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FRACTURE SHAFT HUMERUS Edited by Abdelrahman youssif HYDERABAD Mansoura university faculty of medicine orthopedics department Supervisor: Head of department: Prof.Dr.hani.M.Elmowafy

Humerus fracture

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FRACTURE SHAFT HUMERUS

Edited by Abdelrahman youssif

HYDERABAD

Mansoura universityfaculty of medicineorthopedics department

Supervisor: Head of department:

Prof.Dr.hani.M.Elmowafy

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.

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 long 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

MECHANISM OF HEALING

Inflammation

• Hematoma forms and provides source of hemopoieitic cells capable of secreting growth factors.

• Macrophages, neutrophils and platelets release several cytokines• this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12

• Fibroblasts and mesenchymal cells migrate to fracture site and granulation tissue forms around fracture ends 

• Osteoblasts and fibroblasts proliferate• inhibition of COX-2 (ie NSAIDs) causes repression of runx-2/osterix, which are critical for differentiation of osteoblastic cells

Repair• Primary callus forms within two weeks. If the bone ends

are not touching, then bridging soft callus forms.

• Enchondral ossification converts soft callus to hard callus (woven bone). Medullary callus also supplements the bridging soft callus

• Type II collagen (cartilage) is produced early in fracture healing and then followed by type I collagen (bone) expression

• Amount of callus is inversely proportional to extent of immobilization • primary cortical healing occurs with rigid

immobilization (ie. compression plating)

Remodeling• Begins in middle of repair phase and continues

long after clinical union• chondrocytes undergo terminal differentiation

• signaling pathways including, indian hedgehog (Ihh), parathyroid hormone related peptide (PTHrP), FGF and BMP

• cartilaginous calcification takes place at the junction between the maturing chondrocytes and newly forming bone

• multiple factors are expressed including BMPs, TGF-Betas, IGFs, osteocalcin, collagen I, V and XI

• subsequently, VEGF production leads to new vessel invasion

• newly formed bone (woven bone) is remodeling via osteoblastic/osteoclastic activity 

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 plain x-ray of the humerus,

including the joints below and above the injury.

CT scanning may also be indicated in the rare situation where a significant rotational abnormality exists. A CT scan through the humeral condyles distally and the humeral head proximally can provide exact rotational alignment

MRI for pathological cause

CLASSIFICATION

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

oblique,comminuted segmental SOFT TISSUE STATUS – Gustilo

AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT

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 splint 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.

HUMERUS BRACE- 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

PLATING

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.

DYNAMIC COMPRESSION PLATE

LIMITED CONTACT DCP

LOCKING PLATE

LOCKING PLATE HOLE

LOCKING PLATE

LAG SCREWS

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

Antegrade Technique

Retrograde Technique-best suited for fractures in the middle and distal thirds of the humerus

ANTEGRADE TECHNIQUE

ANTEGRADE TECHNIQUE

RETROGRADE TECHNIQUE

EXTERNAL FIXATION

External fixation is cumbersome for the humerus and the complication rate is high.

AS IT MAY 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.

CASE 1

IMPLANT FAILURE POST OP X RAY

CASE 2

IMPLANT FAILURE POST OP X RAY

REHABILITATION

Allow early shoulder and elbow rom Weight bearing delayed till fracture is

united

Thank you