| ID | 248 |
|---|---|
| Name | FRACTURE SHAFT OF THE HUMERUS |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnosis: X-ray shaft of humerus (b/v): The site of the fracture, its line (transverse, spiral or comminuted) and any displacement are readily seen. The possibility of pathological fracture should be remembered. |
| Investigations | |
| Management | |
| Introduction | Fracture shaft of humerus is as common as 1% of all fractures Mechanism of injury: A fall on the hand may twist the humerus, causing a spiral fracture. A fall on the elbow with the arm abducted, results in an oblique or transverse fracture. A direct blow to the arm causes either a transverse or comminuted fracture. |
| History | |
| Etiology | |
| Clinical Features | Clinical features: 1. Pain in the arm. 2. Bruised and swollen area on the arm. 3. Radial nerve function may be affected. |
| Preventions | |
| Treatment | Treatment: Conservative treatment: In most of the cases of fracture humerus, treatment is conservative and heal readily (90-100%). They require neither perfect reduction nor immobilization; the weight of the arm with an external cast is usually enough to pull the fragments into alignment. A ‘hanging cast’ is applied from shoulder to wrist with the elbow flexed 90°. This cast may be replaced after 2-3 weeks by a short (shoulder to elbow) cast or a functional polypropylene brace which is worn for a further 6 weeks. The wrist and fingers should be exercised from the beginning. Pendulum exercises of the shoulder begin within a week, but active abduction is postponed until the fracture has united. Surgical treatment-I ndications for surgery: 1. When satisfactory position or alignment couldn’t be achieved by conservative treatment. 2. Severe multiple injuries (including vascular injury). 3. An open fracture. 4. Segmental fractures. 5. Displaced intra-articular extension of the fracture. 6. A pathological fracture. 7. A ‘floating elbow’- simultaneous unstable humeral and forearm fractures. 8. Radial nerve palsy after manipulation. 9. Non-union. 10.Neurological disorder- epilepsy, perkinsonism. Fixation can be achieved with either- - a compression plate and screws; - an interlocking intramedullary nail or semi-flexible pins; or - an external fixator. Plating permits excellent reduction and fixation, and has the added advantage that it does not interfere with shoulder or elbow function. However, it requires wide dissection and the radial nerve must be protected. Antegrade nailing is performed with a rigid interlocking nail inserted through the rotator cuff under fluoroscopic control. It requires minimum dissection but has the disadvantage that it causes rotator cuff problems in a significant proportion. If this happens, or if the nail backs out and the fracture has not yet united, exchange nailing and bone grafting of the fracture may be needed; alternatively, the nail can be replaced by an external fixator. Retrograde nailing with multiple flexible rods avoids these problems, but it is more difficult, less widely applicable and less secure in controlling rotation at the fracture site. External fixation may be the best option for high energy segmental fractures and open fractures. It is also a useful salvage procedure after failed intramedullary nailing. |
| Complications | Complications: Early complications: Vascular injury- if there are signs of vascular insufficiency in the limb, brachial artery damage must be excluded. Nerve injury- radial nerve palsy (wrist drop and paralysis of the metacarpophalangeal extensors) may occur with shaft fractures, particularly oblique fractures at the junction of the middle and distal thirds of the bone. The wrist and hand must be regularly exercised through a full passive range of movement to preserve joint motion until the nerve recovers. If there is no sign of recovery by 12 weeks, the nerve should be explored by surgery. Late complications: Delayed union and non-union: Transverse fractures sometimes take months to unite, specially if excessive traction has been used (a hanging cast must not be too heavy). Intramedullary nailing is likely to cause delayed union, but if rigid fixation can be maintained (if necessary by exchange nailing) the rate of nonunion can probably be kept below 10%. The treatment of non-union is operative. Joint stiffness: Joint stiffness is a common complication. It can be minimized by early activity & exercise. |
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