Noon extern ขวัญนพ 4 ก.ค. 61

1. Noon Extern
Ext. Kwannop Kornsritipa

2. History
• ผู้ป่วยหญิงไทยโสด อายุ 19 ปี ขับรถจักรยานยนต์ชนรถจักรยานยนต์ ล้มเอาแขนซ้ายยันพื้น ศีรษะไม่
กระแทกพื้น จาเหตุการณ์ได้ ไม่มีส่วนอื่นกระแทกพื้น หลังเกิดเหตุ ปวดแขนซ้ายมีแขนซ้ายผิดรูป ไม่ชาแขน
ขยับนิ้วมือและข้อมือได้
• Past history: no underlying disease , no food or drug allergy

3. Primary survey
• A : can speak, no stridor, patent airway, no tenderness along c-spine
• B : normal breath sound, equal breath sound both lung, CCT: negative
• C : no active bleeding, no sign of poor tissue perfusion, vital sign
BP116/77 mmHg, RR 20/min, T37.3 C, PR 97 bpm
• D : E4V5M6, pupil 3 mm RTLBE, no lateralization
• E : significant swelling, stepping no creptipation, tender at Lt arm

4. Physical examination
• Left arm
• Tender at Lateral side of left arm
• Stepping
• No crepitation
• Capillary refill < 2 sec
• Radial, ulnar artery 2+
• Can flex, extend Lt. wrist
• Median, Ulnar, radial nerve intact

5. Ininial management
• CXR
• Film Lt Humerus AP, LAT

7. Lt. Humerus AP

8. Lt. Humerus Lat

9. • Film : Spiral fracture of distal one-third of the left humeral shaft with
varus and anterior angulation

10. Diagnosis
• Close fracture of Left distal one-third of humeral shaft (Holstein-Lewis
fracture)

11. Management
• Tramol 50 mg IV stat for pain control
• U slab Left arm
• Film Lt humerus AP,LAT หลังใส่ U slab

14. Humeral Shaft fracture
• Incidence
• 3-5% of all fractures
• Bimodal age of distribution
• Young patuents with high energy trauma
• Elderly, osteopenic patient with low energy injuries

15. • Anatomy of Humeral shaft
• Insertion for
• Pectoralis major
• Deltoid
• Coracobrachialis
• Origin for
• Brachilis
• Triceps
• brachiloradialis

17. • Radial Nerve
• Course along spiral groove
• 14 cm proximal to lateral epicondyle
• 20 cm proxial to the medial epicondyle

19. • Classification แบ่งตาม location และ fracture pattern
• AO classification of diphyseal humeral fracture

20. Holstein-Lewis fracture
• A spiral fracture of the distal one-third of the humeral shaft
commonly associated with neuropraxia of the radial nerve (22 %
incidence)

21. Presentation
• Symptoms
• Pain
• Extremity weakness
• Physical exam
• Examine overall limb alignment
• Will often present with shortening and in varus
• Preoperative or pre-reduction neurovascular exam is
CRITICAL

22. Imaging
• Radiographs
• Views
• AP and lateral

23. • Transthoracic lateral
• Traction views

24. Treatment
• Nonoperative
• Coaptation splint(U-slab) followed by functional brace
• Criteria for acceptable alignment include
• < 20 degree anterior angulation
• < 30 degree varus/valgus angulation
• < 3 cm shortening
• Absolute contraindications
• Severe soft tissue injury or bone loss
• Vascular injury requiring repair
• Brachial plexus injury
• Outcome
• 90% union rate
• Varus angulation is common

25. • Operative
• ORIF
• Absolute indications
• Open fracture
• Vascular injury requiring repair
• Brachial plexus injury
• Ipsilateral forearm fracture (floating elbow)
• Compartment syndrome
• Relative indications
• Intramedullary nailing

26. Compliations
• Humeral shaft fracture nonunion
• Malunion
• Radial nerve palsy

27. Radial nerve injury
• Incidence
• Seen 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
• Spontatneous recovery found at an average of 7 weeks,
with full recovery at an average of 6 months

28. • Treatment
• Observation
• Initial treatment in closed humerus fractures
• Obtain EMG at 3-4 months
• Wrist extension in radial deviation is expected to be regained
first
• Brachioradialis first to recover, extersor indicis is the last

29. • Surgical exploration
• Indication
• Open fracture with radial nerve palsy
• Closed fracture that fails to improve over 3-6 months
• Fibrillations (denervation) seen at 3-4 months on EMG