FRACTURE SHAFT

HUMERUS

[Link] Kumar MS Ortho

Assistant Professor
Department Of Orthopaedics
MIMS.
FRACTURE SHAFT
HUMERUS

 Introduction
 Epidemiology
 Classification
 Clinical features
 Investigations
 Treatment
 Complications
INTRODUCTION
 3% to 5% of all fractures

 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
CONSIDERATION
S
Successful 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
 ANATOM
Y
 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.
ANATOM
Y
 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
ANATOM
Y
RELATIONSHIP OF
NEUROVASCULAR STRUCTURES
TO SHAFT HUMERUS
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, smoking, 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

 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 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)
○ Brachial Artery Injury
TREATMEN
T
• Goal of treatment is to establish union with
acceptable alignment
NON OPERATIVE
TREATMENT
 INDICATIONS
Undisplaced closed simple
fractures

Surgically unfit
HUMERAL SHAFT FRACTURES
 Conservative Treatment

○ 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 subsided
1. Minor movts at # site should be pain
free
2. Any deformity should disappear once
deforming forces are removed
3. 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 SURGICAL
MANAGEMENT
 Plating
 Nailing
 External fixation
PLATIN
G
PLATIN
G
 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 HOLE
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
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
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
Than
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