Proximal fracture # of the &

humersfracture of humeral shaft

ANATOMY OF HUMERUS

VASCULAR SUPPLY

NERVE SUPPLY

SITES

Common))-surgical neck

-anatomical neck

-both tubercities

CLINICAL PICTURE:

# History

# Symptoms Upper extremity held closed to the chest by

contra lat.hand.

Pain,swelling,crepitus, painfull

# signs:

look

palpation

moove

(RANGE OF THE MOTION( ROM

FLEXION 180

ABDUCTION 180

ADDUCTION 75

EXTENTION 50

ETERNAL ROTATION 65

INTERNAL ROTATION 90

CLASSIFICATION

KOCHERS;-based on different anatomic levels.

Anatomic neck

Epiphyseal region

Surgical neck.

Did not included #s at multiple level, degree of displacement, dislocations, mechanism.

Watson Jones-contusion crack #s.

Impacted #s.

Impacted abducted#s.

Codmann”s based on epiphyseal region-identifies four possible #s GT ,LT ,anatomic head, shaft

CLASSIFICATION:

NEER’S CLASSIFICATION

(5-TYPE) THE MOST COMMONLY USED CLASSIFICATION SYSTEM FOR PROXIMAL

HUMERAL

HEAD FRACTURES WAS DEVELOPED IN 1970 BY DR CHARLES NEER.

THE BASIS OF THE SYSTEM ACCORDING TO

1-DISPLACEMENT

2-ANATOMICAL LINES OF EPIPHYSEAL UNION,

INCLUDING THE

HUMERAL HEAD, GREATER TUBEROSITY

, LESSER TUBEROSITY, AND THE SHAFT (SURGICAL NECK).

NEER’S CLASSIFICATION

Displacement defined as greater than 45 degrees of

angulation or 1 cm of separation.

1-One part fracture – No displacement or angulation less than 45 degrees or seperationless than 1cm2-Two part fracture – Displacement of one fragment3-Three part fracture – Displacement of twoindividual fragments from remaining humerus4-Four part fracture – Displacement of all foursegments5-there is dislocation (anterior or posterior ) regardless number of displaced segment

DIAGNOSIS:

CLINICAL PRESENTATION :

> history of trauma

> pain during movement> Large bruise in the upper part of the arm

> Swelling and delayed ecchymosis >Tenderness to palpation> clear deformity

> Signs of axillary nerve or brachial plexus injury

> Crepitus indicative of fracture instability

RADIOLOGY

X-ray1- AP views

2- lat views.

3-axillary views(. Axillary andscapular-lateral views should always be obtained, toexclude dislocation of the shoulder)).

MRI

• CT Scan– articular fractures

• impression

• head split

– glenoid fractures

– assess tuberosity

displacement for

operative decision

making

24.16 X-rays of proximal humeral fractures Classification is all very well,

but x-rays are more difficult to interpret than

line drawings. (a) Two-part fracture. (b) Three-part fracture involving the neck

and the greater tuberosity. (c) Four-part

fracture. (1=shaft of humerus; 2=head of humerus; 3=greater tuberosity;

4=lesser tuberosity). (d) X-ray showing fracturedislocation

of the shoulder

CT SCAN

The advent of 3D CT

reconstruction

has helped to reduce

the degree of inter-

and intra-observer

error, enabling better

planning of treatment

than in the past. CT with three-dimensional reconstruction

Advanced imaging provides a much clearer

picture of the injury, allowing better pre-operative

planning.

TREATMENT

1-One part fracture These comprise the vast

majority. They need no

treatment apart from a week

or two period of rest with the

arm in a sling until the pain

subsides, and then gentle

passive movements of the shoulder. Once the fracture has

united (usually after 6 weeks), active exercises are encouraged;

the hand is, of course, actively exercised from the start.

2-TWO PART FRACTURE

STABLE Closed reduction then sling for about

four weeks or until the fracture feels stable and the

x-ray shows some signs of

healing. Elbow and hand exercises are encouraged

throughout this period; shoulder exercises are

commenced at about four weeks.

if the fracture cannot be reduced closed or if the

fracture is very unstable after closed reduction,

then external fixation is Required Options

.include percutaneous pins, bone sutures,

intramedullary pins

3-THREE PART FRACTURE

4-Four part fracture

5-there is dislocation

they are extremely difficult to reduce closed.

In active individuals this injury is best

managed by open reduction and internal

fixation.

Proximal humerus fractures – treatment

(a) Three-part fracture, treated by

(b) locked nail fixation.

(c) Four-part fracture fixed with a locked plate; the intra-operative

picture

(d) shows how the plate was positioned

INTRA-MEDULLARY K WIRE FIXATION

COMPLICATIONS:

Early complication:

*Rotator cuff syndrom

* Vascular injury .

* Nerve injury.

* Biceps tendon

rupture

* Thoracic injury

late complication:

•* stiffness of the

shoulder.

* malunion.

* infection

* Avascular

necrosis.

HUMERUS SHAFT FRACTURES

THE HUMERUS IS THE LONG,

TUBULAR BONE THAT MAKES UP THE

UPPER ARM. THE HUMERAL SHAFT IS

THE MIDDLE PORTION OF THE BONE

WITH THE SHOULDER JOINT AT THE

TOP END AND THE ELBOW JOINT AT

THE BOTTOM. ONE OF THE NERVES

THAT TRAVELS FROM THE NECK TO

THE HAND, THE RADIAL NERVE,

SPIRALS AROUND THE HUMERAL

SHAFT LYING VERY CLOSE TO THE

BONE ABOUT TWO THIRDS OF THE

WAY TO THE ELBOW. FRACTURES OF

THE HUMERAL SHAFT ARE IMPORTANT

BECAUSE THEY CAN INJURE THE

RADIAL NERVE RESULTING IN THE

INABILITY TO EXTEND (BEND) THE

WRIST AND FINGERS BACKWARDS

ANATOMY

AO/OTA CLASSIFICATION

CLINICAL:

DIAGNOSIS

TETMENT

INDICATIONS FOR ORIF -

INJURY FACTORS

Failed closed treatment

Loss of reduction

Poor patient tolerance/compliance

(Open fractures)

Vascular injury/

Change in neuro exam (radial n.)

Floating elbow

COMPLICATIONS OF HUMERAL

SHAFT FRACTURES

Radial nerve injury

Vascular injury

Nonunion

COMLICATION