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Fracture of the humerus

Proximal Humeral Fracture

Epidemiology

  • Common in older patients with osteoporosis; females more affected
  • Locations – surgical neck, anatomic neck, greater tuberosity, lesser tuberosity

Etiology

  • Low energy falls in elderly, osteoporotic patients
  • High energy falls in young patients
  • Risk factors – osteoporosis, diabetes, epilepsy, female gender
  • Associated conditions – axillary n. injury

Anatomy

Osteology
    • Anatomic neck – represents old epiphyseal plate
    • Surgical neck – more often involved in fractures than anatomic neck
  • Muscles
    • Pectoralis major – displaces shaft anteriorly and medially
    • Supraspinatus, infraspinatus, teres minor – externally rotate greater tuberosity
    • Subscapularis – internally rotates less tuberosity
  • Ligaments
    • Coracohumeral – attaches to coracoids process and greater tuberosity
    • SGHL, MGHL, IGHL
  •    Blood supply
    • Axillary artery → anterior humeral circumflex a. → arcuate artery (supplies greater tuberosity)
    • Axillary artery → posterior humeral circumflex a. (supplies humeral head)

Pathophysiology

  • Can lead to humeral head ischemia if vascularity of the articular segment is compromised

Classification

  • AO/OTA classification
    • Organises fractures into 3 groups based on – fracture location, status of surgical neck, presence/absence of dislocation
    • Types
      • A – extra-articular, unifocal
      • B – extra-articular, bifocal
      • C – articular, involves anatomic neck
  • Neer classification – based on anatomic relationship of 4 segments (considered a separate part if displaced >1cm)
    • Greater tuberosity
    • Lesser tuberosity
    • Articular surface
    • Shaft

Clinical features

  • Pain, swelling
  • Decreased range of motion
  • Extensive ecchymoses of chest, arm, forearm
  • Decreased sensation on lateral shoulder – axillary n. injury

Diagnosis

  • X-ray – cortical thickness; pseudosubluxation (due to blood in the capsule)
  • CT – for pre-operative planning
  • MRI – for associated rotator cuff injury

Treatment

  • Sling and physiotherapy
  • Closed reduction percutaneous pinning (CRPP)
  • ORIF – if greater tuberosity is displaced >5mm
  • Intramedullary nailing
  • Arthroplasty

Distal Humerus Fracture

Epidemiology

  • Most common in young males and older females
  • Distal intercondylar fracture is most common location

Etiology

  • High energy trauma – motor vehicle accident (in younger patients)
  • Low energy falls in the elderly

Anatomy

  • Osteology
    • Trochlea – articulates with trochlear notch on ulna
    • Capitellum – articulates with proximal radius
  • Muscles
    • Common flexor tendon – originates from medial epicondyle
    • Common extensor tendon – originates from the lateral epicondyle
  • Ligaments
    • Medial collateral ligament – originates from distal medial epicondyle
    • Lateral collateral ligament – originates from distal lateral epicondyle
  • Nerves
    • Ulnar nerve – resides in cubital tunnel
    • Radial nerve – resides in radial sulcus

Pathophysiology

  • The position of the elbow determines the type of fracture
  • If the elbow is flexed <90o – leads to transcolumnar fracture
  • If the elbow is flexed >90o – leads to intercondylar fracture
    • Leads to intercondylar fracture

Classification

  • AO/OTA classification
    • Types
      • A – extra-articular (supracondylar)
      • B – intra-articular, single column fractured (partial articular)
      • C – intra-articular, both columns fractured (complete articular)
  • Milch classification – for single column fractures
  • Jupiter classification – for two-column fractures

Clinical features

  • Elbow pain and swelling
  • Instability
  • Decreased pulses – can indicate brachial artery injury
  • Weakness/paraesthesias – can indicate nerve injury (radial, ulnar, median nerves)

Diagnosis

  • X-ray
  • CT – for surgical planning

Treatment

  • Cast immobilisation
  • CRPP
  • ORIF
  • Total elbow arthroplasty

Humeral Shaft Fracture

Epidemiology

  • Bimodal age distribution
    • Young patients with high-energy trauma
    • Elderly patients with low-energy trauma

Anatomy

  • Osteology
    • Humeral shaft is cylindrical, distally becomes more triangular
  • Muscles
    • Insertions – pectoralis major, deltoid, coracobrachialis
    • Origins – brachialis, triceps, brachioradialis
  • Nerves
    • Radial nerve – courses along radial sulcus

Classification

  • OTA classification
    • Types – A (simple); B (wedge); C (complex)
  • Based on location – proximal, middle (most common) or distal third
  • Holstein-Lewis fracture – a spiral fracture of the distal one third shaft is commonly associated with neuropraxia of the radial nerve

Clinical features

  • Pain, extremity weakness
  • Limb is in varus

Diagnosis

  • X-ray

Treatment

  • Coaptation splint followed by brace
  • ORIF – in case of open fracture, vascular injury, brachial plexus injury, compartment syndrome
  • Intramedullary nailing – in severe osteoporotic bone
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