Humeral Shaft Fracture.

1. 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

2. 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.

3. Diagnosis. Signs and Symptoms- • Pain. • Deformity. • Bruising. • Crepitus. • Swelling.

4. 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.

5. Tests Imaging: AP and lateral views of the humerus, including the joints below and above the injury.

6. 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.

7. 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.

8. 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.

10. 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.

11. 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.

12. Intercondylar Elbow Fracture.

13. 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.

15. 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.

16. Diagnosis: Signs and Symptoms: • Severe pain, swelling, and a decreased ability or inability to move the extremity at the elbow.

17. 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).

18. 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.

20. Tests • Radiography: • AP and lateral views of the elbow and humerus. • CT. • MRI.

21. 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.

22. 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.

23. Complications. • Loss of ROM. • Nonunion. • Malunion. • Post traumatic arthritis.

24. Complicatons… • Loss of fixation. • Osteonecrosis. • Neurovascular injury. • Ulnar neuropathy. • Infection. • Heterotopic ossification.