Fracture of humerus

fracture of humerus,symptoms,classifications,investigations,treatments

1. FRACTURE OF HUMERUS BY RAMKUMAR

2. INTRODUCTION The  humerus  is your upper arm bone between your shoulder and elbow. When your  humerus   is fractured  near or at the ball of your shoulder joint, it is commonly known as a  broken  shoulder . 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

3. 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. 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

4. RELATIONSHIP OF NEUROVASCULAR STRUCTURES TO SHAFT HUMERUS

5. 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

6. CLINICAL FEATURES Pain. Deformity. Bruising. Crepitus. Abnormal mobility Swelling. Any neurovascular injury

7. INVESTIGATION 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.

8. INVESTIGATION Radiographs CT scan MRI scan Nerve conduction studies 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. MRI for pathological #

9. CLASSIFICATION CLOSED OPEN LOCATION- proximal, middle, distal FRACTURE PATTERN- tranverse , spiral, oblique,comminuted segmental SOFT TISSUE STATUS – Tscherene & Gotzen Gustilo & Anderson

10. AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT

11. TREATMENT

12. NON OPERATIVE INDICATIONS Undisplaced closed simple fractures Displaced closed fractures with less than 20 anterior angulation, 30 varus / valgus angulation Spiral fractures Short oblique 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

13. NON OPERATIVE 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.

14. OPERATIVE 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.

15. OPERATIVE METHODS OF SURGICAL MANAGEMENT Plating Nailing External fixation ANTERIOR APPROACH Incision Proximal land mark – coracoid process Distal land mark- anterior to lateral supracondylar ridge

16. OPERATIVE ANTERO LATERAL APPROACH Proximally, the plane lies between the deltoid laterally (axillary nerve) and the pectoralis major medially(medial and lateral pectoral nerves). Distally, the plane lies between the medial fibers of the brachialis ( musculocutaneous nerve) medially and the lateral fibers of the brachialis (radial nerve) laterally

17. OPERATIVE POSTERIOR APPROACH Position of the patient for the approach to the upper arm in either the (A) lateral or (B) prone position Incision Tip of olecranon distally to postero lateral corner of acromion proximally Incise the deep fascia of the arm in line with the skin incision. Identify the gap between the lateral and long heads of the triceps muscle

18. 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.

19. REFERENCE http://emedicine.medscape.com/article/825488-overview http://patient.info/doctor/fractured-humerus https://en.wikipedia.org/wiki/Humerus_fracture http://physioworks.com.au/injuries-conditions-1/fractured_humerus-broken_shoulder http://orthoinfo.aaos.org/topic.cfm?topic=A00513