INTRODUCTION 3% to 5% of all fractures Most will heal with appropriate conservative care, although a limited number will require surgery for optimal outcome. Given the extensive range of motion of the shoulder and elbow, and the minimal effect from minor shortening, a wide range of radiographic malunion can be accepted with little functional deficit
GENERALCONSIDERATIONS 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.
GENERALCONSIDERATIONSSuccessful treatment demands a knowledge of : Anatomy, Biomechanics Techniques Patient Function and Expectations.
EPIDEMIOLOGY High energy trauma is more common in the young males Low energy trauma is more common in the elderly female
AGE AND GENDER SPECIFICINCIDENCE OF SHAFTHUMERUS FRACTURE
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.
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
RELATIONSHIP OFNEUROVASCULARSTRUCTURES TO SHAFTHUMERUS
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
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 # )
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.
IMAGINGAP 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. A CT scan through the humeral condyles distally and the humeral head proximally can provide exact rotational alignment MRI for pathological #
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)
DIAGNOSIS History Clinical examination imaging
TREATMENTGoal of treatment is to establishunion with acceptable alignment
NON OPERATIVETREATMENT INDICATIONS Undisplaced closed simple fractures Displaced closed fractures with less than 20 anterior angulation, 30 varus/ valgus angulation Spiral fractures Short oblique fractures
HUMERAL SHAFTFRACTURES 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 spint or a hanging arm cast followed by placement of a fracture brace
NON OPERATIVEMETHODS 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.
FCB - 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.
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.
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.
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 subsided1. Minor movts at # site should be pain free2. Any deformity should disappear once deforming forces are removed3. Reasonable resistance to telescoping.
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.
METHODS OF SURGICALMANAGEMENT Plating Nailing External fixation
ANTERIOR APPROACH SUPINEON THE ARM TABLE WITH 600 ABDUCTION AT SHOULDER
ANTERO LATERALAPPROACH Incision Proximal land mark – coracoid process Distal land mark- anterior to lateral supracondylar ridge
ANTERO LATERALAPPROACH Proximally, the plane lies between the deltoid laterally (axillary nerve) and the pectoralis major medially(medial and lateral pectoral nerves).
ANTERO LATERALAPPROACH Distally, the plane lies between the medial fibers of the brachialis (musculocutaneous nerve) medially and the lateral fibers of the brachialis (radial nerve) laterally.
POSTERIOR APPROACH Position of the patient for the approach to the upper arm in either the (A) lateral or (B) prone position.
POSTERIOR APPROACH Incision Tip of olecranon distally to postero lateral corner of acromion proximally
POSTERIOR APPROACH Incise the deep fascia of the arm in line with the skin incision.
POSTERIOR APPROACH Identify the gap between the lateral and long heads of the triceps muscle.
POSTERIOR APPROACH Proximally develop the interval between the two heads by blunt dissection, retracting the lateral head laterally and the long head medially. Distally split their common tendon along the line of the skin incision by sharp dissection. Identify the radial nerve and the accompanying profunda brachii artery.
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. limited contact compression (LCD) plate helps prevent longitudinal fracture or fissuring of the humerus because the screw holes in these plates are staggered.
PLATE OSTEOSYNTHESIS There are several practical advantages to the use of the LCD plates over standard compression plates: they are easier to contour, allow for wider angle of screw insertion, and have bidirectional compression holes. Theoretical advantages include decreased stress shielding and improved bone blood flow due to limited plate-bone contact.
PLATE OSTEOSYNTHESIS Recently angle stable or locked plating systems have gained wide popularity. By locking the screws to the plate a number of mechanical advantages are gained, including a reduced risk for screw loosening and a stronger mechanical construct compared with conventional screws and plates. With locking plate systems, the pressure exerted by the plate on the bone is minimal as the need for exact anatomical contouring of the plate is eliminated.
PLATE OSTEOSYNTHESIS A theoretical advantage of this is less impairment of the blood supply in the cortical bone beneath the plate compared to conventional plates. For humeral shaft fractures,MIPO has been considered too dangerous due to the risk of neurovascular injuries, particularly to the radial nerve.
PEARLS AND PITFALLS—COMPRESSION PLATING Use an anterolateral approach for midshaft or proximal fractures, and a posterior approach for distal fractures. Use a 4.5-mm compression plate in most patients, with a minimum of 3 (and preferably 4) screws proximal and distal. A 4.5-mm narrow plate is acceptable for smaller individuals. Insert a lag screw between major fracture fragments, if possible. Check the distal corner of the plate for radial nerve entrapment prior to closure following the anterolateral approach. The intraoperative goal is to obtain sufficient stability to allow immediate postoperative shoulder and elbow
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)
INTRAMEDULLARY NAILING Problems such as insertion site morbidity, iatrogenic fracture comminution (especially in small diameter canals), and nonunion (and significant difficulty in its salvage) have been reported the use of locking nails is restricted to widely separate segmental fractures, pathologic fractures, fractures in patients with morbid obesity, and fractures with poor soft tissue over the fracture site (such as burns).
INTRAMEDULLARY NAILING One point emphasized in most series of large-diameter nails is that the humerus does not tolerate distraction. This is a risk factor for delayed and nonunion. Antegrade Technique Retrograde Technique-best suited for fractures in the middle and distal thirds of the humerus
PEARLS AND PITFALLS—INTRAMEDULLARY NAILING Avoid antegrade nailing in patients with pre-existing shoulder pathology or those who will be permanent upper extremity weight bearers (para- or quadriplegics). Use a nail locked proximally and distally with screws: use a miniopen technique for distal locking for all screws.
PEARLS AND PITFALLS—INTRAMEDULLARY NAILING Avoid intramedullary nailing in narrow diameter (<9 mm) canals: excessive reaming is not desirable in the humerus. Choose nail length carefully, erring on the side of a shorter nail: do not distract the fracture site by trying to impact a nail that is excessively long. Insertion site morbidity remains a concern: choose your entry portal carefully and use meticulous technique.
EXTERNAL FIXATION Is a suboptimal form of fixation with a significant complication rate and has traditionally been used as a temporizing method for fractures with contraindications to plate or nail fixation. These include extensively contaminated or frankly infected fractures , fractures with poor soft tissues (such as burns), or where rapid stabilization with minimal physiologic perturbation or operative time is required (―damage-control orthopaedics‖)
EXTERNAL FIXATION External fixation is cumbersome for the humerus and the complication rate is high. This is especially true for the pin sites, where a thick envelope of muscle and soft tissue between the bone and the skin and constant motion of the elbow and shoulder accentuate the risk of delayed union and malunion, resulting in significant rates of pin tract irritation, infection, and pin breakage.
PLATE OR NAIL? Plate Nail Reliable, 96% Less incision union required Good Higher incidence shoulder/elbow of complications? function Lower union rate? Soft tissue – scars, radial nerve, bleeding
WHAT IS THE ROLE FORNAILING? Segmental fractures Particularly with a very proximal fracture line Pathologic fractures ? Cosmesis
COMPLICATIONS OF OPERATIVEMANAGEMENT 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.
REHABILITATION Allow early shoulder and elbow rom Weight bearing delayed till fracture is united