FRACTURE HUMERUS SHAFT IN ADULTS

TEAM D AUDIT

KHOULA HOSPITAL

Supervised by

Dr. Ghassan Al YASSRI

Dr. Ahmed Al-Gazzar

3-5 % of all fractures

Bimodal distribution

Males in 3rd decade

Females in 7th decade

Coaptation splint followed by functional brace

Klenerman found that:-

•indicated in vast majority of humeral shaft fractures

•criteria for acceptable alignment includes

- anterior angulation < 20 *

- varus/valgus angulation <30*

- shortening < 3cm

•90 % union rate

•increased risk of non union with proximal third oblique or spiral fractures

•varus angulation is common but rarely has functional or cosmetic sequelae

**Klenerman L: Fractures of the shaft of the humerus. J Bone Joint Surg Br 1966; 48(1):105-

111.

I. Conservative:-

In the largest clinical analysis to date, Sarmiento et al reported on 922

patients treated with a functional brace for both closed and open

humeral shaft fractures:-

98% of all closed injuries and 94% of all open fractures healed.

Malunion, described as angular deformity greater than 16 degree in

any plane, 13% and 19%.

Only 2% of patients reported loss of shoulder motion

**Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of fractures of

the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

**Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of

fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

ABSOLUTE INDICATIONS :-

1. open fracture

2. vascular injury requiring repair

3. brachial plexus injury

4. ipsilateral forearm fracture (floating elbow)

5. compartment syndrome

RELATIVE INDICATIONS:-

1. Bilateral humerus fracture

2. Polytrauma or ASSOCIATED lower extremity fracture

3. Pathological fractures

4. Burns or soft tissue injury

5. Long oblique or spiral proximal fracture

6. Intraarticular extension

II. Operative:

RELATIVE INDICATIONS:-

1. pathologic fractures

2. segmental fractures

3. severe osteoporotic bone

4. overlying skin compromise limits open approach

5. polytrauma

AUDIT

Outcome of the fracture

Risk factors of associated injuries with ORIF , specially the

iatrogenic radial nerve injury.

PLAN

We have analysed 57 consecutive fractures of the

humeral shaft treated over two-years period from July

2012 to July 2014

The fractures were defined by their type “ closed

versus open and by AO morphology

The data of the study is collected from khoula hospital

electronic system

We have reviewed 57 patients with fracture humerus shaft

-43

-14

55 cases with primary ORIF and 2 cases with revision fixation

Male : Female is 3:1

Age ranges from 16 – 72 years

Average age 33.2

OLD

MID

DLE

Yo

un

g16 – 40 yrs

42 cases

41-60 yrs

12 cases

61- 72

3 CASES

Age groups of the patients

Interval between the incidence of injury and surgery in primary

cases ranged from 0 day to 20 weeks.

The 2 revision cases one done after 21 weeks due to re-fracture

and the other done after 3 years due to non union.

Types of Fractures

Closed fractures

• 54 cases

Open fractures

• 3 Cases

A1 --- 6 cases

A2 --- 6 cases

A3 --- 19 cases

B1 --- 8 cases

B2 --- 7 cases

B3 --- 3 cases

C1 type --- 8 cases

Classification of fractures (AO)

Associated Injuries

Radial nerve injury

8 cases

Brachial artery injury

2 cases

Multiple nerve injury

1 case

6 cases

4 primary fractures

2 revision fractures

51 cases

ORIFby

plating

ORIFby

plating + bone graft

Operative Technique

Posterior 31 cases Anterolateral 20 cases

Anterior 2 cases

Lateral 2 cases

Medial 1 case

Anteromedial 1 case

Approaches for surgery

Medical officer

1 case

Resident

1 case

Sr.consultant

2 cases specialist

25 cases

Sr.specialist

28 cases

Level of Surgeon

Supervision of surgery

supervised by Sr. consultant

•2 cases

Supervised by Sr. Specialist

•15 cases

2

complications

10 cases

By specialist

Without supervision

1 case

Deep SSI

1 case

Malunion

Supervision of surgery

Complications of the fracture

9 cases with radial nerve injury 19 %

8 cases initial isolated Radial nerve injury

1 case with multiple upper limb nerve injury

Complications of surgery (ORIF)

1 case

Varusangulation

1 case

Delayed union

1 case

Deep SSI

2 cases

Non union

2 cases

Iatrogenic

radial n.

palsy

1.75 % 1.75 % 1.75 %

3.5% 3.5 %

Iatrogenic Radial Nerve Palsy

Iatrogenic Radial Nerve Palsy

NON UNION

Deep SSI

VARUS ANGULATION

9 cases of initial radial nerve injury:-

5 cases recovered completely

2 cases recovered partially

2 cases didn’t recover

There was no proper documentation of the radial nerve deficit regarding sensory and motor

Major morbidity of the fracture was the radial nerve injury

2 cases of Iatrogenic radial nerve injury didn’t recover.

Both cases were operated through anterolateral approach

Both cases were operated by specialist and supervised by Sr.

Specialist .

One case had shown radial nerve degeneration by EMG

study done after 1 year of injury .

The other case was shown to the clinic only up to 4 months

after surgery with no recovery.

Injury to the radial nerve with neuropraxia is the most frequently

encountered nerve deficit associated with humeral fractures and is

found in up to 18% of all patients.spontaneous recovery over a period

of 4 months occurs in 70% to 92% of patients managed with

observation; therefore, its presence is not an indication for open

management and nerve exploration.

Shao Y, Harwood P, Grotz M, Limb D, Giannoudis P. Radial nerve palsy associated with fractures of the

shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005;87:1647-52. doi:10.1302/0301

620X.87B12.16132

Compare Data

Khoula

(57)

USA

(213)

Singapore

(53)

Iatrogenic Radial n. palsy 3.5 % 8% 5.7%

Non union 3.5% 9% 3.7%

malunion 1.7% 1% ---

Deep SSI 1.7% 5% 3.7%

**Operative versus Nonoperative Treatment of Humeral Shaft Fractures: A Retrospective Review of 213 Patients from Two

Level I Trauma Centers Fri., Southeastern Fracture Consortium; Michael C. Tucker, MD1 (10-Southeastern Fracture

Consortium research grant); William T. Obremskey, MD2 (5A-Medtronic, Osteogenix; 7-Synthes); Mark Floyd,

BS3 (n); Anthony Denard, BS2 (n); 10/9/09 Upper Extremity, Paper #49, 11:45 am OTA-2009.

**Surgical Results of Open Reduction and Plating of Humeral Shaft Fractures. H T Hee,*MBBS, FRCS (Edin), FRCS (Glas), BY

Low,**FAMS, FRCS (Edin), FRCS (Glas), H F See,***FAMS, MBBS, FRCS (Glas). Ann Acad Med Singapore 1998; 27:772-5.

The surgical approach used in the analysed cases with iatrogenic radial

nerve palsy was anterolateral approach That means the injury to the

nerve could happened due to over traction during reduction or during

putting the hardware.

Surgeries done by specialist level with no supervision had a complication

rate of 20 %

Conclusion

Proper assessment of the neurologic deficit at the time of injury ,

pre operative and postoperative is of greatest importance.

Plan the proper approach prior to surgery according to type of

fracture , plan of fixation , associated injuries , skills of the

operating surgeon.

Where is the nerve

Length of observation for radial n. palsy remains a subject of debate.

During the observation period: Brace & aggressive ROM physiotherapy.

Recommendations

Thank you