Orthopedic Care and Consultation
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...]
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...]
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.
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...]
Modern closed treatment methods rely substantially on the effect of gravity to achieve proper position of the fracture.
Hanging Cast
With the elbow bent at 90 degrees, a long arm cast is placed and upper part of the cast is molded carefully to align the humeral fracture. The cast must be lightweight or distraction may occur at the fracture site that may interfere with union of the fracture site. A series of loops are incorporated into the cast at the junction of the middle and distal thirds of the forearm.
After application, the cast is then suspended by a strap around the neck connected to the loops on the cast.
By changing the position at which the strap connects to the loops, the alignment of the fracture can be adjusted.
The arm must remain dependent at all times all the times. The patient should be sleeping in Fowler’s semireclining position, and while sitting, the patient should avoid support under the elbow. Distraction and poor healing is a complication with this technique.
One of the better methods is functional bracing.
U-splinting
This method can be used for temporary or definitive treatment. It involves placement of a well molded plaster slab from the axilla, around the elbow, and over the deltoid with the elbow flexed to 90 degrees. A collar-and-cuff suspension sling supports the forearm. This method has less tendency for distraction as compared to hanging cast.
For definitive treatment it is effective, functional bracing method perform better.
Humeral fracture orthosis
Humeral fracture orthosis is the preferred method of non operative treatment of fracture humer. A rigid, light-weight plastic brace composed of an anterior and posterior shell joined by Velcro straps. A flare extending over the deltoid with an additional strap meant to extend around the thorax may prevent the brace from slipping distally.
A coaptation splint may be applied initially, with placement of the orthosis delayed for 7 to 14 days.
When fitted properly, the splint extends from the axilla medially to a position as far distal as possible without limiting motion of the elbow joint.
Straps help to adjust he brace and prevent from slipping.
In earlsy period of treatment, a collar-and-cuff type of suspension strap connected to the wrist.
The patient should be sleeping in Fowler’s semireclining position, and while sitting, the patient should avoid support under the elbow
As healing progresses, the patient is encouraged to do active range-of-motion exercises of the elbow joint as well as pendulum and circumduction exercises of the shoulder as pain allows.
The position of the fracture fragments must be verified at 1 week and again at 2 weeks after fracture. Radiographs should be checked every 3 to 4 weeks during healing until the fracture is clinically and radiographically united. Bracing should be continued for at least 8 weeks to prevent refracture.
Shaft of humerus fracture can occur in motor vehicle accidents, fall from heights or direct trauma.
The patient presents with extreme pain at the site and skeletal instability. The patient often supports his injured limb with other one to ease out pain. On examination tenderness and swelling is noted. [Read more...]
The shaft of the humerus lies between the upper border of the pectoralis major insertion proximally and the supracondylar ridge distally. This constitutes the middle three fifths of the entire humerus. The anterior portion of the greater tuberosity extends into an anterior ridge that ends at the coronoid fossa distally. The posterior aspect of the greater tuberosity continues distally as a lateral ridge that ends in the lateral supracondylar ridge. The lesser tuberosity melds into a medially located ridge that forms the medial supracondylar ridge distally. [Read more...]
Complications in fractures of proximal humerus are more likely after surgical than after nonoperative fracture care. Therefore a careful postoperative follow-up is necessary to note the complication at the earliest and intervene at the right time
Most common complications associated with fractures of proximal humerus are- [Read more...]
Three Part Fractures
Three part fractures involves a fracture of surgical neck of humerus along with fracture of either greater tuberosity or lesser tuberosity. While surgical neck is quite displaced to miss out, small degree of tuberosity displacement may be easily missed and may require additional radiographic views.
Open reduction and internal fixation is the preferred treatment. Failure of the treatment may lead to hemiarthroplasy i.e. replacement of head component with prosthesis. [Read more...]
Displaced fractures in an older patient with lower demands can be treated with conservative methods. In such cases the patient would even accept higher angulation and if the shoulder is well rehabilitated, the motion of shoulder joint would compensate most of the movements hampered by angulation.
However in young, active patients with higher demands, a surgical procedure would be necessary.
Closed Reduction
The arm is adducted and is flexed 90 degrees. This maneuver relaxes Pectoralis muscle.. A translation force (usually posteriorly and laterally) is applied to reduce the deformity while longitudinal traction is applied. After it is felt that reduction has been achieved a gentle reimpaction is tried.
After the fracture has been reduced immobilization is continued for 4 weeks.
If the fracture is reducible but unstable, percutaneous pins after closed reduction might be used. If a reduction cannot be achieved, open reduction and internal fixation are considered.
Rehabilitation After Surgery
If fixation is good and fracture is stable, early passive range of motion is instituted, including pulley elevation in the scapula plane, external rotation with a stick, pendulum, and hand and elbow range of motion. Progression to full stretches is rapid. Strengthening is added at 6 weeks.
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