Closed fracture distal one-third of humerus

1. CASE CONFERENCE Cherrin Pomsoong
PCM

2. CASE
ผู้ป่วยหญิงไทย อายุ 56 ปี
เหตุเกิด 11 กค. 2560 เวลา 12.40 น. ถึง ER 16.54 น.
Chief complaint: ปวดแขนขวา 5 ชม. PTA

4. CASE
Present illness
5 ชม. PTA ผู้ป่วยยกถังน้า แล้วถังน้าตกใส่แขนขวา
(ถังน้าหนักประมาณ 8 กิโลกรัม) แขนขวาผิดรูป ขยับ
แขนขวาไม่ได้ กระดกข้อมือไม่ขึ้นเนื่องจากมีอาการปวด
แขนขวา ขยับนิ้ วได้ ชาบริเวณแขนส่วนบนเล็กน้อย ไม่มี
บาดแผล ไม่มีการบาดเจ็บที่ส่วนอื่น

5. PRIMARY SURVEY
A : patent airway, not tender along c-spine
B : equal breath sound, RR 18/min
C : V/S : BP 139/67 mmHg, P67 bpm, no
external bleeding
D : E3V5M6, pupil 3 mm. RTLBE
E : no external wound, no wound at back

6. SECONDARY SURVEY
A : No drugs allergy
M : Enalapril 1 tab po pc morning
P : Hypertension
L : 12.40 11/7/2560
E : ยกถังน้าแล้วถังน้าตกใส่บริเวณต้นแขนขวา

7. PHYSICAL EXAMINATION
Head and face : no wound at face and head
CVS : normal S1 S2 , no murmur
Lung : normal and equal breath sound
Abdomen : soft, not tender
Ext : Lt. arm : As picture
CNS : Grossly intact

8. PHYSICAL EXAMINATION
Right arm : deformity , marked swelling, marked
tender at mid shaft of humerus, limit ROM of shoulder
due to pain, can flex/extend elbow joint, no external
wound
neurovascular : Radial pulse 2+, cap refill < 2 sec
Motor : intact
Sensory : decrease

9. INVESTIGATIONS
Film Humerus AP, Lateral

10. FILM HUMERUS AP, LATERAL

11. DIAGNOSIS
CFx Right distal one-third of shaft
humerus

12. MANAGEMENT
Control pain
 Morphine 4 mg IV stat
Close reduction and on U-slab
Advice เรื่อง slab และนัดติดตาม follow up 1 wk
Film Rt. humerus หลัง on U-slab
HM :
Paracetamol (500) 1 tab PO prn q 4-6 hr.
B1-6-12 1 tab PO tid. pc.

13. AFTER REDUCTION

14. AFTER REDUCTION

15. FRACTURE SHAFT OF HUMERUS
Incidence
3-5% of all fractures
bimodal age distribution
young patients with high-energy trauma
elderly, osteopenic patients with low-energy injuries

16. ANATOMY
humeral shaft is cylindrical
distally humerus becomes triangular
Muscles
 insertion for pectoralis major, deltoid, coracobrachialis
 origin for Brachialis, triceps, brachioradialis
Radial nerve
 14cm proximal to the lateral epicondyle
 20cm proximal to the medial epicondyle

17. ANATOMY

19. HOLSTEIN-LEWIS FRACTURE
(SPIRAL FRACTURE)
A spiral fracture of the
distal one-third of the
humeral shaft
22% incidence
associated with
neuropraxia of the radial
nerve

20. PRESENTATION
Symptoms
 pain
 extremity weakness
Physical exam
 examine overall limb alignment
 shortening and in varus
neurovascular exam is critical
status of radial nerve pre and post-reduction

21. INVESTIGATIONS
Radiographs views
AP and lateral
include joint above and below the site of injury

22. TREATMENT: NON-OPERATIVE
Nonoperative
 coaptation splint followed by functional brace
indications
 indicated in vast majority of humeral shaft fractures
 criteria for acceptable alignment include:
 < 20° anterior angulation
 < 30° varus/valgus angulation
 < 3 cm shortening

23. FUNCTIONAL BRACE

25. TREATMENT: NON-OPERATIVE
Absolute contraindications
 severe soft tissue injury or bone loss
 vascular injury requiring repair
 brachial plexus injury
Outcomes
 90% union rate
 increased risk with proximal third oblique or spiral fracture
 varus angulation is common but rarely has functional or
cosmetic sequelae

26. TREATMENT: OPERATIVE
Operative
 open reduction and internal fixation
Absolute indications
 open fracture
 vascular injury requiring repair
 brachial plexus injury
 ipsilateral forearm fracture (floating elbow)
 compartment syndrome

27. TREATMENT: OPERATIVE

28. COMPLICATION
Humeral shaft fx nonunion
Malunion
 varus angulation is common but rarely has functional or
cosmetic sequelae
 risk factors
 transverse fracture patterns
Radial nerve palsy

30. 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

31. RADIAL NERVE PALSY
Treatment
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
surgical exploration
 open fracture with radial nerve palsy (likely neurotomesis injury to the
radial nerve)
 closed fracture that fails to improve over ~ 3-6 months
 fibrillations (denervation) seen at 3-4 months on EMG

32. Thank
you