The Management of Humeral Shaft Fractures. David Chapple MSc FRCS

Transcription

1 The Management of Humeral Shaft Fractures David Chapple MSc FRCS

2 SHAFT NOT Proximal Distal

3 Anything New? Anatomy Classifications MOI and Clinical aspects Management options Management indications Management Complications

4 Anatomy three borders Anterior Medial lateral three surfaces anterolateral anteromedial posterior

5 The Humerus Anterior aspect Head necks tuberosities < > & Deltoid sulcus, bicipital groove supracondylar ridges epicondyles Coronoid fossa trochlea/capitulum Supracondylar process

6 Anterior Muscle attachments supraspinatus subscapularis Pectoralis major latissimus dorsi Teres Major triceps medial head deltoid coracobrachialis Brachialis Brachioradialis Extensor Carpi radialis longus Pronator Teres Common Origins

7 The Humerus Posterior aspect Head Necks greater tuberosity Sulcus for radial nerve supracondylar ridges epicondyles Olecranon fossa Trochlear

8 The Humerus Posterior Muscle attachments infraspinatus teres minor Triceps lateral head Deltoid Brachialis triceps Medial Head Anconeus

9 Coracobrachialis Muculocutaneous Biceps Pectoralis major Median nerve Brachial artery Basilic vein Deltoid Ulnar nerve Profunda artery Radial nerve Lateral head of Triceps Long head of Triceps

10 Biceps Median nerve Brachial artery Basilic vein Ulnar nerve Muculocutaneous Brachialis Radial nerve Profunda artery

11 Biceps Median nerve Brachial artery Muculocutaneous Brachialis Radial nerve Basilic vein Ulnar nerve

12 Cross-section Upper section cylindrical Lower section comma shaped flattened AP IM device diameter and length posterior flat surface plates

13 Ossification 8 ossification centres shaft appears at middle of bone and grows towards ends at 8th week of intrauterine life

14 Radial Nerve between long and medial heads of triceps Whitson JBJS the radial nerve transversed the triceps at such a depth that it was nowhere in contact with the humerus...as the supracondylar ridge was approached, the radial nerve was

15 Whitson JBJS It was apparent that the separation of the triceps into three heads was artificial and that the medial and lateral heads were in reality a single muscle group traversed by a nerve and an artery. similar to posterior interosseous passes through the supinator. The Spiral Groove in every specimen gave origin to the uppermost fibres of the brachialis,

16

17

18 Whitson JBJS 1954 Admit clinical importance of these observations is not great. Explain that the muscle fibres of triceps and brachialis offer some protection from sharp bone edges.

19 Peripheral Nerve Injury Unit Mr Birch on Whitson s findings.. Not his experience, felt that the nerve had a close relationship to the bone for a considerable distance. possible explanation could be that the cadavers had been lying supine and so compression deformation occurred which distorted the true in vivo anatomical position of the nerve

20 Blood Supply MainNutrient artery to humerus Profunda brachii Gives nutrient deltoid posterior descending radial collateral

21 Blood supply Laing 1956 JBJS 38-A main nutrient artery enters the humerus at the junction of the middle and distal third, or in the lower part of the middle third. Middle third fractures damage this vessel higher rate of delayed union Klenerman JBJS 48-B

22 Humeral Shaft fractures Humeral shaft fractures 3% all all fractures Christensen Acta Chir Scand 1967 Humeral Shaft fractures 1% of all fractures Emmett and Breck 11,000 #

23 Shaft Fractures Classifications anatomical management based comparison useless

24 Classification No universally accepted system for humeral shaft fractures anatomical proximal shaft, middle shaft, or distal shaft relative to muscle attachments pectoralis major, deltoid Character description

25

26 Classification Fracture comminution A-simple B-butterfly fragments C-comminuted

27 Classification Associated soft tissue injury periarticular involvement nerve injury vascular injury intrinsic condition of the bone

28 Mechanism of Injury Klenerman experimental # s Compression proximal or distal # s bending produce transverse # s Torsional forces give spiral # s Bending combined with torsion produces an oblique # with a butterfly fragment

29 Mechanism of Injury Direct and Indirect trauma Falls(FOOSH) RTA s Direct blow to arm Extreme muscle contraction ball and javelin throwing arm wrestling

30 Arm Wrestling Ogawa and Ui 1997 J Trauma 42-2, Tokyo 30 cases all spiral # s 23% radial nerve palsy occurred when trying to change from a static to dynamic phase shoulder rotators:- intense rotational force

31 Andy

32 Signs and Symptoms Pain, swelling and deformity motion and crepitus associated injuries vascular neural secondary injury due to swelling particularly the multiple trauma or unconscious pt.

33 Imaging Plain AP and 90 0 lateral move whole patient not limb include joints associated dislocations, # s into joints traction radiographs for comminuted # s Comparison films for planning Bone scan for pathological # s

34 Goals of treatment Establish union with an acceptable humeral alignment and restore patients to their previous level of function

35 Mal-Union Klenerman JBJS B Concluded: The degree of radiological deformity that can be accepted is far greater than in other long bones anterior bowing of 20 0 varus of 30 0 before clinically obvious

36 Methods of Treatment NUMEROUS OPTIONS Closed Open Good to excellent results have been reported with all methods Patient characteristics Fracture characteristics

37 Management CONSERVATIVE

38 Most humeral shaft fractures can be managed nonoperatively

39 Closed Management Methods Greater than 90% expected union rate Hanging arm cast U-shaped brachial splint Velpeau dressing Abduction humeral splint/shoulder spica cast skeletal traction functional brace

40 Hanging arm cast Gravity traction for reduction arm and cast must be dependant at all times Problems RoM of shoulder and elbow impaired fracture distraction and hinging avoid transverse fractures Indications midshaft spiral or oblique with shortening

41 Hanging arm cast Lightweight elbow at 90 0, forearm in neutral at least 2cm proximal to fracture distal forearm loops dorsal, volar and neutral must hang free regular Follow-up

42 Hanging arm cast Apex anterior angulation shortening of the sling Apex posterior angulation lengthening the sling

43 Hanging arm cast Valgus(Apex medial) angulation using the volar loop Varus(Apex lateral) angulation using the dorsal loop

44 U-shaped splint with C/C Indicated for acute management of # s with minimal shortening slipping of the cast is common poor patient tolerance often exchanged for a functional brace at 2/52

45 Thoracobrachial immmobilization Velpeau shoulder dressing inexpensive, comfortable and easily applied and adjusted minimally displaced # s axillary pad early pendulum exercises

46 Traction rarely indicated, as operative management has same indications

47 Functional bracing Sarmiento 1977JBJS 59-A effects fracture reduction through soft tissue compression allows good shoulder and elbow movement after one week until eight weeks

48 Functional bracing Sarmiento et al 1990, 72-B suggests well proven method for mid shaft # s presents a series of distal shaft # s which had good results from functional bracing after a period of hanging cast treatment

49 Functional bracing Sarmiento et al 1990, 72-B control of angulation showed average of 9 o varus in 81% of patients (n65) high incidence of radial nerve damage (18%) all were resolved or improving residual stiffness of shoulder and elbow minimal loss of RoM and good functional results 96% went onto union

50 Functional bracing Balfour et al 1982 JBJS 64-A, LA California adapted Sarmiento s brace proper fit swelling of the forearm discomfort shoulder flare with sling support

51 Functional bracing Balfour et al 1982 JBJS 64-A Stress that the brace requires the influence of gravity on the dependent arm of an ambulatory patient all except in one patient the fracture united average of 9 0 varus and 6 0 AP bowing RoM elbow and shoulder excellent

52 Functional bracing Camden et al 1992 Injury 23-4 comparison of U-slab with functional brace no difference for healing time and alignment better RoM at elbow Zagorski 1988 JBJS 70-A can be used to treat proximal shaft fractures have less angulation

53 Operative treatment INDICATIONS

54 INTERVENTION INDICATIONS It s Begging for a nail It will be Good fun to plate it? I need the experience. Why don t we try that new nail from? That rep had a delightful, intelligent and generous personality so why don t we use.?

55 Indications for operative management Open fracture associated vascular injury floating elbow segmental fracture pathological fracture Bilateral humeral fractures polytrauma patients radial nerve palsy neurological deficiency after penetrating injury fractures with unacceptable alignment

56 Indications for operative Open fracture management require debridement fracture stabilisation afterwards to reduce infection Not absolute Sarmiento shown cases where no debridement of low velocity gun shot fractures and non operative management of fracture

57 Indications for operative management Associated vascular injury internal or external fixation prior or post repair If repaired then non-operative management is contra-indicated fracture motion jeopardise the repair

58 Associated vascular injury Arteriography controversial clinical assessment can detect 50% time delay Urgent exploration and repair intraluminal shunts end to end or grafts

59 Indications for operative management Floating Elbow Rogers et al 1984 JBJS 66-A, Houston retrospective study higher incidence of non-union of the humerus in injuries without ORIF ORIF of both forearm and humerus indicated

60 Floating Elbow Rogers et al 1984 JBJS 66-A, Houston 19 patients traffic elbow, sideswipe injury severe injury with poor outcome amputation, arthrodesis, non-union and poor elbow function Two groups elbow involvement

61 Floating Elbow Rogers et al 1984 JBJS 66-A, Houston Group I no elbow involvement all mid-shaft humerus 5 open, 6 closed closed did better than open conservatively managed had more nonunions all forearm fractures healed

62 Indications for operative management Segmental fractures Foster et al 1985 JBJS 67-A multi centre trial segmental humeral fractures have a high rate of non-unions if treated nonoperatively at one or both the fracture sites

63 Indications for operative management Pathological fractures internal fixation Enders nails, locked nails, no reaming cement augmentation patient comfort pain relief, regain function daily activities, independence

64 Indications for operative management Bilateral humeral shaft fractures improves patients ability to perform daily tasks and personal toilet

65 Indications for operative management Multiple trauma patient advantages pain relief protect adjacent soft tissues fracture disease help nursing and rehab Brumback et al 1986 JBJS 68-A, Baltimore

66 Multiple trauma patient Brumback et al 1986 JBJS 68-A, Baltimore 58 patients with multiple trauma Shock Trauma Center 2000 patients annually most scooped and run by helicopter retrospective ISS, average 23.5

67 Multiple trauma patient Brumback et al 1986 JBJS 68-A, Baltimore stabilise long bone fractures 95% were stabilised within 1st 24 hrs. Used Rush rods and Enders nails semi-rigid fixation minimal violation of fracture haematoma no reaming

68 Multiple trauma patient Brumback et al 1986 JBJS 68-A Results 5 deaths alignment 98% <15 0 varus RoM dependant on insertion point epicondylar approach had poor results 55% had devices removed

69 Multiple fractures Jensen and Rasmussen 1995 Injury 26(4), Denmark showed poor results for multiple injured patients with bracing Neer score small study

70 Indications for operative Radial nerve palsy management mandatory if occurs after closed manipulation and reduction Packer et al 1972 CORR 88 Shergill and Birch 1997 open wounds arterial injury

71 Radial nerve palsy Commonly middle third # s higher rate in distal third # s Holstein-Lewis fracture oblique, distal third

72 Radial Nerve palsy Triceps sparing Supination lost in the extended elbow flexed allows biceps wrist drop unable to extend MCPj DIP/PIPj s extend via intrinsics

73 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A Retrospective 15 yrs, 23 patients, all with CLOSED treatment of # humerus with a Radial Nerve Palsy 6% of all humeral shaft # s (11% lit) 13 male, 10 female, (1mth-63yrs)

74 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A mainly severe trauma 3 segmental, 5 oblique 4 comminuted 5 transverse 7 spiral

75 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A 3 open, 21 closed 2 prox. 1/3 5 middle 1/3 14 distal 1/3 3 segmental

76 # and Radial palsy Conservative methods of treatment sugar-tong 8 shoulder spica 5 hanging cast 5 palm to axilla cast 3 olecranon traction 2 posterior splint 1

77 # and Radial palsy Extent of palsy complete M & S (n9) partial M (n6) partial M & S (n3) complete M, intact S (n3) isolated S (n1) partial lesions distributed through out length of humerus

78 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A All patients in this series had a complete return of radial nerve function.

79 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A Distal 1/3 fractures have a high incidence of palsies vast majority have a lesion in continuity clinical or EMG improvement should be apparent by 14 to 16 weeks if not then explore and repair

80 Treatment of Radial Neuropathy Associated with Fractures of the Humerus Pollock et al, San Francisco, 1981, JBJS 63-A Time course of recovery complete loss first signs of recovery between 6 days and seven months average seven weeks Full recovery one day to one year, average fifteen weeks

81 Early Exploration Literature review n95 12% found nerve lacerated Nerve recoveries 70% non-recovery 20% lost to follow-up 10%

82 Delayed exploration Literature review n53 3 to 6 months delay divided nerves found 19% entrapped in callus 6% reasonable recovery

83 Delayed exploration Advantages over early time for recovery neurapraxia, axonotmesis evaluation of nerve lesion degree, tinel sign, neurophysiology fracture united results of late repair reported similar to early

84 Indications for operative management Neurological loss after penetrating injury almost an absolute indication similar to other areas of the body primary repair of nerve, requires stabilisation tag and refer after stabilisation

85 Indications for operative management Failure of conservative management failure to maintain acceptable alignment obese, pendulous breasts 20 0 AP 30 0 varus thin individuals, less tolerant 3cm of shortening malrotation well tolerated

86 Obese Failure of conservative Jensen et al 1995 Injury 26-4, Denmark Sarmiento brace compared with nonobese Neer scores lower 45% non-unions pendulous breasts management

87 What Operation? Screws screws and plates cerclage wires External fixation Intra medullary fixation

88 Approaches Anterolateral supine, incision lateral border of biceps, proximal fractures Anterior coracoid to deltoid insertion then lateral border of biceps limited distally Posterior excellent exposure, limited proximally, 8cm from acromium lateral and long heads of triceps, medial head incised

89 Open reduction and internal Disadvantages infection non-union requiring re-operation injury to the radial nerve initially or on removal of metal work prolonged disability fixation

90 Open reduction and internal fixation Advantages early mobilization of limb good joint function good pain relief exploration of radial nerve repair prognosis for recovery bone grafting

91 Open reduction and internal fixation Bell et al 1985 JBJS 67-B, Sunnybrook Griend et al 1986 JBJS 68-A, Mississipi 36 patients had AO plating indications multiple injuries open fractures retrospective

92 AO plating Griend et al 1986 JBJS 68-A, Mississipi..comparisons may not be entirely valid.. multiple methods of fixation uncomplicated fractures cf. Problem fractures anterolateral approach 4.5mm DCP bone grafted if bone loss or comminution

93 AO plating Griend et al 1986 JBJS 68-A, Mississipi One non-union no deep infection, two superficial infections one (transient)post operative radial nerve palsy radial nerve palsy 9 explored, 1 lacerated, 4 contused, 4 normal 6 resolved good RoM, except in severe vascular or neural defect

94 AO plating Griend et al 1986 JBJS 68-A, Mississipi Conclude safe if nerve exposed and protected high rates of union good function only where non-operative management not indicated

95 External fixation Indications open fractures extensive soft tissue injury fractures over burns infected non-unions neurovascular injury

96 External fixation Complications pin tract infections impalement muscle, tendon neurovascular non-union advise direct visual placement of pins

97

98 advise direct visual placement of pins Humerus Musculocutaneous Ulnar nerve Brachial artery Median nerve Brachial veins Radial nerve

99 Intramedullary fixation General advantages mechanical axis less likely to fail by fatigue load-sharing axial gliding osseus alignment less stress shielding less refracture after nail removal biological benefits

100 Intramedullary fixation Flexible intramedullary nails Enders nails, Hackenthal, Rush rods not rigid, # can shorten and rotate entrance point Interlocked nails numerous on the market to ream or not, antegrade insertion can cause impingement

101 Intramedullary fixation Antegrade high rates of shoulder stiffness subacromial impingement Retrograde no shoulder problems can get elbow restriction of extension Epicondylar portal p poor results

102 Locking nails Habernek and Orthner 1991 JBJS 73-B, Austria 19 Seidel nails good results no non-unions, infections, radial nerve palsies only fractures in the middle 60% of the humerus secondary radial palsies lower 5th of shaft # s should not be nailed mal-alignment

103 Locking nails Court-Brown et al 1992 JBJS 74-B, Edinburgh 30 Seidel nails poor results (87% complication rate) technical difficulties failed distal (30%)locking nail protrusion (40%) poor shoulder function did not advocate its use

104 Rehabilitation RoM of hand and wrist started immediately RoM of elbow and shoulder as pain allows shoulder to avoid postfracture stiffness elbow ACTIVE exercises only myositis ossificans post # healing strengthening exercises isometric to isotonic

105 Management of humeral shaft fractures Summary Vast majority can be managed closed There are absolute indications for open management You can find supporting evidence for each type of open method Patient and fracture characteristics dictate management

106 Thank you