SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez nos Conditions d’utilisation et notre Politique de confidentialité.
SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez notre Politique de confidentialité et nos Conditions d’utilisation pour en savoir plus.
faculty of medicine
Supervisor: Head of department:
Mechanism of injury
3% to 5% of all fractures
Most will heal with appropriate
conservative care, although a limited
number will require surgery for optimal
Current research -- decreasing the
surgical failure rate through
New implants and techniques,
Optimizing the postinjury rehabilitation
Minimizing the duration and magnitude
of remaining disability.
Successful treatment demands a
knowledge of :
Patient Function and Expectations.
High energy trauma is more common in
the young males
Low energy trauma is more common in
the elderly female
AGE AND GENDER SPECIFIC
INCIDENCE OF SHAFT
Proximally, the humerus is roughly
cylindrical in cross section, tapering to a
triangular shape distally.
The medullary canal of the humerus
tapers to an end above the
The humerus is well enveloped in
muscle and soft tissue, hence there is a
good prognosis for healing in the
majority of uncomplicated fractures.
Nutrient artery- enters the bone very
constantly at the junction of M/3- L/3 and
foramina of entry are concentrated in a
small area of the distal half of M/3 on
Radial nerve- it does not travel along the
spiral groove and it lies close to the inferior
lip of spiral groove but not in it
It is only for a short distance near the
lateral supracondylar ridge that the nerve is
direct contact with the humerus and
pierces lateral intermuscular septum
TO SHAFT HUMERUS
MECHANISM OF INJURY
Direct trauma is the most common especially
Indirect trauma such as fall on an outstretched
Fracture pattern depends on stress applied
○ Compressive- proximal or distal humerus
○ Bending- transverse fracture of the shaft
○ Torsional- spiral fracture of the shaft
○ Torsion and bending- oblique fracture usually
associated with a butterfly fragment
• Hematoma forms and provides source of
hemopoieitic cells capable of secreting growth
• Macrophages, neutrophils and platelets release
• this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12
• Fibroblasts and mesenchymal cells migrate to
fracture site and granulation tissue forms around
• Osteoblasts and fibroblasts proliferate
• inhibition of COX-2 (ie NSAIDs) causes repression
of runx-2/osterix, which are critical for differentiation of
• Primary callus forms within two weeks. If the bone
ends are not touching, then bridging soft callus
• Enchondral ossification converts soft callus to hard
callus (woven bone). Medullary callus also
supplements the bridging soft callus
• Type II collagen (cartilage) is produced early in
fracture healing and then followed by type I
collagen (bone) expression
• Amount of callus is inversely proportional to extent
• primary cortical healing occurs with rigid
immobilization (ie. compression plating)
• Begins in middle of repair phase and
continues long after clinical union
• chondrocytes undergo terminal differentiation
• signaling pathways including, indian hedgehog
(Ihh), parathyroid hormone related peptide
(PTHrP), FGF and BMP
• cartilaginous calcification takes place at the
junction between the maturing chondrocytes
and newly forming bone
• multiple factors are expressed including BMPs,
TGF-Betas, IGFs, osteocalcin, collagen I, V and
• subsequently, VEGF production leads to new
• newly formed bone (woven bone) is remodeling
via osteoblastic/osteoclastic activity
Mode of injury
Velocity of injury
Alchoholic abuse, drugs ( prone for
repeated injuries )
Age and sex of the patient ( osteoporosis )
Previous treatment( massages)
Previous bone pathology ( path # )
Any neurovascular injury
Skin integrity .
Examine the shoulder
and elbow joints and
the forearm, hand,
and clavicle for
Check the function of
the median, ulnar, and,
particularly, the radial
Assess for the
presence of the radial
AP and lateral views plain x-ray of the
including the joints below and above the
CT scanning may also be indicated in
the rare situation where a significant
rotational abnormality exists. A CT scan
through the humeral condyles distally and
the humeral head proximally can provide
exact rotational alignment
MRI for pathological cause
AO CLASSIFICATION OF THE
HUMERUS FRACTURE SHAFT
○ Radial Nerve injury = Wrist Drop =
Inability of extend wrist, fingers, thumb,
Loss of sensation over dorsal web
space of 1st digit
Neuropraxia at time of injury will often
Nerve palsy after manipulation or
splinting is due to nerve entrapment
and must be immediately explored by
○ Ulnar and Median nerve injury (less
○ Brachial Artery Injury
Goal of treatment is to
union with acceptable
Undisplaced closed simple
Displaced closed fractures with
less than 20 anterior angulation, 30
varus/ valgus angulation
Short oblique fractures
FRACTURES Conservative Treatment
>90% of humeral shaft fractures
heal with nonsurgical
○ 20degrees of anterior
angulation, 30 degrees of varus
angulation and up to 3 cm of
shortening are acceptable
○ Most treatment begins with
application of a coaptation splint
or a hanging arm cast followed
by placement of a fracture brace
Fractures are splinted with a hanging splint,
which is from the axilla, under the elbow,
postioned to the top of the shoulder .
The U splint.
The splinted extremity is supported by a
Immobilization by fracture bracing is
continued for at least 2 months or until
clinical and radiographic evidence of fracture
healing is observed.
A closed method of treating fractures
based on the belief that continuing
function while a fracture is uniting ,
encourages osteogenesis, promotes the
healing of tissues and prevents the
development of joint stiffness, thus
Not merely a technique but constitute a
positive attitude towards fracture
The end to end bone contact is not
required for bony union and that rigid
immobilization of the fracture fragment
and immobilization of the joints above
and below a fracture as well as
prolonged rest are detrimental to
It complements rather than replaces
other forms of treatment.
Lack of co-operation by the pt.
Bed-ridden & mentally incompetent pts.
Deficient sensibility of the limb [D.M with
When the brace cannot fitted closely
Fractures of both bones forearm when
reduction is difficult.
TIME TO APPLY
Not at the time of injury.
Regular casts, time to correct any angular
or rotational deformity.
Compound # es , application to be
Assess the # , when pain and swelling
1. Minor movts at # site should be pain free
2. Any deformity should disappear once
deforming forces are removed
3. Reasonable resistance to telescoping.
Fractures in which reduction is unable to be
achieved or maintained.
Fractures with nerve injuries after reduction
Intra articular extension injury.
Impending pathologic fractures.
Multiple extremity fractures.
Plate osteosynthesis remains the
criterion standard of fixation of humeral
high union rate, low complication rate,
and a rapid return to function
Complications are infrequent and
include radial nerve palsy, infection and
Rush pins or Enders nails, while effective
in many cases with simple fracture
patterns, had significant drawbacks such
as poor or nonexistent axial or rotational
With the newer generation of nails came a
number of locking mechanisms distally
including interference fits from expandable
bolts (Seidel nail) or ridged fins (Trueflex
nail), or interlocking screws (Russell-Taylor
nail, Synthes nail, Biomet nail)
Retrograde Technique-best suited for
fractures in the middle and distal thirds
of the humerus
External fixation is cumbersome for the
humerus and the complication rate is
AS IT MAY accentuate the risk of delayed
union and malunion, resulting in
significant rates of pin tract irritation,
infection, and pin breakage.
PLATE OR NAIL?
Soft tissue –
Lower union rate?
WHAT IS THE ROLE FOR
Particularly with a very proximal fracture line
COMPLICATIONS OF OPERATIVE
Injury to the radial nerve.
Nonunion rates are higher when fractures
are treated with intramedullary nailing.
Shoulder pain -when fractures are treated
with nails and with plates .
Elbow or shoulder stiffness.