basic trauma skills

1. DEPARTMENT OF
ORTHOPAEDICS
BMC SAGAR

2. FRACTURE SHAFT OF
HUMERUS
MODERATOR- DR ANSHUL GUPTA
PRESENTOR-DR MAYANK SHROTRIYA
DR PROF. RAJESH JAIN(HOD,SUPERINTENDENT BMC
SAGAR)

3. INTRODUCTION
• ACCOUNT FOR 3% OF ALL FRACTURES.
• CHARNLEY STATED “IT IS PERHAPS THE EASIEST FRACTURE OF MAJOR
LONG BONES TO TREAT BY CONSERVATIVE METHODS”

4. ANATOMY
• PROXIMALLY, THE HUMERUS IS ROUGHLY CYLINDRICAL IN CROSS
SECTION,CONICAL IN MIDDLE , DRAMATICALLY FLATTENED IN DISTAL
THIRD IN CORONAL PLANE.
• 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.

6. ANATOMY
• NUTRIENT ARTERY- ENTERS THE BONE VERY CONSTANTLY AT THE
JUNCTION OF M/3- L/3 AND FORAMINA OF ARTERY ARE
CONCENTRATED IN A SMALL AREA OF THE DISTAL HALF OF M/3 ON
MEDIAL SIDE.
• AXILLARY NERVE AND POSTERIOR CIRCUMFLEX HUMERAL ARTERY
ORIGINATE POSTERIORLY AND WIND AROUND SURGICAL NECK
ABOUT 5-6cm below THE LATERAL EDGE OF ACROMIAN.

7. ANATOMY

9. MECHANISM OF INJURY
• DIRECT TRAUMA IS THE MOST COMMON.
• 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

10. EXAMINATION
• TENDERNESS
• SWELLING
• CREPITUS.
• ABNORMAL MOBILITY
• ANY NEUROVASCULAR INJURY

11. EXAMINATION
• 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.

12. INVESTIGATION
• Radiographs
• CT scan
• MRI scan
• Nerve conduction studies
• Routine investigations

15. IMAGING
• AP AND LATERAL VIEWS OF THE HUMERUS, INCLUDING THE JOINTS
BELOW AND ABOVE THE INJURY.
• COMPUTED TOMOGRAPHIC (CT) SCANS OF ASSOCIATED INTRA-
ARTICULAR INJURIES PROXIMALLY OR DISTALLY.
• 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.
• MRI FOR PATHOLOGICAL #

16. AO/OTA FRACTURE AND DISLOCATION
CLASSIFICATION

18. GARNAVOS CLASSIFICATION

19. GARNAVOS CLASSIFICATION

20. CONSERVATIVE MANAGEMENT
• INDICATIONS
• UNDISPLACED CLOSED SIMPLE FRACTURES
• DISPLACED CLOSED FRACTURES WITH LESS THAN 20 ANTERIOR
ANGULATION,
• 30 VARUS/ VALGUS ANGULATION SPIRAL FRACTURES
• SHORT OBLIQUE FRACTURES

21. CONSERVATIVE MANAGEMENT
• >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
FRACTURE BRACE

22. CONSERVATIVE METHODS OF
MANAGEMENT
OBLIQUE OR COMMUNITED FRACTURES
TRANSVERSE OR OBLIQUE FRACTURES

23. CONSERVATIVE METHODS OF MANAGEMANT
• SLING OR COLLAR AND CUFF

24. CONSERVATIVE
METHODS OF
MANAGEMENT
OBLIQUE AND COMMUNITED FRACTURES
OF HUMERUS

25. CONSERVATIVE
METHODS OF
MANAGEMENT
TECHNIQUE FOR TRANSVRSE OR BLUNT
OBLIQUE FRACTURES

26. FUNCTIONAL BRACING
SARMIENTO et.al 1977, THE FUNCTIONAL
BRACE WORKS ON THE PRINCIPLES OF :
HYDRAULIC EFFECT OF BRACE
ACTIVE CONTRACTION OF MUSCLES
BENEFICIAL EFFECT OF GRAVITY
UNION OF 90-100% REPORTED

27. FUNCTIONAL BRACING
• BRACE IS WORN UNTILL:
• PT IS PAIN FREE.
• THERE IS EVIDENCE OF RADIOGRAPHIC UNION.
• A NON RANDOMIZED TRIAL BY JAWA et.al COMPARED OUT COMES IN
21 DISTAL ONE THIRD DIAPHYSEAL FRACTURES TREATED FUNCTIONAL
BRACING TO THOSE 19 TREATED WITH PLATE SCREW FIXATION.

28. RADIAL NERVE PALSY
FINGER SHOULD BE KEP MOBILE.
LIVELY SPLINTING(CAPENER) IS ESSENTIAL

29. INDICATIONS FOR OSTEOSYNTHESIS

30. TIMING OF SURGERY
• RARELY ANY INDICATION FOR EMERGENCY SURGERY OTHER THAN
ASSOCIATED VASCULAR INJURY.
• THESE FRACTURE BEST TREATED BY AN EXPERIENCED SURGEON IN A
TIMLEY FASHION.

31. IMPLANT SELECTION
• MOST OF PATIENTS REQUIRE 4.5 NARROW LCP.
• LOCKING HEAD SCREWS MUST BE BICORTICAL DUE TO LARGE
ROTATIONAL FORCES.

32. IMPLANT SELECTION
• PERIARTICULAR FRACTURE OFTEN OPTIMALLY PLATED USING
ANATOMICALLY SPECIFIC PRECONTOURED PLATES SUCH AS THICKER
METAPHYSEAL VERSION OF THE PHILOS SYSTEM
• CANNULATED EXPERT HUMERAL NAIL
• MULTILOC NAIL
• RUSH NAIL
• ENDERS NAIL

33. OPERATING ROOM
SETUP
TORNIQUET
STERILE DRAPES
SURGEON
ASSISTANT
IMAGE INTENSIFIER
PATIENT POSITION

34. SURGICAL APPROACH
ANTERIOR

37. ANTERIOR APPROACH

38. SURGICAL APPROACH
POSTERIOR

39. POSTERIOR APPROACH

40. POSTERIOR APPROACH

41. EGLSEDER TECHNIQUE

42. MEDIAL APPROACH
• NOT COMMONLY USED BUT IS AN OPTION WHEN POSTERIOR AND
ANTERIOLATERAL SOFT TISSUE ARE POOR OR WHEN THERE IS AN
ASSOCIATED VASCULAR INJURY.

43. SURGICAL APPROACH
MINIMALLY INVASIVE PLATE
OSTEOSYNTHESIS

44. INTERMEDULLARY NAILING

45. INTERMEDULLARY NAILING

46. INTERMEDULLARY NAILING

47. INTERMEDULLARY NAILING

48. EXTERNAL FIXATOR
UNILATERAL HALF PIN FRAME IS SUFFICIENT
FOR FRACTURE STABILIZATION

50. REDUCTION
• IN OBLIQUE OR SPIRAL FRACTURES THIS CAN BE MAINTAINED WITH
POINTED REDUCTION FORCEPS OR CIRCLAGE WIRES.
• TRANSVERSE FRACTURES OFTEN BEST REDUCED USING PLATES.
• MINIMALLY INVASIVE TECHNIQUES

51. FIXATION
• PLATE
• IM NAIL
• EXTERNAL FIXATOR

52. CHALLANGES
• OBESE WOMEN WITH OSTEOPOROSIS
• RADIAL NERVE ASSESMENT

53. AFTERCARE
• ACTIVE ASSISTED MOBILIZATION UNTILL THE INCISON HEALED.
• ACTIVE MOTION THEN CAN BEGIN,THE PATIENT CAN SAFELY MOVE
THE EXTERMITY EVENT AGAINST RESISTANCE.
• AFTER IM NAILING SHOULDER AND ELBOW EXCERCISES CAN START
IMMIDIATLEY.
• PENDULUM EXCERCISES

54. This Photo by Unknown Author is licensed under CC BY-SA

55. PHYSIOTHERAPY

56. QUICK DASH SCORING SYSTEM

57. COMPLICATIONS
• IATROGENIC FRACTURE WITH NAILING
• RADIAL NERVE PALSY WITH INITIAL INJURY,WITH CLOSED REDUCTION
OR WITH OPERATIVE INTERVENTION.
• DELAYED UNION
• MALUNION
• INFECTION

58. RADIAL NERVE PALSY

59. LATE COMPLICATIONS
• NON UNION
• MALUNION
• IMPLANT FAILURE ESPECIALLY IN OSTEOPOROTIC BONE

60. PROGNOSIS AND OUTCOME

61. PROGNOSIS AND OUT COME
FRACTURE GAP ,SMOKING ,FEMALE GENDER ALL INDEPENDENTLY
INCRASE HEALING TIME.
CAPMAN JR,HENLEY MB,AGEL et.al-RANDOMIZED STUDY REPORTS
SIMILAR UNION RATES BUT THERE IS HIGH COMPLICATION RATE WITH
IN IM NAILING GROUP

62. TAKE HOME MESSAGE
• MORE THAN 95% OF NERVE WILL RECOVER SPONTANEOUSLY .THE
PATIENTS CAN BE FOLLOWED UP CLINICALLY AND WITH SERIAL
ELECTRODIAGNOSTIC STUDIES.
• IMPLANT FAILURE IS UNCOMMON OTHER THAN IN OSTEOPOROTIC
BONE OR IN COMBINATION WITH POOR IMPLANT SELECTION OR
OPERATIVE TECHNIQUE.
• PLATE FIXATION ACHIEVES CONSISTENTLY GOOD RESULT WHEN USED
FOR BOTH OPEN AND CLOSED FRACTURE.

63. TAKE HOME MESSAGE
• ACCORDING TO PUBLISHED REPORTS OF 600 HUMERAL PLATINGS,
THERE IS 92-98% UNION RATE.
• PRIMARY BONE GRAFTING IS ONLY USED FOR COMPLEX,
MULTIFRAGMENTARY FRACTURES OR BONE LOSS.
• THE INFECTION RATE IS LESS THAN 1% AND IATROGENIC RADIAL
NERVE PALSY IS 3%.
• MORE THAN 97% OF THESE PATIENTS ACHIEVE GOOD FUNCTIONAL
RESULTS.

64. BIBILOGRAPHY
• ROCKWOOD AND GREENS FRACTURE IN ADULTS 8E
• AO PRINCIPLES OF FRACTURE MANAGEMENT 3RD EDITION
• CAMPBELL’S OPERATIVE ORTHOPAEDICS
• JOHN EBNEZER