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:
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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- • 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 hangingsplint, 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 -2weeks), 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.
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 high-velocity 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. • Loss of ROM. • Nonunion. • Malunion. • Post traumatic arthritis.
Complicatons… • Loss of fixation. • Osteonecrosis. • Neurovascular injury. • Ulnar neuropathy. • Infection. • Heterotopic ossification.