HUMERUS FRACTURE

INTRODUCTION:
  • The humerus is your upper arm bone between your shoulder and elbow. When your humerus is fractured near or at the ball of your shoulder joint, it is commonly known as a broken shoulder.
  • Fracture of lateral condyle of humerus is seen in age group of 5-15 years
  • Fracture neck Humerus is common in Elderly woman
  • Given the extensive range of motion of the shoulder and elbow, and the minimal effect from minor shortening, a wide range of radiographic malunion can be accepted with little functional deficit
  • The most common elbow injury in children is Extension type of supracondylar fracture of humerus
  • Nerve Innervations:
  1. The radial nerve innervates the triceps, brachioradialis, wrist and finger extensors, and supinator. The extensor carpi radialis longus is a wrist extensor and is innervated by the radial nerve.It related to the posterior aspect of shaft at the spiral groove, hence it is injured in fracture of mid shaft of the humerus and also following careless injection into the triceps muscle.
  2. The biceps muscles are innervated by the musculocutaneous nerve.
  3. The flexor carpi radialis is innervated by the median nerve. 
  4. Ulnar nerve is related to the posterior aspect of medial epicondyle and it is injured in case of fracture of the medial epicondyle.
  5. The axillary nerve is related to the surgical neck of humerus and is damaged in fracture of the surgical neck and in anterior dislocation of the humeral head.
CLINICAL FEATURES:
  • Pain.
  • Deformity.
  • Bruising.
  • Crepitus.
  • Abnormal mobility
  • Swelling.
  • Any neurovascular injury:
  • Nerve involvement differ with the type of fracture.
  1. Anterior interosseous nerve is mostly affected during posterolateral displacement of the distal fragment
  2. Radial nerve is mostly affected with posteromedial displacement
  3. Ulnar nerve is involved in flexion type of supracondylar fracture
  4. Fracture of surgical neck of humerus leads to loss of abduction movement of the corresponding shoulder joint due to injury of Axillary nerve
  5. Tingling sensation and numbness in the little finger with history of fracture in the elbow region 4 years back is suggestive of Lateral condyle fracture humerus
INVESTIGATION:
  • 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.
  • Radiographs
  • CT scan
  • MRI scan
  • Nerve conduction studies
  1. AP and lateral views of the humerus,including the joints below and above the injury.
  • Computed Tomographic (CT) scans of associated intra-articular injuries proximally or distally.
  • MRI for pathological #
TREATMENT:
  • NON OPERATIVE:
  1. Conservative Treatment
  • >90% of humeral shaft fractures heal with nonsurgical management
  • Most treatment begins with application of a coaptation splint or a hanging arm cast followed by placement of a fracture brace
  • Periosteum is responsible for producing the majority of the new bone that will reunite the two fragments
  1. 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 Triangular arm sling.
  • Immobilization by fracture bracing is continued for at least 2 months or until clinical and radiographic evidence of fracture healing is observed.
  • OPERATIVE 
  1. METHODS OF SURGICAL MANAGEMENT
  • Plating
  • Nailing
  • External fixation
  • ANTERIOR APPROACH
  • Incision
  1. Proximal land mark – coracoid process
  2. Distal land mark- anterior to lateral supracondylar ridge
ANTERO LATERAL APPROACH
  • Proximally, the plane lies between the deltoid laterally (axillary nerve) and the pectoralis major medially(medial and lateral pectoral nerves).
  • Distally, the plane lies between the medial fibers of the brachialis (musculocutaneous nerve) medially and the lateral fibers of the brachialis (radial nerve) laterally POSTERIOR APPROACH
  • Position of the patient for the approach to the upper arm in either the (A) lateral or (B) prone position
  • Incision
  • Tip of olecranon distally to postero lateral corner of acromion proximally
  • Incise the deep fascia of the arm in line with the skin incision.
  • Identify the gap between the lateral and long heads of the triceps muscle
COMPLICATIONS:
  1. Injury to the radial nerve.
  2. Nonunion rates are higher when fractures are treated with intramedullary nailing.
  3. Malunion.
  4. Shoulder pain -when fractures are treated with nails and with plates .
  5. Elbow or shoulder stiffness. "Cubitus-valgus" deformity is complication of # Lateral condyle of humerus
  6. Varus Gunstock deformity is due to Supracondylar fracture of humerus 
Exam Question
  • Fracture shaft of humerus damages Radial nerve
  • Fracture of surgical neck of humerus leads to loss of abduction movement of the corresponding shoulder joint due to injury of Axillary nerve
  • Fracture of lateral condyle of humerus is seen in age group of 5-15 years
  • Most common nerve involved in supracondylar fracture of humerus is Anterior Interosseous nerve
  • In supracondylar fracture of the humerus in children Admission to hospital is essential following reduction
  • Displaced fracture of the surgical neck of humerus as well as a fracture of the medial epicondyle of his distal humerus with pain swelling & abnormal motor functions of arm suggest sustained nerve injury causing trouble in Extensor carpi radialis longus action
  • Ulnar nerve is injured in fracture of the medial epicondyle of humerus
  • Periosteum is responsible for producing the majority of the new bone that will reunite the two fragments
  • Fracture neck Humerus is common in Elderly woman
  • Treatment of choice for fracture neck of humerus in a 70 year old male Analgesic with arm sling
  • Hanging cast is used in fracture humerus
  • "Cubitus-valgus" deformity is complication of # Lateral condyle of humerus
  • Tardy ulnar nerve palsy seen in Lateral condyle #humerus
  • Tingling sensation and numbness in the little finger with history of fracture in the elbow region 4 years back is suggestive of Lateral condyle fracture humerus
  • Ideal treatment for a displaced fracture lateral condyle of the humerus is Open reduction and internal fixation
  • The most common injury in a 7 years old child due to fall on outstretched hand is Supracondylar fracture of humerus
  • The most common elbow injury in children is Extension type of supracondylar fracture of humerus 
  • The most common deformity seen in supracondylar fracture of humerus is Varus 
  • Gunstock deformity is due to Supracondylar fracture of humerus
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