orthopedic teleconference mnrh ext montakarn_humeral shaft fracture
TRANSCRIPT
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Orthopedic TeleconferenceMaharat Nakorn Ratchasima Hospital
Extern Montakarn Deeyai5402123
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Patient profile ผปวยหญงไทยค อาย 45 ป ภมลำาเนา อ. โนนสง จงหวดนครราชสมา
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Chief complaint ปวดแขนขวา 2.5 ชวโมงกอนมารพ.
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Present illness 2.5 ชวโมงกอนมารพ. ผปวยขบรถ
มอเตอรไซคชนรถยนต ลมตนแขนขวา กระแทกพน ปวดบวมตนแขนขวามาก ม
บาดแผลถลอกบรเวณตนแขนขวา มแขน ขวาผดรป ขยบแขนขวาไมได แตยงกระดก
ขอมอได ไมชา ไมมศรษะกระแทกพน จำาเหตการณได ไมสลบ
ไมปวดคอ ไมปวดหลง ไมไดดมสรา
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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
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Secondary surveyA : No allergyM : No current medicationP : No underlying diseaseL : last meal 6 hours agoE : ผปวยขบรถมอเตอรไซคชนกบรถยนตแลวลมแขนขวาลงกระแทกกบพน
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Past historyNo Underlying diseaseNo Past surgery
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Personal historyNo Drug allergyNo Alcohol drinkingNo Smoking
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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
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Radialnerve
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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
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InvestigationFilm Right humerus AP, Lateral
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Radiographs
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Problem listsClose fracture shaft of Right
humerusObesity
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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
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ManagementTry conservativeClose reductionImmobilization : On U-slabPain control
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ManagementClose reductionneurovascular : intactNo radial nerve palsy (post-reduction)
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U-slab
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Radiographs
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Radiographs (Change U-slab 1)
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ManagementBone gap , obesityAdmitPlan surgery
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Humeral shaft fracture
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Anatomy
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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
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Humeral shaft fractureIncidence3-5% of all fracturesbimodal age distribution
◦young patients with high-energy trauma
◦elderly, osteopenic patients with low-energy injuries
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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.
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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
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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
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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
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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
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outcomes◦90% union rate
increased risk with proximal third oblique or spiral fracture
◦varus angulation is common but rarely has functional or cosmetic sequelae
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Operative Gold standard : Plate and screw
◦absolute indications open fracture vascular injury requiring repair brachial plexus injury ipsilateral forearm fracture (floating
elbow) compartment syndrome
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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
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ComplicationsEarly :Radial nerve palsyBrachial artery damageLate :MalunionNonunion Joint stiffness
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Humeral shaft fractureSurgical cases
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Referenceshttp://www.orthobullets.com/
trauma/1016/humeral-shaft-fractures\
AO Principles Of Fracture Management
http://www2.aofoundation.org
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THANK YOUFOR YOUR ATTENTION