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Humerus fracture

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Humerus fracture

  1. 1. FRACTURE SHAFT HUMERUS Edited by Abdelrahman youssif HYDERABAD Mansoura university faculty of medicine orthopedics department Supervisor: Head of department: Prof.Dr.hani.M.Elmowafy
  2. 2. FRACTURE SHAFT HUMERUS  Introduction  History  Epidemiology  Mechanism of injury  Classification  Clinical features  Investigations  Treatment  Complications
  3. 3. INTRODUCTION  3% to 5% of all fractures  Most will heal with appropriate conservative care, although a limited number will require surgery for optimal outcome.
  4. 4. GENERAL CONSIDERATIONS  Current research -- decreasing the surgical failure rate through  New implants and techniques,  Optimizing the postinjury rehabilitation programs  Minimizing the duration and magnitude of remaining disability.
  5. 5. GENERAL CONSIDERATIONS Successful treatment demands a knowledge of :  Anatomy,  Biomechanics  Techniques  Patient Function and Expectations.
  6. 6. HISTORY
  7. 7. Sir JOHN CHARNLEY (1911- 1982)  “It is perhaps the easiest of major long bones to treat by conservative methods”
  8. 8. SARMIENTO (February 15, 1811 – September 11, 1888)
  9. 9. RICHARD WATSON (1737- 1816)
  10. 10. EPIDEMIOLOGY  High energy trauma is more common in the young males  Low energy trauma is more common in the elderly female
  11. 11. AGE AND GENDER SPECIFIC INCIDENCE OF SHAFT HUMERUS FRACTURE
  12. 12. ANATOMY  Proximally, the humerus is roughly cylindrical in cross section, tapering to a triangular shape distally.  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.
  13. 13. 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 medial side  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
  14. 14. ANATOMY
  15. 15. RELATIONSHIP OF NEUROVASCULAR STRUCTURES TO SHAFT HUMERUS
  16. 16. MECHANISM OF INJURY  Direct trauma is the most common especially MVA  Indirect trauma such as fall on an outstretched hand  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
  17. 17. MECHANISM OF HEALING
  18. 18. Inflammation • Hematoma forms and provides source of hemopoieitic cells capable of secreting growth factors. • Macrophages, neutrophils and platelets release several cytokines • this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12 • Fibroblasts and mesenchymal cells migrate to fracture site and granulation tissue forms around fracture ends • Osteoblasts and fibroblasts proliferate • inhibition of COX-2 (ie NSAIDs) causes repression of runx-2/osterix, which are critical for differentiation of osteoblastic cells
  19. 19. Repair • Primary callus forms within two weeks. If the bone ends are not touching, then bridging soft callus forms. • Enchondral ossification converts soft callus to hard callus (woven bone). Medullary callus also supplements the bridging soft callus • Type II collagen (cartilage) is produced early in fracture healing and then followed by type I collagen (bone) expression • Amount of callus is inversely proportional to extent of immobilization • primary cortical healing occurs with rigid immobilization (ie. compression plating)
  20. 20. Remodeling • Begins in middle of repair phase and continues long after clinical union • chondrocytes undergo terminal differentiation • signaling pathways including, indian hedgehog (Ihh), parathyroid hormone related peptide (PTHrP), FGF and BMP • cartilaginous calcification takes place at the junction between the maturing chondrocytes and newly forming bone • multiple factors are expressed including BMPs, TGF-Betas, IGFs, osteocalcin, collagen I, V and XI • subsequently, VEGF production leads to new vessel invasion • newly formed bone (woven bone) is remodeling via osteoblastic/osteoclastic activity
  21. 21. CLINICAL FEATURES  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 # )
  22. 22. CLINICAL FEATURES  Pain.  Deformity.  Bruising.  Crepitus.  Abnormal mobility  Swelling.  Any neurovascular injury
  23. 23. 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 of the radial pulse.
  24. 24. INVESTIGATIONS  Radiographs  CT scan  MRI scan  Nerve conduction studies  Routine investigations
  25. 25. IMAGING AP and lateral views plain x-ray of the humerus, including the joints below and above the injury.  CT scanning may also be indicated in the rare situation where a significant rotational abnormality exists. A CT scan through the humeral condyles distally and the humeral head proximally can provide exact rotational alignment  MRI for pathological cause
  26. 26. CLASSIFICATION  CLOSED  OPEN  LOCATION- proximal, middle, distal  FRACTURE PATTERN-tranverse, spiral, oblique,comminuted segmental  SOFT TISSUE STATUS – Gustilo
  27. 27. AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT
  28. 28. 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 ○ Ulnar and Median nerve injury (less common) ○ Brachial Artery Injury
  29. 29. DIAGNOSIS History Clinical examination imaging
  30. 30. TREATMENT Goal of treatment is to establish union with acceptable alignment
  31. 31. TREATMENT OPTIONS Non operative operative
  32. 32. 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
  33. 33. 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 splint or a hanging arm cast followed by placement of a fracture brace
  34. 34. NON OPERATIVE METHODS  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.
  35. 35. HUMERUS BRACE - 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.
  36. 36. 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.
  37. 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. 38. TIME TO APPLY  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 1. Minor movts at # site should be pain free 2. Any deformity should disappear once deforming forces are removed 3. Reasonable resistance to telescoping.
  39. 39. OPERATIVE MANAGEMENT
  40. 40. OPERATIVE TREATMENT 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.
  41. 41. METHODS OF SURGICAL MANAGEMENT  Plating  Nailing  External fixation
  42. 42. PLATING
  43. 43. 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.
  44. 44. DYNAMIC COMPRESSION PLATE
  45. 45. LIMITED CONTACT DCP
  46. 46. LOCKING PLATE
  47. 47. LOCKING PLATE HOLE
  48. 48. LOCKING PLATE
  49. 49. LAG SCREWS
  50. 50. 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)
  51. 51. INTRAMEDULLARY NAILING  Antegrade Technique  Retrograde Technique-best suited for fractures in the middle and distal thirds of the humerus
  52. 52. ANTEGRADE TECHNIQUE
  53. 53. ANTEGRADE TECHNIQUE
  54. 54. RETROGRADE TECHNIQUE
  55. 55. EXTERNAL FIXATION  External fixation is cumbersome for the humerus and the complication rate is high.  AS IT MAY accentuate the risk of delayed union and malunion, resulting in significant rates of pin tract irritation, infection, and pin breakage.
  56. 56. EXTERNAL FIXATION
  57. 57. EXTERNAL FIXATION
  58. 58. PLATE OR NAIL?  Plate  Reliable, 96% union  Good shoulder/elbow function  Soft tissue – scars, radial nerve, bleeding  Nail  Less incision required  Higher incidence of complications?  Lower union rate?
  59. 59. WHAT IS THE ROLE FOR NAILING?  Segmental fractures  Particularly with a very proximal fracture line  Pathologic fractures  ? Cosmesis
  60. 60. 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.
  61. 61. CASE 1 IMPLANT FAILURE POST OP X RAY
  62. 62. CASE 2 IMPLANT FAILURE POST OP X RAY
  63. 63. REHABILITATION  Allow early shoulder and elbow rom  Weight bearing delayed till fracture is united
  64. 64. Thank you

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