92 | Essential Orthopaedics
example, a fracture where the head, the greater
tuberosity, the lesser tuberosity and the shaft,
all have separated, it will be called a four-part
fracture. This classification helps in deciding the
treatment and prognosis.
TREATMENT
In elderly persons, even with moderate
displacements, it is generally adequate to immobilise
the affected shoulder in a triangular sling. As soon
as the pain subsides, shoulder mobilisation is
started. In younger persons, if the fragments are
widely displaced, they are reduced by manipulation
under anaesthesia. Once reduced, the fracture
can be stabilised by multiple K-wires passed
Fig-13.7 Arthroscopic repair of shoulder dislocation
percutaneously under image intensifier control.
Often, open reduction and internal fixation may
d) Arthroscopic Bankart repair (Fig-13.7) : With the
be required. A number of internal fixation devices
development of arthroscopic techniques, it
have been in use; from simple K-wires to modern
has become possible to stabilise a recurrently
LCP based special plates (Fig-13. ). In badly
unstable shoulder arthroscopically. Initially
comminuted fractures in an elderly, replacement
it was considered suitable for cases where
arthroplasty is desirable. Axillary nerve palsy and
number of dislocations has been less than 5.
shoulder stiffness are common complications.
But, with present day arthroscopic techniques,
it is possible to stabilise most unstable
shoulders arthroscopically. Apart from being
a more cosmetic option, the rehabilitation after
arthroscopic repair is faster and better. It is
a technically demanding operation, and the
anchor sutures used for repair are expensive.
This technique is available only in select
centres.
FRACTURE OF THE SURGICAL NECK OF THE HUMERUS
Fracture through the surgical neck of the humerus
occurs most often in elderly women. The fracture
is usually caused by a fall on the shoulder.
In the majority of cases, these fractures are
impacted; sometimes they are widely displaced.
The possibility of this fracture should be kept in
Fig-13.8 Methods of fixation of
mind in all elderly persons complaining of pain in
surgical neck of the humerus
the shoulder following a fall. Often the symptoms
are minimal.
It is important to properly evaluate these fractures
FRACTURE OF THE GREATER TUBEROSITY OF
by AP and axial X-rays. Neer has classified THE HUMERUS
these fractures into types depending upon the Fracture of the greater tuberosity of the humerus
construction of the fracture. e identified parts in occurs in adults. The fracture is usually caused
the upper end of the humerus – shaft, head, greater by a fall on the shoulder, and is undisplaced and
tuberosity and lesser tuberosity. Depending upon comminuted. Sometimes, it is widely separated due
in how many parts the bone has fractured, he to the pull by the muscle (supraspinatus) attached
divided them into one to four part fracture. For to it.
Injuries Around the Shoulder, Fracture Humerus | 93
TREATMENT
For minimally displaced, comminuted fractures,
rest in a triangular sling is enough. The shoulder
is mobilised as soon as the pain subsides. For
displaced fractures, reduction is achieved by either
holding the shoulder abducted in a plaster cast, or
by open reduction and internal fixation. Painful arc
syndrome (see page 30 ) and shoulder stiffness are
the usual complications.
FRACTURE OF THE SHAFT OF THE HUMERUS
This is a common fracture in patients at any age.
It is usually sustained from an indirect twisting Fig-13.9 Displacement in fracture shaft of the humerus
or bending force – as may be sustained in a fall
on out-stretched hand or by a direct injury to
distraction occurs at the fracture site because of the
the arm.
gravity.
RELEVANT ANATOMY DIAGNOSIS
The humerus is a typical long bone (see page ).
Diagnosis is simple because the patient presents
The upper-half of the shaft is roughly cylindrical,
with the classic signs and symptoms of a fracture.
and begins to flatten in its lower-half in the
There may be wrist drop, if the radial nerve is
antero-posterior direction. The deltoid muscle is
injured. An X-ray of the whole arm including the
inserted on the deltoid tuberosity on the antero-
shoulder and elbow should be done.
lateral surface of the bone just proximal to its
middle-third. The posterior surface is crossed TREATMENT
obliquely by a shallow groove for the radial Most of these fractures unite easily. Anatomical
nerve. reduction is not necessary as long as the fracture is
stable. Some amount of displacement and angula-
The humerus is surrounded by muscles. This has
tion is acceptable.
the following clinical relevance: (i) the incidence
of compound fractures is low (ii) the union of This is due to the following reasons: (i) limitation
fractures occurs early because a bone so well of motion because of a moderate malunion in
surrounded by muscles has a rich periosteal blood angulation or rotation goes unnoticed because of
supply and (iii) some degree of malunion is masked the multi-axial shoulder joint proximally (ii) some
by the thick muscle cover. amount of shortening goes undetected in the upper
limb (unlike in the lower limb where shortening
PATHOANATOMY produces a limp) and (iii) the bone is covered
A humerus fracture can be considered a prototype
with thick muscles so that a malunited fracture is
fracture because it occurs in all patterns (transverse,
not noticeable (unlike the tibia where malunion is
obli ue, spiral, comminuted, segmental etc.),
easily noticeable).
may be closed or open, and may be traumatic or
pathological. Strict immobilisation is not necessary. The aim of
treatment is pain relief and prevention of lateral
Displacements are variable. It may be an undisplaced
angulation and distraction. It is possible to achieve
fracture, or there may be marked angulation or
this by conservative means in most cases.
overlapping of fragments. Lateral angulation is
common because of the abduction of the proximal Conservative methods: The following conservative
fragment by the deltoid muscle (Fig-13. ). This methods are useful in most cases:
angulation is further increased by the tendency of a) U-slab (Fig-13.10a): This is a plaster slab
the patient to keep the limb by the side of his chest, extending from the base of the neck, over the
resulting in adduction of the distal fragment. Often, shoulder onto the lateral aspect of the arm;
[Link]
94 | Essential Orthopaedics
under the elbow to the medial side of the arm. manipulation of the fracture or while the fracture is
It should be moulded on the lateral side of the healing (nerve entrapment in the callus). A special
arm in order to prevent lateral angulation. The type of humerus fracture, where there is a spiral
U-slab is supported with a triangular sling. fracture at the junction of the middle and distal
Once the fracture unites, the slab is removed third, is commonly known to be associated with
(approximately - weeks) and shoulder a radial nerve palsy. This is called Holstein Lewis
exercises started. fracture. The radial nerve injury results in paralysis
b) Hanging cast (Fig-13.10b): It is used in some cases of the wrist, finger and thumb extensors (wrist
of lower-third fractures of the humerus. The drop), brachioradialis and the supinator. There is a
weight of the limb and the cast is supposed to sensory change in a small area on the radial side of
provide necessary traction to keep the fracture the back of the hand.
aligned.
c) Chest-arm bandage: The arm is strapped to the Treatment: For cases reporting early, treatment
G
chest. This much immobilisation is sufficient depends on the expected type of nerve injury
for fracture of the humerus in children less than (for details, refer to Chapter 10). In most closed
R
five years of age. fractures, the nerve recovers spontaneously. In
open fractures, exploration is usually required. In
V
neglected cases or when repair of a divided nerve is
d
impractical, tendon transfers are needed. Modified
Jone's transfer is most popular. Here the muscles of
ti e
the forearm, supplied by median and ulnar nerves,
are used for substituting wrist extension, finger
n
extension and thumb abduction-extension. The
following tendons are used:
U
• Pronator teres → Ext. carpi radialis brevis
→ Ext. digitorum
-
• Flex. carpi ulnaris
• Palmaris longus → Ext. pollicis longus
9
Fig-13.10 Methods of treating fracture humerus
2. Delayed and non-union: Fractures of the shaft
ri 9
of the humerus, especially transverse fracture of the
In adults, early mobilisation of the limb can be midshaft, often go into delayed or non-union. The
begun by using a cast-brace once the fracture causes of non-union are: inadequate immobilisation
becomes sticky.
h
or distraction at the fracture site because of the
Operative method: In cases where a reduction is gravity.
ta
not possible by closed manipulation or if the frac-
ture is very unstable, open reduction and internal Treatment: Open reduction, internal fixation with
fixation is required. Most fractures can be fixed well a plate, and bone grafting is usually performed. In
with plate and screws. Intramedullary nailing is cases where the quality of bone is poor, an intra-
another method of internal fixation. Contaminated medullary fibular graft may be used to enhance the
open or infected fractures are stabilised by using an fixation. The limb is suitably immobilised using a
external fixator. U-slab or a shoulder spica.
COMPLICATIONS Further Reading
1. Nerve injury: The radial nerve is commonly
• Rockwood CA (Jr.), Green DP (Eds.): Fractures in Adults, Vols
injured in a fracture of the humeral shaft. The 1 and 2, 2nd edn. Philadelphia: JB Lippincott Co, 1 .
injury to the nerve is generally a neurapraxia only. • Chapman MW (Ed.): Operative Orthopaedics ol., 1 to , 2nd
It may be sustained at the time of fracture, during edn. Philadelphia: JB Lippincott Co, 1 3.
