A Funny Fracture

Case Study:

A 44 years old male casually strolls into triage saying his right arm dosen’t feel right post altercation with the local law enforcement. What is the injury, and what is the most common complication of this injury?

Humerus fracture

Humeral Shaft Fractures:

  • Humeral shaft fractures commonly occur in the third decade (active young men) and in the seventh decade of life (osteoporotic women), and account for 3% of overall fractures.
  • The most common site for fracture, is in the middle third of the humerus accounting for 60% of humerus fractures.
  • Humeral shaft fractures generally result from two types of mechanisms;
    • A direct blow from a fall or motor vehicle accident typically results in a transverse fractures,
    • An indirect force, such as a fall on an elbow or outstretched arm, will cause an oblique or spiral fracture.
  • 11-16% of midshaft humerus fractures will result in radial nerve damage, making neurovascular assessment paramount.
  • Non-displaced humeral shaft fractures generally heal within 10-12 weeks, with spiral fractures healing faster than transverse fractures.

Classification of Humeral Fractures:

Unfortunately there is no classification scheme to describe humerus fractures, they are traditional described by:

Location – proximal, middle or distal

Type of fracture line – such as transverse, oblique, spiral, comminuted, or segemental

Open or closed status

Complication’s of humerus shaft fractures:

Radial nerve injury is the most common complication of midshaft humerus fractures, caused by either the injury itself or during reduction of the fracture. Radial nerve injury is characterised by wrist drop, and altered sensation in the first dorsal space.

Pathological fractures can occur with minimal trauma in the following:

  • Cancer metastatic to the bone
  • Paget disease
  • Bone cyst

Assessment:

  • Patients generally present with pain and swelling over the area
  • Examination generally reveals shortening, obvious deformity, or abnormal mobility with crepitation may be detected
  • Thoroughly assess for injuries to the brachial artery and radial nerve, and also examine the shoulder and elbow as injuries to these areas are associated with humeral shaft fractures.

 

Emergency Department Management:

Treatment of humeral shaft fractures depends on the degree of displacement and neurovascular injury, fractures not displaying any of these are generally manage conservatively with plaster cast, slings,and orthopaedic follow-up. Fractures that are displaced, angulated, open and with neurovascular injury require prompt orthopaedic review and generally operative management.

Closed Uncomplicated Fractures:

  • Immobilise the affected arm in a sling, and provided analgesia.
  • X-ray: two views are generally enough, (anteroposterior and lateral)
  • Provided adequate analgesia and sedation, for fracture reduction. Remembering to assess the brachial artery and vein, and ulnar, median and radial nerves pre and post-reduction.
  • A functional brace is required such a a hanging or U-shaped plaster cast, with a collar and cuff sling for comfort, traction and support. (The acceptable deformity is 20° anterior/posterior angulation, and 30° valus/vagus deformity. The union rate is usually higher than 90°.)
  • Discharge home with analgesia and referral to orthopaedics for conservative Vs operative management.

Open fracture: “Time to get the orthopod out of the gym and at the bedside”

  • Keep the patient Nil by Mouth
  • Provide analgesia and order X-rays
  • Give ADT, if not had in the past 5-10 years
  • IV antibiotics (as per local guidelines)
  • Cover open wound with povodine-iodine dressing
  • Prepare for theatre, IVC, FBC, U&E, Group and Hold

Medical VS Surgical Management:

Operative intervention is indicated in the following circumstances, and generally requires plate fixation:

  • Inability to maintain alignment of <15° angulation
  • Noncompliance with nonoperative techniques
  • Brachial artery injury (emergency orthopaedic consult)
  • Additional injuries that require a prolonged recumbent position that will not allow dependency traction
  • Associated fractures that require early mobilisation
  • Injuries to the ispilateral brachial plexus. If the brachial plexus is injured, the soft tissue sleeve surrounding the muscles of the arm will loose its stability. Alignment will be difficult to maintain since gravity will distract the ends of the fracture.
  • Segmental fracture, pathologic fracture, open fractures, or bilateral humeral shaft fractures.

References:

Cameron P, Jelinek G, Kelly AM, Murray L, Brown AFT. Textbook of Adult Emergency Medicine (3rd edition), Churchill Livingstone Elsevier 2009.

Lawless, M. (2010). Midshaft Humerus Fractures. emedicine.com

Simon RR, Sherman SC, Koenigsknecht SJ. Emergency Orthopedics — The Extremities (5th edition), McGraw-Hill, 2007.

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