FRACTURE HUMERUS PROXIMAL

Presented By:
Fian Christo Kusuma
Fera M. Patiung
Virna Septiana
Dwi Prasetyo
Diyana
Fatin Najiha

Resident:
dr. Thomson S.
dr. Roichan Firdaus

Supervisor:
dr. A. Dhedie P. Sam, M.Kes Sp.OT
 IDENTITY
Name : Z

Age : 16 years old / Male

Admission : October 1st , 2017 at 00:02

Registration : 817462

Status : BPJS

Phone : 085342828647
number
 AUTOANAMNESIS
(at 00.10)

Chief Complain : Pain at right arm

Suffered since 6 hours before admitted to wahidin general
Hospital due to motor vehicle accident
Patient was riding a motorcycle then suddenly he was hit
by another motorcycle from front direction
History of projectil vomit (-)
History of convulsion (-)
Prior treatment at Barru Hospital
 PRIMARY SURVEY
(at 00.15)

A : Clear
B : RR = 26 x/min, symmetric, spontaneous,
thoracoabdominal type.
C : HR: 80 x/min, reguler, strong
Blood pressure 120/60 mmHg
D : GCS 15(E4M6V5), light reflex +/+ , pupil
isochors, : 2.5 mm/2.5mm,
E : T = 36.70 C (axillary)
 SECONDARY SURVEY
(at 00.20)
Right Arm Region
Look : Deformity (+), Swelling(-), hematome(-) Bone exposed at
proximal humerus
Feel : Tenderness(+)
Move : Active and passive movement of shoulder joint is can
not be evaluated due to pain
Active and passive movement of elbow joint is can not
be evaluated due to pain
NVD : Sensibility is within normal limit.
Pulsation of radialis and ulnaris arteries are palpable
CRT <2 seconds
 SECONDARY SURVEY
(at 00.20)
Right Forearm Region
Look : Deformity (+), Swelling(-), hematome(-), multiple
lacerated wound subkutis based
Feel : Tenderness(+)
Move : Active and passive movement of wrist joint is can not
be evaluated due to pain
Active and passive movement of elbow joint is can not
be evaluated due to pain
NVD : Sensibility is within normal limit.
Pulsation of radialis and ulnaris arteries are palpable
CRT <2 seconds
CLINICAL FINDING
(00.30)
CLINICAL FINDING
(00.30)
RADIOLOGY FINDING
at (00.40)
RADIOLOGY FINDING
at (00.40)
RADIOLOGY FINDING
at (00.40)
RADIOLOGY FINDING
at (00.40)
AO Classification
at (00.45)
AO Classification
at (00.45)
 DIAGNOSIS
Open Fracture Proximal right humerus grade IIIA
AO 12-A3, IO4, MT4, NV 1
Closed fracture incomplete distal left ulna Salter
Harris type III
Buckled fracture at metaphyseal distal left ulna
Closed fracture complete distal left radius Salter
Harris type II
[AO 23r-E/1, IC1, MT1, NV1]
 LABORATORY FINDINGS
(at 02.00)

WBC : 12.8/ul Natrium : 142

RBC : 3.950.000/ul Kalium : 4,2
HGB : 9,9 g/dl Clorida : 105
HCT : 33 %
PLT : 600.000/ul
CT : 730
BT : 330
SGPT : 8
SGOT: 12
HBsAg : Non Reactive
 DIAGOSIS PRE OPERATION
Open fracture 1/3 proximal right humerus
grade IIIA
Closed fracture distal radius salter harris type
II
Closed fracture distal ulna salter harris type III
Closed buckled fracture metaphyseal distal
ulna
Lacerated wound at Scrotal Region
 MANAGEMENT
IVFD
antibiotic
Analgesic
Tetanus prophyaxis
Report to Orthopaedic senior, advice :
Plan for Emergency debridement
Apply Coaptation Splint right upper limb
Apply Dorsal slab above elbow at left upper limb
Report to Orthopaedic Consultant
 OPERATION REPORT
Operation start : 13.05
Operation done : 14.05
Operation report :
1. Patient lying supine position under spinal anesthesia
2. Disinfection and draping until right and left lower limb seen as operation
field
3. Identification. Left lower limb: Look deformity, edema and hematom at
left thigh, look stitched wound aspect anterior left knee size 10 cm
vertical shape, look edema, hematoma and deformity at left foot region.
Right lower limb: look deformity edema and hematom at right thigh
region. There are 2 stitched wound at cruris anterior aspect, at proximal
region with every size is 3 cm and 2 cm. There is stitched wound at
dorsal aspect and plantar aspect right foot. Aff hecting: there is skin
degloving right foot, look dirty wound . Pin prick test 1st-4th toes
positive. Pin prick test 5th toe negative.
DISCUSSION
 INTRODUCTION
Fractures => a break in the continuity of the bone cortex, may be associated with
abnormal motion, some form of soft tissue injury, bony crepitus, and pain.

Proximal humerus fractures comprise 4 5% of all fractures and represent the

most common humerus fractures (45%)

Nonoperative management - mainstay for treatment of the majority of these

injuries, acceptable healing in > 90% of patients.

Surgical treatment is generally reserved for open fractures, polytrauma patients,

ipsilateral humeral shaft and forearm fractures, and cases in which there is a failure
to tolerate or maintain alignment in a functional brace.

American College of Surgeon. Advance Trauma Life Support 9th Ed. 2012
Walker M, Palumbo B, et al. Humeral Shaft Fractures: A Review. J Shoulder Elbow Surg. 2011. p. 1-12
 HUMERUS

Thompson, J. netters Concise Orthopaedic Anatomy 2nd Edition. Kansas: Elsevier

Periscapular
Muscle
Rotator Cuff
muscle
Deltopectoral
muscle
 NERVE OF THE ARM : ANT. VIEW

Thompson, J. netters Concise Orthopaedic Anatomy 2nd Edition. Kansas: Elsevier

 NERVE OF THE ARM : POST. VIEW

Thompson, J. netters Concise Orthopaedic Anatomy 2nd Edition. Kansas: Elsevier

 ARTERIES

Thompson, J. netters Concise Orthopaedic Anatomy 2nd Edition. Kansas: Elsevier

 MECHANISM OF INJURY

Direct trauma to the arm from a blow or motor

Direct vehicle accident results in transverse or
communited fractures

A fall on an outstretched arm result in spiral

or oblique fractures
Fractures pattern depends on the type of
force applied : - bending transverse
Indirect fractures
-torsional spiral fractures
Torsional and bending : oblique fracture,
often accompanied by a butterfly fragment

Koval Kj, Zuckerman jd. In: Hanbook of fracture third editor. USA: teppincot willams & wilking.2012
 MECHANISM OF INJURY
Young ages : High Energy

Old ages : Low Energy

 Classification
AO/OTA
Organizes fractures into 3 main groups
and additional subgroups based on
fracture location
status of the surgical neck
presence/absence of dislocation
 Neer classification

based on anatomic relationship of 4 segments

Greater tuberosity
Lesser tuberosity
Anatominal Neck
Surgical Neck
Considered a separate part if :
Displacement of > 1 cm
 DIAGNOSIS
History Taking

Physical Examination

Diagnostic Test

Koval Kj, Zuckerman jd. In: Hanbook of fracture third editor. USA: teppincot millams & wilkiring.2012
Frassica, FJ. Et all. The 5 minute Orthopaedic Anatomy 2nd Edition. Lippincutt Williams & Wilkins. 2007
 RADIOLOGICAL EVALUATION
recommended views:
AP
Scapular Y
Axillary

Fracture OF The Upper Extremity

 NON-OPERATIVE TREATMENT

Frassica, FJ. Et all. The 5 minute Orthopaedic Anatomy 2nd Edition. Lippincutt Williams & Wilkins. 2007
Simon, RR. Et all. Emergency Orthopaedics the extremities 5th edition. Mc Graw. Hills
 OPERATIVE TREATMENT
Indications for operative treatment are

Multiple trauma
Inadequate closed reduction or unacceptable malunion
Pathologic fracture
Associated vascular injury
Segmental fracture
Intra-articular extension
Bilateral humeral fractures
Open fracture

Handbook of fracture
 OPERATIVE TREATMENT
Surgical neck or subcapital fractures without major displacement
will normally be treated by sling immobilization until the pain is
gone.
OPERATIVE TREATMENT
Surgical neck or subcapital fractures
without major displacement (11-
A2.1: less than 10 mm and
angulation below 45) will normally
be treated by sling immobilization
until the pain is gone. This is
followed by an early rehabilitation
program.

Early rehabilitation (within 14 days

after surgery) results in a better
outcome
 OPERATIVE TREATMENT
Surgical neck or subcapital fractures without major displacement (11-A2.1: less than 10
mm and angulation below 45) will normally be treated by sling immobilization until the
pain is gone. This is followed by an early rehabilitation program.

Early rehabilitation (within 14 days after surgery) results in a better outcome

OPERATIVE TREATMENT
OPERATIVE TREATMENT
 OPERATIVE TREATMENT

INDICATIONS FOR HEMIARTHROPLASTY

anatomical neck fracture dislocations
in split-head fractures
elderly
 COMPLICATION

Non-union
Mal-union
Axillary nerve injury and Brachial Plexus Injury
Shoulder Stiffness
Bone Necrosis
Thorax Injury
Vascular Injury
 SCAPULA FRACTURE

Types :
Body ( A )
Neck ( D )
Glenoid ( B & C )
Acromion ( E )
Coracoid ( G )
 SCAPULA FRACTURE

MECHANISM OF INJURY

Fracture of the acromion is due to direct

force.
 ACROMION
MECHANISM OF INJURY

Motor vehicle accident in approximately

50% of cases and motorcycle accident in
Direct 11% to 25%
a blow or fall (scapula body fracture) or
through direct trauma to the
point of the shoulder (acromion, coracoid
fracture).
 Classification

Fractures of Acromion process

Type I : Minimally Displaced
Type II : Displaced but not
reducing subacromial space
Type III : Inferior displacement
and reduced subacromial space
 TREATMENT FRACTURE ACROMION

Undisplaced fractures are treated non-operatively.

Only Type III acromial fractures, in which the
subacromial space is reduced, require operative
intervention to restore the anatomy.
 NON- OPERATIVE TREATMENT
Most scapula fractures are extra-articular and are amenable to
nonoperative treatment, consisting of sling use and early range of shoulder
motion.
 OPERATIVE TREATMENT
Indications for surgery are controversial, but include :
Fractures of the acromion that impinge on the subacromial space

Acromion fractures: Os acromiale must first be ruled out, as well as

concomitant rotator cuff injuries. Displaced acromion fractures may be
stabilized by dorsal tension banding, if displacement causes subacromial
impingement.
Tension band wiring
 COMPLICATION
Associated injuries: These account for most serious complications because
of the high-energy nature of these injuries. Increased mortality is associated
with concomitant first rib fracture.
Malunion: Fractures of the scapula body generally unite with nonoperative
treatment; when malunion occurs, it is generally well tolerated but may
result in painful scapulothoracic crepitus.
Nonunion: This is extremely rare, but when present and symptomatic it
may require open reduction and internal fixation.
Suprascapular nerve injury: This may occur in association with scapula
body, neck, or coracoid fractures that involve the suprascapular notch.
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