FRACTURE OF HUMERUS

BYRAMKUMAR

INTRODUCTIONThe 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 fracturesMost 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

ANATOMYProximally, 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

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 FEATURESPain.Deformity.Bruising.Crepitus.Abnormal mobilitySwelling.Any neurovascular injury

INVESTIGATIONSkin 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.

INVESTIGATIONRadiographsCT scanMRI scanNerve conduction studiesAP 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 #

CLASSIFICATIONCLOSEDOPENLOCATION- proximal, middle, distalFRACTURE PATTERN-tranverse, spiral,

oblique,comminuted segmentalSOFT TISSUE STATUS – Tscherene &

Gotzen Gustilo &

Anderson

AO CLASSIFICATION OF THE HUMERUS FRACTURE SHAFT

TREATMENT

Non operative operative

NON OPERATIVE INDICATIONS Undisplaced closed simple fractures Displaced closed fractures with less than 20 anterior

angulation, 30 varus/ valgus angulation Spiral fractures Short oblique fracturesConservative 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

NON OPERATIVESplinting:

◦ 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.

OPERATIVEINDICATIONS◦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.

OPERATIVEMETHODS OF SURGICAL MANAGEMENTPlatingNailingExternal fixationANTERIOR APPROACHIncisionProximal land mark – coracoid processDistal land mark- anterior to lateral

supracondylar ridge

OPERATIVEANTERO LATERAL APPROACHProximally, 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

OPERATIVEPOSTERIOR APPROACHPosition of the patient for the approach to the upper arm in either the (A) lateral or (B) prone positionIncisionTip of olecranon distally to postero lateral

corner of acromion proximallyIncise 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

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.

REFERENCEhttp://emedicine.medscape.com/

article/825488-overviewhttp://patient.info/doctor/fracture

d-humerushttps://en.wikipedia.org/wiki/Hum

erus_fracturehttp://physioworks.com.au/injurie

s-conditions-1/fractured_humerus-broken_shoulder

http://orthoinfo.aaos.org/topic.cfm?topic=A00513