Fifty six years old lady injured her arm in a motor vehicle accident and xray revealed spiral fracture of humerus.

Spiral Fracture of Lower Third HumerusThe Fracture Operated and Fixed Using Narrow DCP and Interfragmentary screw

The fracture was treated by open reduction and internal fixation using locking compression plate and interfragmentary screw.

The Fracture Operated and Fixed Using Narrow locking Compression Plate and Interfragmentary screw

There was postoperative radial nerve palsy that recovered within 3 months.

The fracture healed within 6-8 weeks.

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1. Postoperative Film Of Femoral Fracture In Poliotic Limb Treated With Locked Compression Plate And Interfragmentary Screw
2. Postoperative Xray of Oblique Subtrochanteric Fracture of Femur With Dynamic Hip Screw and Interfragmentary Screw
3. Supracondylar Femur Fracture Fixed With Femoral Condylar Plate In A Patient WIth Dynamic Hip Screw In Situ For Previous Intertrochanteric Fracture

Broken Knail Humerus Fracture Bullet Pellets

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1. Implant Failure – Xray of Broken Assembly of Dynamic Hip Screw In Intertrochanteric Fracture
2. Xray Of Bullet Injury In Shoulder Region
3. Broken Needle In Foot Of 7 Years Old Child

Uniting Fracture of Shaft Of Humerus

The xray was taken between change of cast at 3 weeks. Callus formation is visible. The fracture eventually united well.

Related posts:

1. Xray of Uniting Fracture of Shaft of Humerus Treated Nonoperatively
2. Xray of United Fracture of Lateral Condyle Of Humerus
3. Xray of Comminuted Fracture of Shaft In Humerus With Previously Operated Surgical Neck Fracture Fixed With PHILOS

The xray showed an atrophic non union of distal third of humerus. The fracture was treated with open reduction and internal fixation using dynamic compression plate, and bone grafting

Related posts:

1. Fracture Humerus Upper End – Anteroposterior Xray
2. Anteroposterior Xray of Fracture Distal End Radius With Fracture Of Ulnar Styloid
3. Xray of Comminuted Fracture of Upper End of Humerus

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.

Related posts:

1. Xray Of Comminuted Fracture of Upper End Of Tibia
2. Fracture Humerus Upper End – Anteroposterior Xray
3. Fracture Of Upper End Of Humerus With Subluxation Of Humeral Head – Anteroposterior Xray

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.

Due to non biological stresses and forces the implant itself may loosen where it is fixed to the bone. Earliest sign of loosening is the radiolucent line that appears around the implant.

Loosening may lead to failure of the fixation.

If bone has not united till the time of failure, non union may result.

Following xrays are of 38 years old female who had been operated for fracture shaft of humerus about 6 months back.

She complained of pain in the arm for past two months. AP and lateral view of arm were done and revealed following.

Anteroposterior view above shows radiolucent area around the screws [marked with arrow on one screw] and there appears a lack of  union.

The lateral view revealed an area of radiolucency (black line) almost all around the plate signifying that the plate itself was also loose.

The non union is very evident on lateral view.

The patient treated with bone grafting and intelock nailing of the humerus.

Related posts:

1. AP and Lateral Xrays of Fracture Capitellum and Medial Epicondyle Humerus Fixed With Screws
2. Xray of Fracture Shaft of Humerus With Failed Implant
3. Spiral Fracture of Humerus Fixed With Interfragmentary Screw and Locking Compression Plate

Fracture Humerus Showing Callus Formation

It may be noted that most of humerus shaft fractures heal well on conservative treatment.

Related posts:

1. Xray Of Uniting Fracture Humerus On Conservative Treatment
2. Xray of Comminuted Fracture of Shaft In Humerus With Previously Operated Surgical Neck Fracture Fixed With PHILOS
3. Xray of Fracture Shaft of Humerus With Failed Implant

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.

Related posts:

1. Xray of Uniting Fracture of Shaft of Humerus Treated Nonoperatively
2. Xray of Comminuted Fracture of Shaft In Humerus With Previously Operated Surgical Neck Fracture Fixed With PHILOS
3. Fracture Humerus Fixed Plates and Screws With Radiological Signs of Implant Loosening

Anatomy of Distal Humerus

Humerus bone widens distally in the coronal plane to a maximum between the medial and lateral epicondyles and narrows from proximal to distal in the sagittal dimension  before its distal most articular segment expands and juts anteriorly.

This forms kind of lateral and medial column which diverge diverging medial and lateral columns. At their most distal point, they are joined by the “tie arch,” consisting of the articular segment—the trochlea and the capitellum.

The capitellum itself is the most distal portion of the lateral column and the trochlea is intermediate between it and the distal end of the medial column.

The fracture typically occurs  when there is a force applied to upper limb when the joint is flexed more than 90 degrees.

Clinical Presentation

Patients with a distal humeral fracture present with pain and swelling of the distal arm and elbow. Displaced fractures may cause a deformity and  painful attempted movements.

The patient should be given an above elbow splint after thorough examination of limb including neurovascular examination and xrays.

Radiography

A good quality  anteroposterior and lateral projection surfice for the purpose of diagnosis making. These xrays should be obtained  while maintaining gentle longitudinal traction with inclusion of the elbow joint on the film.

Xrays without traction are not that useful { as xrays in splints} for accurate diagnosis, for classifying the fracture, and for formal preoperative planning

If there is an additional injury present, investigations might be needed accordingly. For example, arteriogram for arterial injury.

Fracture classification

Ao/OTA classificationn is the most widely used classification used .

• A-type
  Fracture is nonarticular.
• B Type
  A fracture of the B type is partially articular. A part of the articular segment remains in continuity with the shaft
• C Type
  Fractures are articular, but have no articular fragments remaining in continuity with the shaft

Type C is further divided into subtypes 1

• C1: T or Y fractures
• C2: Articular fracture is simple, but the nonarticular supracondylar area is segmental or comminuted
• C3: Articular segment is segmental or comminuted.

Treatment

Displaced distal humeral fractures are  managed by open reduction and stable internal fixation. The aim is to achieve anatomis reduction of the fragments and to facilitate  a painless elbow motion and maximize the likelihood of full functional restoration.

However there could be circumstances where patient is not suitable to get operative treatment. For exmple debilitated patients, patients with other ailments that make them a poor canditdate for anaesthesia, problem with local sites such as degloving injuries

Such cases need to be treated non operatively.

Method

Most common method of treatment includes passing a transolecronon pin through proximal ulna for traction on to the fracture and once fracture becomes sticky, a cast/functional cast/cast brace or  hinged brace may be applied.

Mobilization is begun as dictated and subsequently advanced as determined by patient comfort.

Another method, used in case of comminuted fractures  includes  the placement of the arm in a collar and cuff  with as much flexion as possible. The elbow is left hanging free, allowing gravity to exert a ligamentotaxic effect. Hand and finger motion and shoulder pendulum exercises are begin after 10th day. Gradual elbow motion is started as guided by patient comfort. By 6 weeks,  the collar and cuff are discontinued and more intensive exercises are begun.

Related posts:

1. Non Operative Treatment of Fractures of Humerus
2. Proximal Humerus Fractures – Treatment of Displaced Surgical Neck Fractures
3. Xray of Non Union Of Fracture of Distal End Of Humerus

Non unions are two types

• Hypertrophic
• Atrophic

Hypertrohic occurs due to increased vascularity which allows abundant callus to form. The callus formed has insufficient stability to prevents union.

In atrophic non unions, the fracture has inadequate blood supply and prevents callus.

Operative treatment methods have higher rate of non union as compared to non operative method. Apart from this there are various factors that increase the chance whether a patient would develop non union. These factors are

• Inadequate immobilization
• Distraction at the fracture site resulting in a gap between fractured surfaces
• Energy of the injury
• Open fractures

Treatment

Treatment of the non union aims at removal of the cause if known, fixation of the fracture with surgery and bone grafting to augment the healing process.

The bone can be fixed by plating or intramedullary nailing. The graft is usually taken from iliac crest.

In caes of non union and osteoporosis, it might be difficult to attain the fixation. In such cases an additional procedure like filling he cabity with cement or augumentation with fibula may be needed

Related posts:

1. Xray of Non Union Of Fracture of Distal End Of Humerus
2. Xray of Uniting Fracture of Shaft of Humerus Treated Nonoperatively
3. Fracture of Shaft of Humerus- When To Operate?