2:1

• Osteoporotic elderly (low energy falls)→on outstretched arm
• in young individual (high energy trauma): might also have associated Soft tissue + neurovascular injuries

• if one part displace → 2 part fracture
• if 2 displaced → 3 part
• if 3 displaced → 4 part fracture
• dislocation

No/minimal displacement = 1 part fracture 📷

muscles pull up → rotator cuff muscle

3 PART HUMERAL HEAD FRACTURE

gr. tuberosity displaced

humeral head more then >45° change if you compare to diaphysis

• Pain
• Decreased motions
• Extensive ecchymosis

NeVas exam ⇒ axillary nerve injury most common

• Sensory loss lat shoulder
• Abduction + ext. Rotation not possible (deltoid, teres minor)

📷

most of the cases xray: AP + scapular view

CT: prepare for surgery, see more detailed view if unclear on xray (head-split fracture? Head or gr. tuberosity uncertain?), intraarticular comminution

MRI: any rotator cuff injury or other soft T damage?

• 70-80% of prox. humerus fracture
• 2-4 weeks of immobilization
• nondisplaced (<1cm; <45°) = 1 part fx
• use extra-fixation (Dessault bandage) if you think the patient is not gonna be compliant
• Also you might consider this in older patients with more severe surgical neck fracture (2 part fractre)! → risk too high

head preserving treatment

• 2-3 parts fracture (less than 4) , esp. in younger individuals
• percutaneos pinning (K-wires) 📷
• philos-plates: open reduction
• CRIF: intra-medullary nail 📷 + k-wires: closed reduction → small incision sup. to the humerus → introduction of IM nail → nail through 5cm incision ⇒ stabilizes extremly good but is hard to place (needs a lot of xrays) + might damage rotator cuff
• ORIF: philos-plates 📷 : Holes in the plates: rotator cuff muscles can be re-attached here

head replacing treatment

Hemiartroplasty only in young

ball + socket reverse 📷 → deltoid muscles will act like the rotator cuff

only in old people

• screw cut-out: screws come out + scratch glenoid 📷
• avascular necrosis
• nerve injury during surgery
• malunion / nonunion
• Rotator cuff injury
• Arthritis
• Infection
• other classics

Indirect/direct trauma

classic fracture signs

• Pain localized to the fracture site • Redness and swelling • Limb deformity • Palpable step-off or gap • Bone crepitus • Ecchymosis • Possible neurovascular compromise below the site of injury • Possible signs of an open fracture

Nope just the usual

→ classic simple, comminuted, wedge, etc...

• simple
• wedged
• comminuted
• displaced or undisplaced
• closed or open.

neuro-vascular damage 📷

esp. radial nerve (also ulnar nerve) → palsy 📷

• Early
• open fracture
• vascular damage
• Late
• delayed union
• non-union
• mal-union

Fall hand

dorsal part sensitivity loss

no dorsiflexion possible

almost all conservative → in nondisplaced + old

• U-slab → then hanging cast 📷 or Sarmiento 📷 (after 3 weeks)
• radial n. palsy in common during the first 6 weeks

eventually start with hanging cast (3 weeks)→ then sarmiento (3 weeks)

Ellbow shouldnt be immobilized longer than 3 weeks

→ general rule: surgery only when hard displaced

SURGICAL TREATMENT:

ORIF 📷

vascular involvement/compartment/open/polytrauma fracture → surgery

→ radial nerve palsy AFTER 6 weeks→ conservative most of the time due to temporarly nerve palsy

in really long, displaced shaft fractures:

CRIF with IM-nails 📷

closed reduction with minimal invasive fixation

(right pic: intramedullary not deep enough→ will scrape acromial process)

mainly indirect trauma, can be direct too

• Supra condylar
• Intercondylar
• Both
• Epicondylar

children: supracondylar or isolated epicondilar

adults: supra + intercondylar → various degrees in comminution

• open
• Volkmann contracture 📷
• vascular
• ulnar n. compression → cubital tunnel sy 📷
• osteoarthritis → stiffness

→ intraarticular fractures need ORIF!! (with plates + screw)

• anatomical reduction of articulation, stable internal fixation ⇒ ORIF
• early ROM and rehabilitation
• mainly operative

• undisplaced
• probably without articular involvement
• Eldery + comminuted

⇒ Casts for 3 weeks

mainly

in articular, displaced, cartilage damage

isolate + protect ulnar nerve