FRACTURE HUMERUS SHAFT IN ADULTS

TEAM D AUDITORTHOPAEDIC DEPARTMENT

KHOULA HOSPITAL

By Supervised byDr. AHMED AZMY Dr. GHASSAN AL YASSARI

SPECIAL THANKS

Dr. Ahmed Al-Gazzar

3-5 % of all fractures

Bimodal distribution

Males in 3rd decade

Females in 7th decade

Overview

Coaptation splint followed by functional brace 

Klenerman found that:-• indicated in vast majority of humeral shaft fractures• criteria for acceptable alignment includes

- anterior angulation < 20 * - varus/valgus angulation <30* - shortening < 3cm

• 90% union rate • increased risk of non union with proximal third oblique or spiral fractures   • varus angulation is common but rarely has functional or cosmetic sequelae

Management

**Klenerman L: Fractures of the shaft of the humerus. J Bone Joint Surg Br 1966; 48(1):105-111.

I. Conservative:-

In the largest clinical analysis to date, Sarmiento et al

reported on 922 patients treated with a functional brace for both closed and open humeral shaft fractures:-

98% of all closed injuries and 94% of all open fractures healed.

Malunion, described as angular deformity greater than 16 degree in any plane, 13% and 19%.

Only 2% of patients reported loss of shoulder motion

**Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

**Sarmiento A, Zagorski J, Zych G, Latta L, Capps C. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-86.

ABSOLUTE INDICATIONS :-

1. open fracture 2. vascular injury requiring repair3. brachial plexus injury 4. ipsilateral forearm fracture (floating elbow)  5. compartment syndrome

RELATIVE INDICATIONS:-

1. Bilateral humerus fracture2. Polytrauma or ASSOCIATED lower extremity fracture 3. Pathological fractures4. Burns or soft tissue injury 5. Long oblique or spiral proximal fracture6. Intraarticular extension

II. Operative: A. ORIF

RELATIVE INDICATIONS:-

1. pathologic fractures2. segmental fractures3. severe osteoporotic bone4. overlying skin compromise limits open approach 5. polytrauma

B. Intramedullary nailing (IMN)

AUDIT

PLAN

Define the objective

plan data collection

Outcome of the fracture

Risk factors of associated injuries with ORIF , specially the iatrogenic radial nerve injury.

PLAN

DO Carry out th

e plan

Collect the data

Begin analysis o

f the data

Materials and methods

We have analysed 57 consecutive fractures of the humeral shaft treated over two-years period from July 2012 to July 2014

The fractures were defined by their type “ closed versus open and by AO morphology

The data of the study is collected from khoula hospital electronic system

Study

Complete the analysis of

dataCompare data

We have reviewed 57 patients with fracture humerus shaft

-43

-14

55 cases with primary ORIF and 2 cases with revision fixation

Male : Female is 3:1

Age ranges from 16 – 72 years

Average age 33.2

Analysis of the data

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OLD

MID

DLE

Youn

g

16 – 40 yrs

42 cases

41-60 yrs12 cases

61- 723 CASES

Age groups of the patients

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Interval between the incidence of injury and surgery in primary cases ranged from 0 day to 20 weeks.

The 2 revision cases one done after 21 weeks due to re-fracture and the other done after 3 years due to non union.

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Types of Fractures

Closed fractures • 54 cases

Open fractures• 3 Cases

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A1 --- 6 cases A2 --- 6 cases A3 --- 19 cases

B1 --- 8 cases B2 --- 7 cases B3 --- 3 cases

C1 type --- 8 cases

Classification of fractures (AO)

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Associated Injuries

Radial nerve injury

8 cases

Brachial artery injury

2 cases

Multiple nerve injury

1 case

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6 cases4 primary fractures2 revision fractures

51 cases

ORIFby

plating

ORIFby

plating + bone graft

Operative Technique

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Posterior 31 cases Anterolateral 20

cases Anterior 2 cases

Lateral 2 cases

Medial 1 case Anteromedial

1 case

Approaches for surgery

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Medical officer 1 case

Resident 1 case

Sr.consultant2 cases

specialist25 cases

Sr.specialist28 cases

Level of Surgeon

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Supervision of surgery

supervised by Sr. consultant • 2 cases

Supervised by Sr. Specialist• 15 cases

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Supervision of surgery

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Complications of the fracture

9 cases with radial nerve injury 19 %

8 cases initial isolated Radial nerve injury

1 case with multiple upper limb nerve injury

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Complications of surgery (ORIF)

1 case Varus

angulation

1 caseDelayed union

1 case

Deep SSI

2 cases

Non union

2 cases

Iatrogenic radial n.

palsy

1.75 %

1.75 %

1.75 %

3.5%

3.5 %

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Iatrogenic Radial Nerve Palsy

Iatrogenic Radial Nerve Palsy

NON UNION

Deep SSI

VARUS ANGULATION

9 cases of initial radial nerve injury:-

5 cases recovered completely 2 cases recovered partially 2 cases didn’t recover

There was no proper documentation of the radial nerve deficit regarding sensory and motor

Major morbidity of the fracture was the radial nerve injury

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2 cases of Iatrogenic radial nerve injury didn’t recover.

Both cases were operated through anterolateral approach

Both cases were operated by specialist and supervised by Sr. Specialist .

One case had shown radial nerve degeneration by EMG study done after 1 year of injury .

The other case was shown to the clinic only up to 4 months after surgery with no recovery.

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Injury to the radial nerve with neuropraxia is the most frequently encountered nerve deficit associated with humeral fractures and is found in up to 18% of all patients.

spontaneous recovery over a period of 4 months occurs in 70% to 92% of patients managed with observation; therefore, its presence is not an indication for open management and nerve exploration.

Shao Y, Harwood P, Grotz M, Limb D, Giannoudis P. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005;87:1647-52. doi:10.1302/0301 620X.87B12.16132

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Compare DataKhoula

(57)USA

(213)Singapore

(53)Iatrogenic Radial n.

palsy3.5% 8% 5.7%

Non union 3.5% 9% 3.7%

malunion 1.7% 1% ---

Deep SSI 1.7% 5% 3.7%**Operative versus Nonoperative Treatment of Humeral Shaft Fractures: A Retrospective Review of

213 Patients from Two Level I Trauma Centers Fri., Southeastern Fracture Consortium; Michael C. Tucker, MD1 (10-Southeastern Fracture Consortium research grant);  William T. Obremskey, MD2 (5A-Medtronic, Osteogenix; 7-Synthes); Mark Floyd, BS3 (n);  Anthony Denard, BS2 (n); 10/9/09 Upper Extremity, Paper #49, 11:45 am OTA-2009.

**Surgical Results of Open Reduction and Plating of Humeral Shaft Fractures. H T Hee,*MBBS, FRCS (Edin), FRCS (Glas), BY Low,**FAMS, FRCS (Edin), FRCS (Glas), H F See,***FAMS, MBBS, FRCS (Glas). Ann Acad Med Singapore 1998; 27:772-5.

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The surgical approach used in the analysed cases with iatrogenic radial nerve palsy was anterolateral approach That means the injury to the nerve could happened due to over traction during reduction or during putting the hardware.

Surgeries done by specialist level with no supervision had a complication rate of 20 %

Conclusion

Proper assessment of the neurologic deficit at the time of injury , pre operative and postoperative is of greatest importance.

Plan the proper approach prior to surgery according to type of fracture , plan of fixation , associated injuries , skills of the operating surgeon.

Where is the nerve

Length of observation for radial n. palsy remains a subject of debate.

During the observation period: Brace & aggressive ROM physiotherapy.

Recommendations

ACTPlan the next

cycle

Charnley stated, “It is perhaps the easiest of the major long bones to

treat by conservative methods ”.

TAKE HOME MESSAGE

Thank you