Orthopedic TeleconferenceMaharat Nakorn Ratchasima Hospital

Extern Montakarn Deeyai5402123

Patient profile ผปวยหญงไทยค อาย 45 ป ภมลำาเนา อ. โนนสง จงหวดนครราชสมา

Chief complaint ปวดแขนขวา 2.5 ชวโมงกอนมารพ.

Present illness 2.5 ชวโมงกอนมารพ. ผปวยขบรถ

มอเตอรไซคชนรถยนต ลมตนแขนขวา กระแทกพน ปวดบวมตนแขนขวามาก ม

บาดแผลถลอกบรเวณตนแขนขวา มแขน ขวาผดรป ขยบแขนขวาไมได แตยงกระดก

ขอมอได ไมชา ไมมศรษะกระแทกพน จำาเหตการณได ไมสลบ

ไมปวดคอ ไมปวดหลง ไมไดดมสรา

Primary surveyA : can speak, can flex neck, not

tender at posterior midline of neck

B : equal breath sound both lungsC : BP 120/80 mmHg, PR 86 bpmD : E4V5M6, pupils 3 mm RTLBEE : Abrasion wound and

deformity at right upper arm

Secondary surveyA : No allergyM : No current medicationP : No underlying diseaseL : last meal 6 hours agoE : ผปวยขบรถมอเตอรไซคชนกบรถยนตแลวลมแขนขวาลงกระแทกกบพน

Past historyNo Underlying diseaseNo Past surgery

Personal historyNo Drug allergyNo Alcohol drinkingNo Smoking

Physical examinationVital signs : T 37 c, BP 120/80 mmHg,

HR 86 bpm, RR 20 /minHeight 160 cm , Weight 93 kg BMI 36.33General appearance : A middle-aged

Thai woman, obese, good consciousnessHeart&Lung : WNLAbdomen : Soft, not tenderNeuro : E4V5M6, pupils 3 mm RTLBEMotor gr.V all except Rt arm limit due to pain

Radialnerve

Physical examinationNeuro : no wrist drop or fingers dropCan extend wrist and fingers right handSensory – intact both arms and handsNo radial nerve palsy (pre-reduction)Extremity :Right upper arm deformity, abrasion wound and bruise , tender, swelling, Radial pulse 2+ bothCapillary Refilling time <2 secLimit active ROM right shoulder due to painNot tender at shoulder and elbow

InvestigationFilm Right humerus AP, Lateral

Radiographs

Problem listsClose fracture shaft of Right

humerusObesity

ManagementNonoperative 

coaptation splint followed by functional brace 

◦ indicationsindicated in vast majority of humeral shaft fractures Isolated injury Closed fracture Cooperative patient Acceptable alignmentcriteria for acceptable alignment include: • < 20° anterior angulation• < 30° varus/valgus angulation• < 3 cm shortening

ManagementTry conservativeClose reductionImmobilization : On U-slabPain control

ManagementClose reductionneurovascular : intactNo radial nerve palsy (post-reduction)

U-slab

Radiographs

Radiographs (Change U-slab 1)

ManagementBone gap , obesityAdmitPlan surgery

Humeral shaft fracture

Anatomy

Osteology : humeral shaft is cylindricalMuscles

◦insertion for pectoralis major  deltoid  coracobrachialis 

◦origin for  brachialis  triceps  brachioradialis 

Nerve◦radial nerve 

courses along spiral groove  14cm proximal to the lateral epicondyle 20cm proximal to the medial epicondyle

Humeral shaft fractureIncidence3-5% of all fracturesbimodal age distribution

◦young patients with high-energy trauma 

◦elderly, osteopenic patients with low-energy injuries

Pathological anatomyFractures above the deltoid

insertion, the proximal fragment is adducted by pectoralis major.

Fractures below the deltoid insertion, the proximal fragment is abducted by deltoid.

PresentationSymptoms

◦pain◦extremity weakness

Physical exam◦examine overall limb alignment◦preoperative or pre-reduction

neurovascular exam is critical examine and document status of radial

nerve pre and post-reduction

RadiographsAP and lateral

◦be sure to include joint above and below the site of injury 

transthoracic lateral◦may give better appreciation of sagittal

plane deformity traction views

◦may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated

ManagementNonoperative 

coaptation splint followed by functional brace 

◦indications indicated in vast majority of humeral

shaft fractures criteria for acceptable alignment include:  < 20° anterior angulation < 30° varus/valgus angulation < 3 cm shortening

contraindications◦severe soft tissue injury or bone loss◦vascular injury requiring repair◦brachial plexus injury◦Open fracture◦Polytrauma patient◦Additional ipsilateral fracture◦Patient unable to sit or stand◦ Irreducible displacement◦Obesity◦Nerve injury developing during closed treatment

Nerve interposed in fracture radial nerve palsy is NOT an absolute contraindication to functional bracing 

outcomes◦90% union rate 

increased risk with proximal third oblique or spiral fracture 

◦varus angulation is common but rarely has functional or cosmetic sequelae

Operative Gold standard : Plate and screw 

◦absolute indications  open fracture  vascular injury requiring repair brachial plexus injury  ipsilateral forearm fracture (floating

elbow)   compartment syndrome

Operative 

◦relative indications bilateral humerus fracture polytrauma or associated lower extremity

fracture  allows early weight bearing through humerus 

pathologic fractures burns or soft tissue injury that precludes

bracing Obesity or large breast fracture characteristics

distraction at fracture site short oblique or transverse fracture pattern intraarticular extension

ComplicationsEarly :Radial nerve palsyBrachial artery damageLate :MalunionNonunion Joint stiffness

Humeral shaft fractureSurgical cases

Referenceshttp://www.orthobullets.com/

trauma/1016/humeral-shaft-fractures\

AO Principles Of Fracture Management

http://www2.aofoundation.org

THANK YOUFOR YOUR ATTENTION