Fractures of Humeral Shaft - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University
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devaki21 December 2012

Fractures of Humeral Shaft - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University

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Fractures of Humeral Shaft, Supracondylar Ridge, Humeral Diaphysis, Deforming Forces, Deltoid Tuberosity, Classification Systems, Fracture Descriptors, Violent Muscle Contraction are some points from this lecture. This l...
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Fractures of the Humeral Shaft

Fractures of the Humeral Shaft

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Introduction • Humeral fractures traditionally

treated nonsurgically, with predictably satisfactory outcomes.

• Strong bias formerly existed against surgical intervention due to high rate of complications.

• Both operative and nonoperative treatments have been refined.

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Relevant Anatomy• Humeral diaphysis extends from

the upper border of the insertion of the pectoralis major proximally to the supracondylar ridge distally

• Fracture alignment determined by the location of the fracture relative to the major muscle attachments, most notably the pectoralis major and deltoid attachments

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Deforming Forces

• Example of a fracture distal to pectoralis major attachment and proximal to deltoid tuberosity

• Adduction of proximal fragment results

Reproduced with permission from Epps H Jr., Grant RE: “Fractures of the shaft of the humerus” in Rockwood CA Jr., Green DP, Bucholz RW (Eds.) Rockwood and Green’s Fractures in Adults Ed 3, Philadelphia, PA JB Lippincott, 1991, Vol. 1, pp: 843-869

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• Example of a fracture distal to deltoid tuberosity

• The proximal fragment is abducted and shortening occurs at fracture site due to pull of biceps and triceps

Reproduced with permission from Epps H Jr., Grant RE: “Fractures of the shaft of the humerus” in Rockwood CA Jr., Green DP, Bucholz RW (Eds.) Rockwood and Green’s Fractures in Adults Ed 3, Philadelphia, PA JB Lippincott, 1991, Vol.. 1, pp. 843-869

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Classification Systems

• Classification based on fracture descriptors

• AO Classification

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Fracture Descriptors

• Location • Pattern • Low-energy vs. high-energy • Open / Closed Injury Classifications

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Mechanism of Injury

• Direct or indirect forces • Violent muscle contraction

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Physical Examination

• Cardinal signs of long bone fracture include: – pain – swelling – deformity

• Look for associated injuries

• Document neurovascular exam!

• Radial Nerve Function Docsity.com

Imaging

• Standard radiographic examination – AP – lateral view – Both joints

• CT/MRI if pathologic fx suspected, xrays not clear

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Nonsurgical Treatment

• Most humeral fractures are amenable to closed, nonsurgical treatment – rigid immobilization is not

necessary for healing – perfect alignment is not

essential for an acceptable result

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What is Acceptable Alignment? • Because the shoulder and

elbow are joints capable of wide ranges of motion, the arm is thought to be able to accommodate the following without a significant compromise of function or appearance: – 20 degrees of anterior

or posterior angulation – 30 degrees of varus (less

in thin patients) – 3 cm of shortening

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Closed Treatment

• Initial immobilization with either a coaptation splint or a hanging arm cast with conversion to a functional brace in the subacute phase when swelling and pain have improved, usually at 7 to 10 days

• Coaptation splint is preferred due to the support it offers proximal to the fracture site

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Functional Bracing for the Humerus

• Principles were introduced by Sarmiento in 1977 – 98% union rate with good

functional restoration and minimal angular deformity

– Nearly full ROM of the extremity were restored and complications were minimal

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Functional Bracing for the Humerus

• Effects fracture reduction through soft-tissue compression

• Consists of an anterior and posterior shell held together with Velcro straps

• Can be applied acutely or following application of a coaptation splint

• Success depends on: – Upright patient – Tightening daily – Cannot lean on elbow

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Contraindications to Functional Bracing

• Massive soft-tissue of bone loss • An unreliable or uncooperative patient • An inability to obtain or maintain acceptable

fracture alignment • Fracture gap present - increases risk of

nonunion

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Surgical Treatment

• Surgical intervention is preferable in specific cases– Injury Related Factors – Patient Related Factors

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Indications for ORIF - Injury Factors

• Failed closed treatment – Loss of reduction – Poor patient tolerance/compliance

• Open fractures • Vascular injury/neurologic injury • Floating elbow

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Indications for ORIF - Injury Factors

• Associated intra-articular fractures

• Associated injuries to the brachial plexus

• Chronic problems – Delayed union – Nonunion/malunion – Infection

• Only open fractures and those with vascular injury present absolute indications for surgical intervention

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Indications for ORIF - Patient Factors

• Polytrauma-requiring arm for mobilization – Head injuries – Burns – Chest trauma – Multiple fractures

• Patient unable to be upright • Bilateral fractures of the humerus • Pathologic fractures

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Surgical Treatment • If surgical intervention is elected, the

following options are available: – Plate osteosynthesis – Intramedullary fixation – External fixation

• There is no role for stabilization of the humeral shaft by screw fixation alone due to the high bending and torsional forces imposed on the humerus during patient and extremity mobilization

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Plate Osteosynthesis

• The best functional results after surgical management of humeral shaft fractures have been reported with the use of plates and screws

• These implant allow direct fracture reduction and stable fixation of the humeral shaft without violation of the rotator cuff

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Plate Osteosynthesis

Results: – Union rates averaged 96%

with significant complications ranging from 3% to 13%

– motion restrictions at the elbow or shoulder usually due to other severe bony or soft-tissue injuries to the same extremity

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Plate Osteosynthesis-Approaches • The surgical approach is dependent on the fracture

level and the need to visualize the radial nerve • Anterolateral , posterior, and lateral approaches are

supported by the literature • The anterolateral approach is preferred for proximal

third fractures • The anterolateral and posterior approach are both

adequate for midshaft and distal third fractures • Lateral approach gives good exposure of entire shaft,

but is less familiar.

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Lateral Approach

Benefits of posterior approach: – Allows direct exposure of the radial nerve – Extensile – Supine position

Drawbacks to posterior approach: – Less familiar to surgeons – Posterior antebrachial cutaneous nerve at

risk

Mills WJ, Hanel DP, Smith DG, J Orthopedic Trauma 10: 81-6, 1996. Docsity.com

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