Humeral shaft fracture

1. Orthopedic
Teleconference
Maharat Nakorn Ratchasima Hospital
Extern Montakarn Deeyai
5402123

2. Patient profile
 ผู้ป่วยหญิงไทยคู่ อายุ 45 ปี
 ภูมิลาเนา อ.โนนสูง จังหวัดนครราชสีมา

3. Chief complaint
 ปวดแขนขวา 2.5 ชั่วโมงก่อนมารพ.

4. Present illness
 2.5 ชั่วโมงก่อนมารพ. ผู้ป่วยขับรถมอเตอร์ไซค์ชนรถยนต์ ล้ม
ต้นแขนขวากระแทกพื้น ปวดบวมต้นแขนขวามาก มีบาดแผล
ถลอกบริเวณต้นแขนขวา มีแขนขวาผิดรูป ขยับแขนขวาไม่ได้
แต่ยังกระดกข้อมือได้ ไม่ชา
ไม่มีศีรษะกระแทกพื้น จาเหตุการณ์ได้ ไม่สลบ ไม่ปวดคอ ไม่
ปวดหลัง ไม่ได้ดื่มสุรา

5. Primary survey
 A : can speak, can flex neck, not
tender at posterior midline of neck
 B : equal breath sound both lungs
 C : BP 120/80 mmHg, PR 86 bpm
 D : E4V5M6, pupils 3 mm RTLBE
 E : Abrasion wound and deformity at
right upper arm

6. Secondary survey
 A : No allergy
 M : No current medication
 P : No underlying disease
 L : last meal 6 hours ago
 E : ผู้ป่วยขับรถมอเตอร์ไซค์ชนกับรถยนต์ แล้วล้มแขนขวาลง
กระแทกกับพื้น

7. Past history
 No Underlying disease
 No Past surgery

8. Personal history
 No Drug allergy
 No Alcohol drinking
 No Smoking

9. Physical examination
 Vital signs : T 37 c, BP 120/80 mmHg,
HR 86 bpm, RR 20 /min
 Height 160 cm , Weight 93 kg BMI 36.33
 General appearance : A middle-aged
Thai woman, obese, good
consciousness
 Heart&Lung : WNL
 Abdomen : Soft, not tender
 Neuro : E4V5M6, pupils 3 mm RTLBE
Motor gr.V all except Rt arm limit due to

10. Radial
nerve

12. Physical examination
 Neuro : no wrist drop or fingers drop
Can extend wrist and fingers right hand
Sensory – intact both arms and hands
No radial nerve palsy (pre-reduction)
 Extremity :
Right upper arm deformity, abrasion
wound and bruise , tender, swelling,
Radial pulse 2+ both
Capillary Refilling time <2 sec
Limit active ROM right shoulder due to pain
Not tender at shoulder and elbow

13. Investigation
 Film Right humerus AP, Lateral

14. Radiographs

15. Problem lists
 Close fracture shaft of Right humerus
 Obesity

16. Management
 Nonoperative
coaptation splint followed by functional brace
◦ indications
indicated in vast majority of humeral shaft fractures
 Isolated injury
 Closed fracture
 Cooperative patient
 Acceptable alignment
criteria for acceptable alignment include:
• < 20° anterior angulation
• < 30° varus/valgus angulation
• < 3 cm shortening

17. Management
Try conservative
 Close reduction
 Immobilization : On U-slab
 Pain control

18. Management
 Close reduction
neurovascular : intact
No radial nerve palsy (post-reduction)

19. U-slab

20. Radiographs

21. Radiographs (Change U-slab 1)

22. Management
Bone gap , obesity
 Admit
 Plan surgery

23. Humeral shaft
fracture

24. Anatomy

25.  Osteology : humeral shaft is cylindrical
 Muscles
◦ insertion for
 pectoralis major
 deltoid
 coracobrachialis
◦ origin for
 brachialis
 triceps
 brachioradialis
 Nerve
◦ radial nerve
 courses along spiral groove
 14cm proximal to the lateral epicondyle
 20cm proximal to the medial epicondyle

28. Humeral shaft fracture
 Incidence3-5% of all fractures
 bimodal age distribution
◦ young patients with high-energy trauma
◦ elderly, osteopenic patients with low-
energy injuries

29. Pathological anatomy
 Fractures above the deltoid insertion,
the proximal fragment is adducted by
pectoralis major.
 Fractures below the deltoid insertion,
the proximal fragment is abducted by
deltoid.

31. Presentation
 Symptoms
◦ pain
◦ extremity weakness
 Physical exam
◦ examine overall limb alignment
◦ preoperative or pre-reduction
neurovascular exam is critical
 examine and document status of radial nerve
pre and post-reduction

32. Radiographs
 AP and lateral
◦ be sure to include joint above and below
the site of injury
 transthoracic lateral
◦ may give better appreciation of sagittal
plane deformity
 traction views
◦ may be necessary for fractures with
significant shortening, proximal or distal
extension but not routinely indicated

33. Management
 Nonoperative
coaptation splint followed by functional
brace
◦ indications
 indicated in vast majority of humeral shaft
fractures
 criteria for acceptable alignment include:
 < 20° anterior angulation
 < 30° varus/valgus angulation
 < 3 cm shortening

34.  contraindications
◦ severe soft tissue injury or bone loss
◦ vascular injury requiring repair
◦ brachial plexus injury
◦ Open fracture
◦ Polytrauma patient
◦ Additional ipsilateral fracture
◦ Patient unable to sit or stand
◦ Irreducible displacement
◦ Obesity
◦ Nerve injury developing during closed
treatment
Nerve interposed in fracture radial nerve palsy
is NOT an absolute contraindication to
functional bracing

35.  outcomes
◦ 90% union rate
 increased risk with proximal third oblique or
spiral fracture
◦ varus angulation is common but rarely has
functional or cosmetic sequelae

36. Operative
Gold standard : Plate and screw
◦ absolute indications
 open fracture
 vascular injury requiring repair
 brachial plexus injury
 ipsilateral forearm fracture (floating elbow)
 compartment syndrome

37. Operative
◦ relative indications
 bilateral humerus fracture
 polytrauma or associated lower extremity
fracture
 allows early weight bearing through humerus
 pathologic fractures
 burns or soft tissue injury that precludes
bracing
 Obesity or large breast
 fracture characteristics
 distraction at fracture site
 short oblique or transverse fracture pattern
 intraarticular extension

38. Complications
Early :
 Radial nerve palsy
 Brachial artery damage
Late :
 Malunion
 Nonunion
 Joint stiffness

41. Humeral shaft fracture
Surgical cases

47. References
 http://www.orthobullets.com/trauma/10
16/humeral-shaft-fractures
 AO Principles Of Fracture
Management
 http://www2.aofoundation.org

48. THANK YOU
FOR YOUR ATTENTION