy, bone repair may preceds vascular repair
• External fixation should be considered an option
90. NON UNION
Can be 0 to 15%
CAUSED by biologic and mechanical factors
• Significant bone gaps –fracture distraction ,soft tissue interposition ,bone loss
• Infection
• Transverse pattern fracture
• In adequate immobilization and limitation of shoulder motion
TREATMENT GOALS
• Elimination of non union gap
• Restore or maintain osseous vascularity
• Eradication of infection
• Stable internal fixation is treatment o f choice
• Compression plate fixation provides favourable results
INFECTED NONUNION—
• complete debridement of all pathologic tissue
• Antibiotic bead placement
• External fixation
