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Closed fracture at the humeral shaft
- 2. • A Thai female patient aged 41 yr experienced a MCA 4 hr PTA
- 3. PRESENT ILLNESS • 4 hr PTA , she was accidentally slipped out of her balance while riding a motorbike. She was thoroughly conscious. The only complaint was she put her right forearm against the fall
- 4. PRESENT ILLNESS (CON'T) • The fall made her feel painful at the right forearm and elbow resulting in a limit range of motion and on some extent, the deformity.
- 5. PRESENT ILLNESS (CON'T) • She denied any unconscious moment • She denied any breathing difficulty • She denied any abdominal discomfort • She denied any hip pain • She noted there were no other visible wounds except some abrasion at the right elbow
- 6. PRESENT ILLNESS (CON'T) • She went to a community hospital and was diagnosed she had a fracture of the forearm and on a U-slap before being referred
- 7. PERSONAL HISTORY • No smoking • No alcohol drinking • No known diseases • No drug allergy
- 8. PRIMARY SURVEY • V/S BT 37 degree Celsius, HR 72 bpm, RR 18 bpm, BP 136/78mmHg • A: can talk, not tender along C-spines • B: can breathe, equal breath sound • C: BP stable, HR 70 bpm, no external bleeding • D: E4V5M6, pupils 3 mm RTLBE • E: Rt. forearm deformity with limit ROM due to pain and abrasion wound size 2*3 cm at the right elbow without active bleeding
- 9. SECONDARY SURVEY • A: no allergies • M: no current medication • P: no previous illness • L: last meal at 09:00 AM • E: car accident
- 10. PHYSICAL EXAMINATION • GA: normosthenic build, awake • HEENT: not pale conjunctivae, anicteric sclerae, no external wound • Heart: normal S1S2, no murmur • Lungs: equal breath sound, no adventitious sound
- 11. PHYSICAL EXAMINATION • Abdomen: soft, no distension, not tender • Neurological exams: E4V5M6, pupils 3 mm RTLBE, good consciousness, alert • CN: all intact • Motor and sensory: all intact • Reflexes: all intact
- 12. AFFECTED PART • Rt. forearm : deformity with swelling and contusion size 3*3 cm • Rt. elbow : an abrasion wound size 3*2 cm without active bleeding • Rt. hand : no numbness, capillary refill was less than 2 secs • Motor and sensory: intact
- 13. INVESTIGATION • Film Rt. humerus AP, Lat • Film Rt. elbow AP, Lat
- 20. Anatomy ✤ Distal to the surgical neck - proximal to the supracondylar ridge ✤ Proximal - Cylindrical shape ✤ Distal - Triangular shape ✤ Medullary canal of the humerus tapers to an end above the supracondylar expansion
- 21. Deforming force ✤ Rotator cuff ✤ Pectoralis major m. ✤ Deltoid m.
- 22. Classification ✤ AO/OTA Classification ✤ Diaphysis of humerus : 12 ✤ Fracture pattern, Zone of diaphysis ✤ Reflect increasing fracture severity
- 23. 01
- 24. Treatment ✤ Non-operative ✤ Operative ✤ Humeral Shaft fracture with radial nerve palsy
- 25. Non-OperativeTreatment ✤ Gold Standard treatment ✤ Hanging arm casts ✤ Coaptation splints ✤ Functional Brace (Gold standard)
- 26. Non-OperativeTreatment ✤ Acceptable alignment ✤ AP Angulation < 20 degrees ✤ Varus/Valgus angulation < 30 degrees ✤ Shortening < 3 cm
- 27. Functional Brace ✤ Union rate 90-100% ✤ Principles: Gravity and soft tissue compression to achieve acceptable alignment and function ✤ Position: 1 inch distal to axilla and 1 inch proximal to humeral condyles ✤ Exercise: Passive flex & extend elbow, pendulum exercise ✤ Avoid active abduction and elevation of shoulder
- 28. Functional Brace ✤ Contraindication ✤ Polytrauma patient ✤ Open fracture ✤ Bilateral humeral fractures ✤ Fracture with axial distraction between fragment
- 29. Failure of Non-OperativeTreatment ✤ Definition:1. Inability to maintain reduction 2. Delayed union, non-union ✤ Transverse fracture with gap ✤ Obese patient ✤ Woman with large breast
- 30. OperativeTreatment ✤ Plate Fixation ✤ Intramedullary nail ✤ Multiple Flexible Intramedullary nails ✤ External Fixation
- 31. OperativeTreatment ✤ Indication ✤ Fracture indications ✤ Patient indications ✤ Associated injury
- 32. Fracture indications ✤ Failure to obtain and maintain adequate closed reduction ✤ Shortening > 3 cm ✤ Varus/valgus > 30 degrees ✤ AP Angulation > 20 degrees ✤ Segmental fracture ✤ Pathological fracture ✤ Intraarticular extension (shoulder joint, elbow joint)
- 33. Patient indications ✤ Multiple injuries, polytrauma ✤ Head injury (Glasgow Coma Scale score < 8) ✤ Chest trauma ✤ Poor patient tolerance, compliance ✤ Unfavorable body habitus (morbid obesity, large breasts)
- 34. Associated injury ✤ Open wound ✤ Vascular injury ✤ Brachial plexus injury ✤ Ipsilateral forearm fracture ✤ Ipsilateral shoulder or elbow fracture ✤ Bilateral humeral fractures ✤ Lower extremity fracture requiring upper extremity weight bearing ✤ Burns ✤ High-velocity gunshot injury ✤ Chronic associated joint stiffness of elbow or shoulder
- 35. Associated condition ✤ Radial nerve palsy ✤ Incidence 3-34% ✤ increases with open fractures, polytrauma, vascular injury, and multiple ipsilateral fractures
- 36. Radial Nerve Palsy ✤ Most frequent with fractures of the middle and middle-distal humeral shaft ✤ More common with transverse and spiral fractures ✤ Most injuries are neurapraxia ✤ >90% return to function in 3-4 months
- 37. Radial Nerve Palsy ✤ Indication for early exploration ✤ Open fracture ✤ High-velocity gunshot or penetrating injury ✤ Vascular injury ✤ Nerve deficit after closed reduction ✤ Distal third (Holstein-Lewis) fractures
- 38. Reference ✤ Rockwood and Green' Fracture in Adults, 7th edition, Humeral shaft fracture ✤ Campbell's Operative Orthopedics, 12th edition, Fractures of the shoulder, arm and forearm ✤ www.jaaos.org ✤ www2.aofoundation.org