Fracture Arm: Siti Istiqomah, S. Ked 71 2016 080

FRACTURE ARM
Oleh:
Siti Istiqomah, S. Ked
71 2016 080
Pembimbing:
dr. Rizal Daulay, Sp.OT, MARS
Fractures of the Humeral Neck
• These fractures are often classified as abduction or adduction
types, depending on the relative positions of the proximal and
distal fragments.
• They are often comminuted, with the greater tuberosity
forming a separate fragment.
• The classification is of little value unless manipulative reduction is
to be attempted, in which case it may help to decide if the fracture
is stable or unstable.
• Stable fractures are impacted and may be safely mobilized early.
• Non-impacted fractures may be considerably displaced and can be
associated with damage to the brachial plexus or axillary artery.
• Many of these fractures occur in elderly people following a fall
onto the arm or shoulder.
• The degree of displacement varies but is often not severe.
Treatment
• A broad sling is used to support the arm initially, but
mobilization is encouraged as soon as possible.
• The patient begins to swing the arm in the sling within a few
days and as the pain settles more vigorous physiotherapy is
commenced.
• In younger patients severe displacement may necessitate
manipulation under anaesthesia or open reduction and internal
fixation.
• The head of the humerus is not easy to fix adequately. Modern
techniques make use of special plates with cancellous screws
entering the head. But, ischaemic necrosis of the head of the
humerus may occur.
• In this case, or if it proves impossible to achieve primary fixation, it

may be appropriate to replace the humeral head with a prosthesis.
• Fractures of the greater tuberosity may cause a large fragment
to be pulled upwards by the rotator-cuff muscles and this may
need open reduction and internal fixation to avoid
impingement on the acromion.
Fracture of the Humeral Shaft
• This is fairly common in all age groups and may be caused by a
fall on the outstretched hand or, more usually, by a direct blow
to the upper arm.
Clinical features
• There is usually marked swelling and bruising of the arm due to
bleeding from the bone and soft tissues.
• Radiographs often reveal a spiral fracture with displacement
making the diagnosis easy.
Complications
• The radial nerve is vulnerable as it winds round the shaft of the
humerus and is occasionally injured.
• Rupture of the brachial artery is a rare complication.
Treatment
• In principle, this consists of using the weight of the arm to
realign the fragments.
• A collar and cuff sling, together with gutter splints surrounding
the fracture, extending higher on the lateral side and bandaged
in position, is usually adequate.
• Immobilization is usually needed for 8-12 weeks.
• Nonunion is relatively uncommon.
Non - operative methods of treating fractures of the humeral shaft
• Patients who need to be nursed in bed for other injuries or
whose fractures fail to align may require internal fixation of the
fracture with a plate or intramedullary nail.
• There are reports of a higher non-union rate with nails and so a
return to plate fixation is current practice.
Supracondylar Fracture of the Humerus
• This is essentially an injury occurring in childhood, usually
arising from a fall on the outstretched hand.
• The lower fragment is typically displaced and rotated
backwards.
• The elbow usually swells considerably and is held in a semi-
flexed position.
• Crepitus may be felt on attempting to move the joint.
Complications
• The sharp anterior margin of the upper fragment may kink the
brachial artery, which may also be injured if the elbow is flexed
before reducing the fracture.
• The radial pulse may not be palpable, but usually the
circulation remains adequate.
• Nerve injuries are uncommon but both median and ulnar
palsies may occur.
• Late deformity occasionally occurs because of malunion
(‘gunstock ’deformity).
Treatment
• This is by manipulation under anaesthesia with X-ray control.
• The elbow is kept flexed to about 60 degrees and the
epicondyles are held between the operator ’ s fingers whilst
the fragment is pulled downwards and forwards.
• The epicondyles must be kept level, otherwise the fracture
may unite with a tilt.
• Having reduced the fracture and checked it on X-rays, holding
the arm in a collar and cuff sling against the chest usually gives
reasonably accurate rotation of the lower fragment on the
upper.
• The elbow should not be flexed much above 90 degrees,
particularly if swelling is severe, as this may impair the distal
circulation.
Post-operative management
• The patient is admitted and the circulation in the limb watched
over the next 24 hours.
• The pulse may not return after manipulation, but this in itself
is not a cause for alarm, provided the circulation remains
adequate.
• Pain in the forearm flexor region and particularly on passive
extension of the fingers is a warning sign of ischaemia of the
forearm muscles.
• If this is untreated it will result in muscle necrosis and later
contracture of the fingers, known as Volkmann’s ischaemic
contracture.
• If the circulation is not restored by extending the elbow, the
artery should be explored and if damaged, a segment may
need to be resected and grafted.
• Occasionally, the fracture is unstable in the flexed position and
traction or even immobilization in extension may be necessary.
• If instability is difficult to control by an external technique,
internal fixation may be the best option.
• The position can usually be held with two Kirschner wires
driven across the fracture line from the lateral side of the distal
fragment, taking great care not to damage the ulnar nerve.
• The wires are removed after 3 weeks.
Fractures of the Epicondyles
These injuries usually occur in children from a fall on the arm.

Medial epicondyle
• The medial epicondyle may be avulsed by the medial ligament,
and when this happens it occasionally becomes trapped in the
medial side of the elbow joint and is visible there on a lateral
X-ray film.
Treatment:
• Manipulation may be possible by abducting the elbow and
attempting to draw out the fragment by extending the wrist
and fingers.
• If this fails, surgery is necessary to extract the fragment from
the joint and reposition it. It may be stable in its normal
position or it may need to be pinned.
Lateral condyle
• A fracture of the lateral condyle in a child involves a much
larger piece of bone than is obvious on X-ray.
Treatment:
• The fragment usually needs pinning back in position to avoid
non - union and later deformity due to interference with the
growing epiphysis.
• In particular, cubitus valgus may occur and this is often
associated with ulnar palsy later in life.

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FRACTURE ARM

• In this case, or if it proves impossible to achieve primary fixation, it

These injuries usually occur in children from a fall on the arm.

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