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Humeral Shaft Fracture.
Description:
• Fractures of the diaphysis (shaft) of the
humerus
• Occur at all ages.
Classification:
– Anatomic location:• Proximal 1/3 of the shaft
• Medial 1/3 of the shaft
• Distal 1/3 of the shaft
• Fracture characteristics:
– Fracture pattern (transverse / oblique /comminuted)
– Fractures - open or closed.
– Pathologic (secondary to underlying bone disease)
– Spiral fractures of the distal 1/3 have been termed
Holstein-Lewis fractures and are associated with radial
nerve injury.
Risk Factors:
• Osteoporosis in the elderly.
• High-energy trauma.
• Sports with rotational forces.
Diagnosis.
Signs and Symptoms•
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Pain.
Deformity.
Bruising.
Crepitus.
Swelling.
Physical Exam:
• 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.
Tests
Imaging:
AP and lateral views of the humerus,
including the joints below and above the injury.
Treatment.
• Most closed fractures of the humeral shaft
may be managed nonoperatively.
• Analgesics.
• Reduction should be attempted if there is >20
degree of angulation, >3 cm of shortening.
– Lesser degrees of shortening or angulation are
tolerated satisfactorily.
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.
• Operative fixation; indications include:– Open fractures.
– Articular injury.
– Neurovascular injury.
– Impending pathologic fractures.
– Segmental fractures.
– Multiple extremity fractures.
– Fractures in which reduction is unable to be achieved or
maintained.
– Fractures with nerve injuries after reduction maneuvers.
Physical Therapy:
• None is required in the initial period.
• When pain has subsided (~1 -2 weeks), gentle ROM
of the shoulder and elbow should be started.
Surgery:
• Surgery involves fixation of the bone fragments with
a plate and screws or intramedullary fixation with a
metal nail.
• If severe soft-tissue injury exists, external fixation
may be necessary.
• ~90% of humeral shaft fractures treated without
surgery heal.
Complications
• 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.
Intercondylar Elbow
Fracture.
• The distal humerus forms a triangle composed
of a medial column and a lateral column that
support the articular surface of the trochlea.
• The trochlea articulates with the ulna.
• The capitellum is the part of the humerus that
articulates with the radius and is part of the
lateral column.
• Lateral column fractures are more common
than medial column fractures.
• Young patients (often male) involved in highvelocity trauma, or elderly osteoporotic
patients (often female) with a lesser
mechanism.
Associated Conditions:
• Neurapraxia.
• Vascular injury.
• Polytrauma.
Diagnosis:
Signs and Symptoms:
• Severe pain, swelling, and a decreased ability
or inability to move the extremity at the elbow.
Physical Exam
• These injuries often are associated with substantial
energy, and the patient requires a thorough
examination.
• Extremity:
– Evaluate soft tissues (rule out -open v/s closed fracture
status).
– Marked swelling often is present.
– Assess the limb for vascular status and signs of ischemia.
(pallor, capillary refill, peripheral pulses).
• Neurologic status:
– The neurologic status of the extremity in the ulnar,
median and radial nerve distributions.
– Often the patient cannot or will not move, or allow
passive movement of, the elbow.
– If the patient does move it, or allow it to be moved,
marked crepitus often is present.
Tests
• Radiography:
– AP and lateral views of the elbow and humerus.
• CT.
• MRI.
Treatment.
• If operative care is indicated, surgery preferably is
performed early (within 2- 3 days).
• If the limb has a diminished or absent pulse,open
reduction should be performed.
– If this procedure does not improve the status of the limb,
angiography or surgical exploration should be performed.
• Single-column/condylar fractures:
Nondisplaced fractures:– May be treated nonsurgically.
– Analgesics.
– The duration of immobilization should be <2 weeks.
– Treatment should include gentle passive ROM.
Displaced fractures should be treated surgically
• Bicolumn fractures:
– Treat surgically,
– Followed by immobilization.
– Analgesics , antibiotics.
Complications.
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Loss of ROM.
Nonunion.
Malunion.
Post traumatic arthritis.
Complicatons…
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Loss of fixation.
Osteonecrosis.
Neurovascular injury.
Ulnar neuropathy.
Infection.
Heterotopic ossification.