FRACTURES OF HUMERAL DIAPHYSIS

ANATOMY

INCIDENCE Humerus shaft fractures make up 5% of all

fractures. 

Sixty percent of the fractures are non-displaced or minimally displaced, and therefore, can be managed non-operatively.

Associated injuries are common in patients with osteoporosis.

Sometimes nerve and rarely vascular injuries are associated with humeral shaft fractures. 

HISTORY History of a benign fall in which

the elbow is either struck directly or axially loaded in a fall onto an outstretched hand.

Motor vehicle and sport injuries account for most humeral injuries for younger males.

Pathologic fractures of the humerus may occur with minimal trauma.

Mechanism of Injury

Direct trauma is the most common especially MVA

Indirect trauma such as fall on an outstretched hand

Fracture pattern depends on stress applied▪ Compressive- proximal or distal humerus▪ Bending- transverse fracture of the shaft▪ Torsional- spiral fracture of the shaft▪ Torsion and bending- oblique fracture usually

associated with a butterfly fragment

CLASSIFICATION Morphological classification:Traditionally, humeral shaft fractures are

described according to their level(proximal, middle and

distal thirds) and pattern. – Transverse – Oblique – Spiral – Segmental – Comminuted

AO CLASSIFICATION (Muller)

Bone = humerus = 1 Segment = diaphysis = 2

Groups = A/B/C where A: Simple fracture B: Wedge fracture C: Complex fracture

Subgroups: A1: Simple fracture, spiral A2: Simple fracture, oblique (≥30o) A3: Simple fracture, transverse (<30o) B1: Wedge fracture, spiral wedge B2: Wedge fracture, bending wedge B3: Wedge fracture, fragmented wedge C1: Complex fracture, spiral C2: Complex fracture, segmental C3: Complex fracture, irregular

AO coding

A simple transverse fracture of lower shaft is coded as: 1.2. A 3.3 1= Humerus 2= Diaphysis A= Simple fracture 3= transverse 3= midshaft

Clinical evaluation

Thorough history and physical

Patients typically present with pain, swelling, and deformity of the upper arm

Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

CLINICAL EVALUATION

Diaphyseal fracture patients present with a painful deformed arm. (The direction of displacement of the fractured fragment depends on the level of the fracture. An injury distal to the deltoid insertion causes abduction of the proximal, and adduction of the distal fragment. It is reverse in fractures proximal to deltoid insertion).

Associated with a radial nerve palsy. Usually, the radial nerve palsy is reversible.

Crepitus may be observed. Shortening of the arm suggests displacement. With all humerus fractures, ensure strong radial

and ulnar pulses.

Holstein-Lewis Fractures

Distal 1/3 fractures May entrap or lacerate radial nerve as the

fracture passes through the intermuscular septum

RADIOLOGICAL EVALUATION

Radiographic evaluation AP and lateral views of the humerus Traction radiographs may be indicated

for hard to classify secondary to severe displacement or a lot of comminution.

FRACTURE PATTERNS

FRACTURE PATTERNS

TREATMENT

ATLS

FIRST AID Rest Reassurance Analgesia

DEFINITIVE TRATMENT

DEFINITIVE TREATMENT

Depends on:

Age of patient Fracture pattern Associated co-morbidities Polytrauma Associated complications

DEFINITIVE TREATMENT

TYPES: Conservative Interventional

O.R.I.F EXTERNAL FIXATION RECONSTRUCTION▪ Vascularized fibula▪ Bone grafting▪ Ilizrov / distraction osteosynthesis /

distraction osteogenesis.

Conservative Treatment

Goal of treatment is to establish union with acceptable alignment

>90% of humeral shaft fractures heal with nonsurgical management▪ 20 degrees of anterior angulation,

30 degrees of varus angulation and up to 3 cm of shortening are acceptable

▪ Most treatment begins with application of a coaptation splint or a hanging arm cast followed by placement of a fracture brace

Sling Method

This method utilizes the GRAVITY for treatment

A long arm cast is applied and the supporting sling is kept as far towards the wrist as possible.

Gravity pulls the arm down because of the weight of the plaster and aligns the fragments which then tend to unite in good alignment

Periodic X-rays are necessary to check fracture alignment.

Operative Treatment

▪ Indications for operative treatment include:▪ inadequate reduction, ▪ nonunion, ▪ associated injuries, ▪ open fractures, ▪ segmental fractures, ▪ associated vascular or nerve injuries

Careful prospective planning is essential. The risks of a neurovascular injury, delayed or non-union and other associated problems should be discussed with the patient

Methods of operative interventions

Open reduction and internal fixation The fracture site is exposed, fragments reduced and

fixed with a dynamic compression plate (DCP) and screws. Interlocking Intramedullary nail An ‘ante grade’ or a ‘retrograde’ nail is introduced into

the medullary cavity of the humerus after closed reduction of the fracture. The nail is then locked proximally and distally to achieve rotational stability. This requires image intensification.

External fixation This method of treatment may be used in open or

multiple fractures. Percutaneous pins are threaded into the bone and then held together by an external frame

Open Reduction Internal Fixation

Open reduction with internal fixation may be indicated when: (1) satisfactory position and alignment cannot be achieved by conservative

measures, (2) associated injuries in the extremity require early mobilization, (3) a fracture is segmental, (4) a fracture is pathological, (5) fractures are associated with major vascular injuries (6) a spiral fracture of the distal humerus is of the type described by

Holstein and Lewis, in which radial nerve palsy develops after manipulation or application of a cast or splint ,

(7) when treatment of associated injuries makes bed rest necessary, and (8) Severe neurological disorders, such as uncontrolled parkinsonism, that

make compliance with closed methods impossible may also be an

indication

Open Reduction Internal Fixation

Open Reduction Internal Fixation

INTERLOCKING NAILING

INTERLOCKING NAILING

EX Fix

Used in Gustillo II and onwards Fracture reduction should be as best

as possible Min 2 SS in each fragment Avoid radial nerve Uni-planar Ilizrov Cleanliness

Complications

Malunion Nonunion Radial nerve palsy Infection / iatrogenic osteomyelitis Painful scar Restricted elbow function

QUESTIONS ?

ARSALAN