HUMERAL FRACTURE

FARIZ MUNANDAR C111 05 048 ADVISOR DR. SYARIF HIDAYATULLAH DR. YOGA KURNIAWAN SUPERVISOR

DR. JAINAL ARIFIN, M. KES, SP.OT

IDENTITY

Name : Tn. G

Age
Sex

: 17 years old
: Male

Date of admittance : January, 21 - 2013

Reg : 58-99-17

ANAMNESIS
Chief

complaint : pain at the left arm Suffered Since 5 hours ago before admitted to Wahidin Sudirohusodo hospital due to traffic accident. Mechanism of trauma : Patient was riding a motorcycle and suddenly there was car turn to left without sign lamp. So the patient hit the car. History of unconscious (-), nausea (-), vomit (-) This patient left handed

LOCAL STATUS
Left Arm Region I : Deformity(+), swelling(+), Hematoma(+), Wound (-) P : Tenderness (+) ROM : Active and passive motion of shoulder and elbow joints are limited due to pain NVD : Sensibility is good, radial artery is palpable, Capillary refill time < 2, extend elbow is limited due to pain, extend thumb (+) and extend wrist joint (+)

Clinical Picture (1)

Clinical Picture (2)

LABORATORY FINDINGS
WBC RBC HGB HCT PLT CT BT HBs Ag PT APTT 8,3 x 103 /uL 5,32 x 106 /uL 14,4 g/dL 46,7 % 236 x 103 /uL 730 300 negative 11.5 23.2

RADIOLOGY FINDINGS

RESUME
A

17 years old male. Chief complaint pain at the left arm suffered since 5 hours ago before admitted to hospital due to traffic accident. Left arm shows sign of deformity, hematoma, tenderness. Active and passive motion of the shoulder and elbow joints are limited due to pain. No neurologic deficit. Radiographic showed fracture 1/3 middle left humeral, Butterfly type.

DIAGNOSIS

Close Fracture 1/3 middle left humerus, Butterfly type

TREATMENT

Analgetic

Apply U-Slab
Plan for ORIF

DISCUSSION

EPIDEMIOLOGY

Common injury, representing 3% to 5% of all fractures.

Brinker et al
mean age 28.9 years 13.1 per 100,000 persons per year.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006 Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. 2006

ANATOMY (1)

Putz R. and Pabs R. Sobotta Atlas of Human Anatomy. Volume 1 Head, Neck, Upper Limb. 2006

ANATOMY (2)

The humeral shaft extends from the pectoralis major insertion to the supracondylar ridge. In this interval, the cross-sectional shape changes from cylindric to narrow in the anteroposterior direction. The vascular supply to the humeral diaphysis arises from perforating branches of the brachial artery, with the main nutrient artery entering the medial humerus distal to the midshaft. The musculotendinous attachments of the humerus result in characteristic fracture displacements.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

ANATOMY (3)

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

ANATOMY (4)
ANTERIOR SURFACE POSTERIOR SURFACE

ANATOMY (5)

ANATOMI (6)

Anterior compartments: muscle : brachialis, biceps brachii, dan coracobrachialis. Neurovascular : brachial A., musculocutaneus N., media N., and radial N. Posterior compartments: muscle : triceps brachii. Neurovascular : radial N. and ulnar N.

Thompson JC. Arm. In: Netters Concise Orthopaedic Anatomy. Second edition.

CLASSIFICATION

Open vs Closed.

Location : proximal third, middle third,

distal third.

Degree: nondisplaced, displaced.

Direction and character: transverse, oblique, spiral, segmental, comminuted.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

MECHANISM OF INJURY (1)

Direct (most common): Direct trauma to the arm from a blow or motor vehicle accident results in transverse or comminuted fractures. Indirect: A fall on an outstretched arm results in spiral or oblique fractures, especially in elderly patients. Uncommonly, throwing injuries with extreme muscular contraction have been reported to cause humeral shaft fractures.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

MECHANISM OF INJURY (2)

Fracture pattern depends on the type of force applied: Compressive: proximal or distal humeral fractures Bending: transverse fractures of the humeral shaft Torsional: spiral fractures of the humeral shaft Torsional and bending: oblique fracture, often accompanied by a butterfly fragment

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

POSITION OF FRACTURE FRAGMENTS

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

CLINICAL EVALUATION
pain, swelling, deformity, and shortening neurovascular examination

radial nerve function compartment pressures

instability Soft tissue abrasions and minor lacerations must be differentiated from open fractures.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

RADIOLOGICAL EXAMINATION (1)

The site of the fracture, its line (transverse, spiral or comminuted) and any displacement are readily seen.

The possibility that the fracture may be pathological should be remembered.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

RADIOLOGICAL EXAMINATION (2)

Closed transverse fracture with moderate displacement.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

TREATMENT (1)

Humeral Fracture Non Operative

Operative

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (2)

Applying a U-slab of plaster (after a few days in a shoulder-to-wrist hanging cast) is usually adequate. Ready-made braces are simpler and more comfortable, though not suitable for all cases. These conservative methods demand careful supervision if excessive angulation and malunion are to be prevented.
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

TREATMENT (3)

NON OPERATIVE
Hanging cast: This utilizes dependency traction by the weight of the cast and arm to effect fracture reduction.
Indications include displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns. Transverse or short oblique fractures represent relative contraindications because of the potential for distraction and healing complications.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (4)

NON OPERATIVE
Coaptation splint: This utilizes dependency traction to effect fracture reduction, but with greater stabilization and less distraction than a hanging arm cast. The forearm is suspended in a collar and cuff.

It is indicated for the acute treatment of humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns that may displace with a hanging arm cast. Disadvantages include irritation of the patients Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006 axilla and the potential for splint slippage.

TREATMENT (5)

NON OPERATIVE
Thoracobrachial immobilization (Velpeau dressing): This is used in elderly patients or children who are unable to tolerate other methods of treatment and in whom comfort is the primary concern.
It is indicated for minimally displaced or nondisplaced fractures that do not require reduction.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (5)

NON OPERATIVE
Shoulder spica cast: This has limited application, because operative management is typically performed for the same indications.
It is indicated when the fracture pattern necessitates significant abduction and external rotation of the upper extremity. Disadvantages include difficulty of cast application, cast weight and bulkiness, skin irritation, patient discomfort, and inconvenient upper extremity position.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (6)
NON

OPERATIVE

Functional bracing: This utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints.
It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a hanging arm cast or coaptation splint and swelling has subsided. Contraindications include massive soft tissue injury, an unreliable patient, and an inability to Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006 obtain or maintain acceptable fracture

TREATMENT (7)
OPERATIVE Indications are: Bilateral humeral Multiple trauma fractures Inadequate closed Open fracture reduction or Neurologic loss unacceptable following malunion penetrating trauma Pathologic fracture Radial nerve palsy Associated vascular after fracture injury manipulation Floating elbow (controversial) Segmental fracture Nonunion J.; Intraarticular Koval, Kenneth Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006 extension

TREATMENT (8)

OPERATIVE
SURGICAL TECHNIQUES :
OPEN REDUCTION AND PLATE FIXATION

INTRAMEDULLARY FIXATION
EXTERNAL FIXATION

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (9)

Fractured humerus and other methods of fixation. (a,b) Compression plating, and (c,d,e) external fixation.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

Postoperative Rehabilitation
ROM exercises for the hand and wrist should be started immediately after surgery; shoulder and elbow range of motion should be instituted as pain subsides.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

COMPLICATION (1)
Vascular Injury
EARLY Nerve Injury Delayed Union and Non-union LATE Joint Stiffness

Thank You

PLEXUS BRACHIALIS

Radial Nerve

triceps

brachior adialis

supina tor
Extensor M. of the finger

Extensor M. of the wirst

Open fr. antibiotik : sefalosporin gol. I (