Orthopedic Care and Consultation
Following xray is of 67 years old man who fell in bathroom. He presented in the out patient department three days after the injury with complaint of pain and swelling in the upper part of the arm. There was substantial bruising on the arm and swelling was noted.
The xray revealed comminuted fracture of upper end of humerus.
The patient was advised closed reduction and internal fixation using an interlock nail but patient refused for surgery.
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If after fixation of a fracture, there is failure to unite within certain amount of time, there is danger of implant getting failed.
With improved qualities of implants, meticulous surgical techniques and careful postoperative protocols, the failures can be reduced.
But still failures do occur.
After a fracture is fixed there is kind of race between fracture union and implant fatigue. Fatigue is the progressive and localized structural damage that occurs in materials when a material is subjected to cyclic loading.
In other words every time an implant is subjected to stress, there occurs a damage to it. Repetitive damage accumulates over the periods and ultimately leads to breakage of the implant.
This is one kind of fixation failure. [Read more...]
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Humerus fractures are very common fractures in young adult and elderly patients.
Fracture Humerus Showing Callus Formation
It may be noted that most of humerus shaft fractures heal well on conservative treatment.
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40 years old lady who had been operated for fracture of shaft of humerus at her native place presented in the OPD with complaint of discharge from the fracture site and pain. Patient had angulation of the arm and onexamination it should abnormal mobility.
One of the screws were visible through the wound and had backed out for most of its length.
Fracture of lower third of shaf of humerus with failed implant. The plate is off and screws have come out of the bone
Xray revealed a failed plate with backed out screws.
The patient was planned for implant removal, wound debridement and external fixation to control the infection and then followed by definitive surgery.
The patient never reported back.
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The overall incidence of distal humeral fractures in adults is 0.5% of all fractures. The nature of the injury is commonly severe and is often associated with injury to surrounding soft tissue and nerves. Before we discuss the fractures, we have a look at the anatomy of distal part of humerus. [Read more...]
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Fracture of shaft of humerus is very amenable to treatment but a percentage of fractures do not heal. Normal healing of a humeral fracture occurs over 8 to 10 weeks. If the fracture has not achieved union by 3 to 4 months, it can be considered a delayed union. If union does not occur by 6 to 8 months it is called non union of the fracture.
Non unions are two types
Hypertrohic occurs due to increased vascularity which allows abundant callus to form. The callus formed has insufficient stability to prevents union. [Read more...]
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Radial nerve gets injured in 6 to 15% of the fracture humeral shaft. Most of these palsies occur at the time of injury and would be identified at time of first evaluation. Most palsies occur at the time of the injury and are identified at initial evaluation of the fracture
10-20% of radial nerve palsies occur during the course of treatment. [Read more...]
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Closed treatment yields satisfactory outcome for most humeral fractures, specific situations do exist in which better results have been achieved through surgical stabilization.
Methods of Fixation
Compression Plating
This method involves fixing the fracture using a plate and screws. It is quite effective method of fracture fixation but involves quite significant amount of dissection and soft tissue stripping from the bone. and at itmes may cause blood loss. [Read more...]
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An open fracture is one that has an associated wound over it and that wound communicates with fracture hematoma. Open fractures are always a special situation because they demand prompt and aggressive approach.
Presentation
The presentation is with pain, swelling and an associated bleeding wound. In severe cases the fracture fragments may be jutting out. Because, often the skin has been breached, there are higher chances of neurovascular injuries. Therefore all the nerves and vessels should be carefully examined.
The patient should be thoroughly examined to find and rule out other possible injuries. This is especially true for high velocity traumas.
The wound should be inspected for severity and any bleeding vessel should be ligated. The fracture should be splinted in a coaptation splint or U splint after wound has been cleaned and dressed.
The extent of injury determines the number of investigations. A plain anteroposterior and lateral radiograph would serve the purpose in most of the cases.
If there is associated injury in any part of the body, it should be xrayed.
If there is an arterial injury, a doppler ultrasound would be required to confirm and know the level of injury.
The fracture Treatment
The surgeon must perform a thorough debridement of the bone and soft tissues on an emergent basis to decrease the risk of deep infection. Prophylactic antibiotics should be administered.
If the wound is small and clean the fracture can be managed with closed fracture treatment after debridement.
However moderate clean wounds would require fixation external or internal, depending on the condition of wound after debridement.
External fixation usually is reserved for fractures with such severe injury to the soft tissues and profound contamination that complete debridement is not achieved at the initial procedure. Wound care after the initial debridement of any open fracture consists of additional debridements or healing by secondary intention as dictated by the severity of soft tissue damage.
Gunshot fractures
Gunshot fractures constitute a unique type of open fracture. The injuries vary considerably depending on the type of firearm involved. These fractures, especially if caused by high-velocity bullets, result in more frequent and more severe nerve and vessel injury and a more comminuted fracture.
For wounds from low-velocity missiles, minimal debridement of the wound, to include excision of skin edges and removal of superficial fragments of clothing and debris, followed by superficial irrigation, is sufficient to prevent most infections and can be considered for closed fracture treatment or internal fixation.
Shotgun injuries and high-velocity missile wounds, usually result in severe damage to the soft tissue and formal debridement in the operating room followed by fixation, often with an external fixator, is necessary.
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Non operative treatment of fracture of humerus produces very good results but not a feasible choice in many situations.
In following situations, an operative intervention needs to be considered.
Inability to maintain fracture alignment with functional bracing
In many cases, it is not possible to maintain alignment with closed methods. Poor soft tissue strength, comminuted fractures, obesity percluding molding of the cast are some situations. Sometimes the patient refuse to accept closed treatment because of the discomfort attached.
If there is an angulation of 15 degrees in any plane, surgical treatment may be considered. [Read more...]
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