humeral fracture Flashcards
management of radial nerve injury?
- before humeral brace
- after humeral brace
10% radial nerve injury with humeral fracture
Present before brace
- continue brace
- 85% improve by 3 months
- EMG if present at 3 months
Present after brace
- remove brace
- if still present = operate
management of humeral shaft fractures?
Brace
- sarmiento brace - elbow/ shoulder movement
- weekly xrays
FISH trial
- 80% diaphyseal shaft fractures unite
- fractures that unite have good function
- fracture non-union - harder to fix
Operative fixation
Indications
- open
- vascular injury
- unable to obtain/ maintain fracture reduction
- polytrauma/ bilateral humeral shaft fractures
- floating shoulder/ elbow
- neurological/ brachial plexus injury
- intra-articular extension
Options
- im nail vs plate
- plate with DCP large fragment - less shoulder impingement
Holstein-lewis fracture management?
distal humeral fracture with radial nerve injury
- non-op and observe nerve
- operative - fracture fixation and nerve exploration
- LC-DCP compression plate 4.5mm
- plastics
- nerve - repair, graft and late tendon transfer
O’driscoll principles for distal humerus fixation
- pre-contoured locking plate on each column
- every screw through plate
- every screw in a fragment on the other side
- as many screws as possible in the distal fragments
- distal screws engage as many fragments as possible
- screws as long as possible
- interdigitate screws
- plates strong enough to resist fatigue failue
intra-articular distal humerus fracture management and complications
**non-operative **
- bag of bones
- short immobilisation and then early mobilisation
Operative
Dual locking plate fixation
- posterior approach
- identify ulnar nerve & decompress/ transposition - to avoid metalwork rubbing
- olecranon osteotomy - chevron directed distally
- pre-drill 6.5mm partially threaded screw with washer
- reduce articular surface - k wires
- o’driscoll principles
- principles of fixation:
1. anatomical reduction and rigid fixation of articular surgace
2. functional alignment and relative stability of metaphysis and diaphysis
- complications - heterotopic ossification - indomethacin not indicated due to non-union
- aim 30-130deg rom
Total elbow replacement
- semi-constrained - sloppy hinge - due to dysfunctional collaterals
- triceps sparing approach - windows
- no olecranon osteotomy
- 75% survivorship at 2yrs
- Rheumatoid arthritis - best survivorship
- >65yrs better function at 2yrs with TEA
Complications of TEA:
- higher wear and loosening in trauma TEA
- lifting restriction - 5kg
- periprosthetic fracture
- PJI
Hemiarthroplasty
PROFHER trial
PROFHER 1
- all patients
- non-op vs any op
- oxford shoulder score at 2yrs
- no difference
Criticisms
- Predominately 1 and 2 part fractures
- heterogenicity
what are Hertel’s criteria?
Predictors of head ischaemia but not AVN
- > 45 deg angulation
- increasing fracture complexity - head split, more parts
- > 10mm displacement
- <8mm calcar length attached to articular fragment
- disrupted medial hinge
blood supply to the humeral head?
- anterior and posterior humeral circumflex arteries - branches of axillary artery
- posterior humeral circumflex - main BS to humeral head
- arcuate - anterolater branch of AHCA - GT blood supply
NEER classification of proximal humeral fractures
Based on:
- anatomical relationships - GT, LT, surgical neck and head split
- number of parts
proximal humerus management
Non-op
- PROFHER trial - elderly and poor function
- minimal/ undisplaced GT - rexray
ORIF
- >5mm GT displacement - causes impingement/ poor cuff function (Abduction and ER)
- younger patients - 3 and 4 part
- displaced 2 part
Arthroplasty
- hemi for younger patients with unreconstructable head - convertible stems
- RSA - for older patients - unreconstructable tuberosities, poor bone, fracture-dislocation
- primary RSA better than post ORIF
