Case Report July 2013

CLOSE FRACTURE 1/3 MIDDLE LEFT HUMERUS

By Icha Marissa Sofyan (C 111 08 318) Advisor dr. Lutfi dr. Dhedi P.sam Supervisor

dr. JAINAL ARIFIN, M. KES, SP.OT (K)

DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR 2013

Identity
Name Age : Mr. J : 38 years old

Gender

: Male

Date of admittance : June 15th, 2013 Medical Record Number: 614196

History Taking
Chief complain Pain at left upper arm History of illness Suffered since 1 hours before hospital admittance due to workplace accident Mechanism of trauma To refill the dispenser, patient lifted and moved a bottle (galon) which full of water, suddenly he felt pain at the left upper arm.

General Status
Moderate illnes/Wellnourished/Composmentis Vital Signs T : 130/70 mmHg N : 82x/minutes, reguler P : 20x/minutes, simetris, spontan, tipe thoracolabdominal S : 37,3 c

LOCALIZED STATUS Left Upper Arm Region Look: deformity (+), swelling (+), hematoma (-), open wound (-) Feel: tenderness (+) ROM: Active and passive motion of shoulder elbow joint limited due to pain NVD: Sensibility is good, radialis artery palpable, capillary refill time <2 sec.

Clinical Pictures

Radiologic Findings

AP and lateral radiograph of upper arm

Laboratory Findings
Leukocyte 15,0 103/L 4,0-10.0

Eritrocyte 4,57 103/L Hemoglobin 14,4 g/dL

Hematocrit MCV MCH MCHC 43,9% 96,0 fl 31,4 pg 32,7g/dL

4,0-6,0 12,0-16,0
37,0-48,0

Trombocyte 411 103/L

150-400
80-97 26,5-33,5 31,5-35,0

Laboratory Findings
Na+ 145 mmol/L 136-145

K+ ClGDS

4,2 mmol/L 110 mmol/L

103 mg/dL

3,5-5,1 97-111
<140

Ureum
Kreatinin GOT GPT

25 mg/dL
0,9 mg/dL 15 u/L 40 u/L

10-50
<1,3 <38 <41

Resume
A man, 38 yo, came to the hospital due to pain at left upper arm after involved in a workplace accident since 1 hours before admision. Physical examination revealed deformity, swelling and tenderness of the left upper arm, ROM examination was performed but active and passive motion are limited due to pain. No NVD impairment. Radiologic examination reveal discontinuity of 1/3
middle left humerus.

Diagnosis
Closed fracture 1/3 middle left humerus

Management
Immobilization Analgetics

apply U slab

Plan ORIF

DISCUSSION Fracture of Shaft Humerus

EPIDEMIOLOGY
Common injury, representing 3% to 5% of all fractures. Brinker et al
mean age 28.9 years 13.1 per 100,000 persons per year.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006 Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition. 2006

ANATOMY (1)

Putz R. and Pabs R. Sobotta Atlas of Human Anatomy. Volume 1 Head, Neck, Upper Limb. 2006

ANATOMY (2)

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

ANATOMI (3)
Anterior compartments:
muscle : brachialis, biceps brachii, dan coracobrachialis. Neurovascular : brachial a., musculocutaneus n., media n., and radial n

Posterior compartments:

muscle : triceps brachii. Neurovascular : radial n.and ulnar n.,radial recurrent arteries

Thompson JC. Arm. In: Netters Concise Orthopaedic Anatomy. Second edition.

AO Clasificcation

W.M MURPHY , D. LEU. In AO PRINPCLES Of FRACTURE MANAGEMENT. EDITION 2000

CLASSIFICATION
Open vs. closed. Location: proximal third, middle third, distal third. Degree: nondisplaced, displaced. Direction and character: transverse, oblique, spiral, segmental, comminuted. Articular extension.
Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

MECHANISM OF INJURY (1)

Direct (most common): Direct trauma to the arm from a blow or motor vehicle accident results in transverse or comminuted fractures. Indirect: A fall on an outstretched arm results in spiral or oblique fractures, especially in elderly patients. Uncommonly, throwing injuries with extreme muscular contraction have been reported to cause humeral shaft fractures.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

MECHANISM OF INJURY (2)

Fracture pattern depends on the type of force applied: Compressive: proximal or distal humeral fractures Bending: transverse fractures of the humeral shaft Torsional: spiral fractures of the humeral shaft Torsional and bending: oblique fracture, often accompanied by a butterfly fragment

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

POSITION OF FRACTURE FRAGMENTS

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

CLINICAL EVALUATION
pain, swelling, deformity, and shortening neurovascular examination
radial nerve function compartment pressures

instability Soft tissue abrasions and minor lacerations must be differentiated from open fractures.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

RADIOLOGICAL EXAMINATION
The site of the fracture, its line (transverse, spiral or comminuted) and any displacement are readily seen. The possibility that the fracture may be pathological should be remembered.
Closed transverse fracture with moderate displacement.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

TREATMENT (1)

Humeral Fracture Non Operative Operative

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (2)
Hanging Cast

Coapation Splint

Non Operative

Thoracoabdominal immobilization

Shoulder Spica Cast

Functional Bracing
Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (3)
OPERATIVE
Indications are:
Multiple trauma Inadequate closed reduction or unacceptable malunion Pathologic fracture Associated vascular injury Floating elbow Segmental fracture Intraarticular extension Bilateral humeral fractures Open fracture Neurologic loss following penetrating trauma Radial nerve palsy after fracture manipulation (controversial) Nonunion

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (4)
Operative

OPEN REDUCTION AND PLATE FIXATION

INTRAMEDULLARY FIXATION

EXTERNAL FIXATION

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

TREATMENT (5)

Fractured humerus and other methods of fixation. (a,b) Compression plating, and (c,d,e) external fixation.

Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

Postoperative Rehabilitation
Range-of-motion exercises for the hand and wrist should be started immediately after surgery; shoulder and elbow range of motion should be instituted as pain subsides.

Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition 2006

COMPLICATION

EARLY
Vascular Injury

LATE
Delayed Union and Non-union Joint Stiffness

Nerve Injury

Thankyou

Radiologic ORIF