Humerus_fractures_management_and_outcomes.ppt

Humerus fractures

1. Fractures of the Humeral Shaft
Management and outcomes
Dr Nasir Muzaffar

2. Introduction
•Shaft fractures traditionally
treated nonsurgically
•high rate of complications?
–Infection
–Nonunion
–Radial nerve palsy.

3. Physical Examination
•Cardinal signs:
–pain
–swelling
–deformity
•Look for associated
injuries
•Document
neurovascular exam!
•Radial Nerve Function

4. Imaging
•Standard X-rays
– AP
– lateral view
–Joints above and below
•CT/MRI if pathologic
fx suspected, x-rays
not clear

5. Nonsurgical Treatment
•Most humeral fractures are
amenable to closed,
nonsurgical treatment (Gold
Standard)
–rigid immobilization is not
necessary for healing
–perfect alignment is not
essential for an acceptable
result

6. What is Acceptable Alignment?
•Great tolerances of alignment
•We don’t walk on arms
•Shoulder/elbow have large
ROM
–20 degrees of anterior or
posterior angulation
–30 degrees of varus (less
in thin patients)
–3 cm of shortening

7. What is Acceptable Alignment?
•Varus/valgus angulation is tolerated better proximally,
and more angulation may be tolerated better in patients
with obesity. Patients with large, pendulous breasts who
are treated nonsurgically are at increased risk of varus
angulation. No set values for acceptable malrotation
exist, but compensatory shoulder motion allows for
considerable tolerance of rotational deformity.

8. Closed Treatment
•Coaptation splint ( U Slab) or a
hanging arm cast in ER
•Coaptation splint is preferred due to
the support it offers proximal to the
fracture site
•Conversion to a functional brace in 7
to 10 days

9. Functional Bracing
•Sarmientio, 1977
•Soft-tissue
compression/hydrostatic
pressure
•Anterior and posterior shell w/
Velcro straps
•Applied acutely or following
coaptation splint
•Active shoulder and elbow ROM

10. Contraindications to
Functional Bracing
•Massive soft-tissue or bone loss
•Unreliable or uncooperative patient
•Inability to obtain and maintain
acceptable fracture alignment
•Fracture gap present - increases risk of
nonunion

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

12. Indications for ORIF -
Injury Factors
•Failed closed treatment
–Loss of reduction
–Poor patient tolerance/compliance
•(Open fractures)
•Vascular injury/
•Change in neuro exam (radial n.)
•Floating elbow

13. Indications for ORIF -
Injury Factors
•Associated intra-
articular fractures
•Associated injuries to
the brachial plexus
•Chronic problems
–Delayed union
–Nonunion/malunion
–Infection

14. Indications for ORIF -
Patient Factors
•Polytrauma-requiring arm for
mobilization
–Head injuries
–Burns
–Chest trauma
–Multiple fractures
•Patient unable to be upright

15. Surgical Treatment
•Plate osteosynthesis
–Lag screws alone are
not strong enough
•IM fixation
•External fixation

16. Plate Osteosynthesis
•The best functional results: use of plates
and screws
•Direct fracture reduction
•Stable fixation of the humeral shaft
•No violation of the rotator cuff
•Visualization of radial nerve

17. Plate Osteosynthesis
•Results:
–Union rates have
averaged 96% with
significant
complications ranging
from 3% to 13%
–motion restrictions at
the elbow

18. Complications of Humeral
Shaft Fractures
•Radial nerve injury
•Vascular injury
•Nonunion

19. Radial Nerve Injury
•Incidence varies from 1.8% to 24% of shaft
fractures
•Primary - occurs @ injury
•Secondary - occurs later during closed or
open management
•Management controversial

20. Radial Nerve Injury
•Spontaneous recovery: ~90%
•Even secondary palsies, have a high rate of
spontaneous recovery
•EMG and nerve conduction studies can
help, (but not acutely!)
•If no recovery, tendon transfers very
reliable

21. Preferred Management of Fractures
with Associated Radial Nerve Palsy
•Indications for surgery:
–Open fractures
–Secondary palsies developing after a closed
reduction

22. Vascular Injury
•Uncommon
•Key is clinical diagnosis
•Debate:
–Shunt, ORIF, then bypass/repair
–ORIF then bypass/repair

23. Nonunion
•Rate: 0% to 15%

24. Nonunion: Predisposing Factors
•transverse fracture pattern
•older age
•poor nutritional status
•osteoporosis
•endocrine abnormality affecting calcium
balance
•use of steroids
•anticoagulation
•previous RT

25. Nonunion: Surgical Treatment
•Compression plate
fixation for
hypertrophic
nonunions
•Biologic stimulation +
plate for atrophic
nonunions

26. Nonunion: Surgical Treatment
•Compression plate
fixation for
hypertrophic
nonunions
•Biologic stimulation +
plate for atrophic
nonunions

27. Surgical versus non-surgical interventions for treating humeral shaft fractures in adults
Maurits W Gosler,
 Mark Testroote, JW Morrenhof, Heinrich MJ Janzing
Editorial Group:
 
Cochrane Bone, Joint and Muscle Trauma Group
•There is no evidence available from randomised
controlled trials to ascertain whether surgical
intervention of humeral shaft fractures gives a better or
worse outcome than no surgery. Sufficiently powered
good quality multi-centre randomised controlled trials
comparing surgical versus non-surgical interventions for
treating humeral shaft fractures in adults are needed. It
is likely that the results from the two ongoing
randomised trials on this topic will help inform practice
in due course.

28. Summary
Humeral Shaft Fractures
•Results very good for functional bracing
•Need to carefully document radial nerve
exam
•Most radial nerves injuries recover
•Most prefer plates over nails
•Look for prospective study of immediate
fixation vs. functional bracing