FRACTURE SHAFT HUMERUS

Dr. RAMKISHANASSISTANT PROFESSORDEPT. OF ORTHOPAEDICS AND TRAUMATOLOGYOSMANIA GENERAL HOSPITAL HYDERABAD

FRACTURE SHAFT HUMERUS Introduction History Epidemiology Mechanism of injury Classification Clinical features Investigations Treatment Complications

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

GENERAL CONSIDERATIONS 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.

GENERAL CONSIDERATIONS Successful treatment demands a

knowledge of : Anatomy, Biomechanics Techniques Patient Function and Expectations.

HISTORY

Sir JOHN CHARNLEY    (1911-1982)

“It is perhaps the easiest of major lonf bones to treat by conservative methods”

SARMIENTO  (February 15, 1811 – September 11, 1888) 

RICHARD WATSON (1737- 1816)

EPIDEMIOLOGY

High energy trauma is more common in the young males

Low energy trauma is more common in the elderly female

AGE AND GENDER SPECIFIC INCIDENCE OF SHAFT HUMERUS 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

ANATOMY

RELATIONSHIP OF NEUROVASCULAR STRUCTURES TO SHAFT HUMERUS

MECHANISM OF INJURYDirect trauma is the most common especially

MVAIndirect trauma such as fall on an outstretched

handFracture 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

Pain. Deformity. Bruising. Crepitus. Abnormal mobility Swelling. Any neurovascular injury

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.

INVESTIGATIONS

Radiographs CT scan MRI scan Nerve conduction studies Routine investigations

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. A CT scan through the humeral condyles distally and the humeral head proximally can provide exact rotational alignment

MRI for pathological #

CLASSIFICATION

CLOSED OPEN LOCATION- proximal, middle, distal FRACTURE PATTERN-tranverse, spiral,

oblique,comminuted segmental SOFT TISSUE STATUS – Tscherene &

Gotzen

Gustilo & Anderson

AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT

AO CLASSIFICATION

1 – HUMERUS 2--- DIAPHYSIS

A – SPIRAL– 1-PROXIMAL ZONE

2- MIDDLE ZONE

3- DISTAL ZONE

B- OBLIQUE

C- TRANSVERSE

AO CLASSIFICATION

AO CLASSIFICATION

A3

AO CLASSIFICATION

AO CLASSIFICATION

AO CLASSIFICATION

AO CLASSIFICATION

AO CLASSIFICATION

AO CLASSIFICATION

ASSOCIATED INJURIES

○ Radial Nerve injury = Wrist Drop = Inability of extend wrist, fingers, thumb, Loss of sensation over dorsal web space of 1st digitNeuropraxia at time of injury will

often resolve spontaneouslyNerve 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)

○ Brachial Artery Injury○ Clavicle, forearm, wrist & Chest injuries

DIAGNOSIS

History

Clinical examination

imaging

TREATMENT

Goal of treatment is to establish

union with acceptable alignment

TREATMENT OPTIONS

Non operative operative

NON OPERATIVE TREATMENT INDICATIONS

Undisplaced closed simple fractures

Displaced closed fractures with less than 20 anterior angulation, 30 varus/ valgus angulation

Spiral fractures

Short oblique fractures

HUMERAL SHAFT FRACTURES

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 OPERATIVE METHODS 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 MANAGEMENT

OPERATIVE TREATMENT

INDICATIONSFractures 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 SURGICAL MANAGEMENT Plating Nailing External fixation

ANTERIOR APPROACH

SUPINE ON THE ARM TABLE WITH 600 ABDUCTION AT SHOULDER

ANTERO LATERAL APPROACH

Incision Proximal land mark

– coracoid process Distal land mark-

anterior to lateral supracondylar ridge

ANTERO LATERAL APPROACH

Proximally, the plane lies between the deltoid laterally (axillary nerve) and the pectoralis major medially(medial and lateral pectoral nerves).

ANTERO LATERAL APPROACH

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.

INTRA OP PHOTO

PLATING - POSTERIOR APPROACH

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.

DYNAMIC COMPRESSION PLATE

LIMITED CONTACT DCP

LOCKING PLATE

LOCKING PLATE HOLE

LOCKING PLATE

LAG SCREWS

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 motion.

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.

ANTEGRADE TECHNIQUE

ANTEGRADE TECHNIQUE

RETROGRADE 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.

EXTERNAL FIXATION

EXTERNAL FIXATION

PLATE OR NAIL?

PlateReliable, 96%

unionGood

shoulder/elbow function

Soft tissue – scars, radial nerve, bleeding

NailLess incision

requiredHigher incidence

of complications? Lower union rate?

WHAT IS THE ROLE FOR NAILING? Segmental fractures

Particularly with a very proximal fracture line Pathologic fractures ? Cosmesis

COMPLICATIONS OF OPERATIVE MANAGEMENT

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

CASE 1

IMPLANT FAILURE POST OP X RAY

CASE 2

IMPLANT FAILURE POST OP X RAY

THANK YOU