CASE PRESENTATION

PRESENTED BY : Agus durman|C11109001 ADVISOR: dr. Naharuddin Imo dr. Sebastian Mihardja SUPERVISOR: dr. Zulfan Oktasatria Siregar, Sp.OT

CLOSED FRACTURE DISTAL OF THE LEFT HUMERUS

ORTHOPHEDIC AND TRAUMATOLOGY DEPARTMENT MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR, 2013

Patient Identity
Name Gender Date of birth Medical Record : Mr. G : Boy : June 11th 2011 : 635528

Date of admission

: November 4th 2013

History Taking
Chief Complaint : Pain at left arm History Taking Suffered since 5 days before admission to the hospital due to traffic accident. Mechanism of trauma : The patient was walking at roadside when suddenly got hit by a car from the back and the patient fell on the asphalt with the left side of the body. History of unconscious (-), nausea (-), vomit (-).

Prior treatment in Hospital of Barru.

Physical Examination
General Status:
Mild illness / conscious / well-nourished

Vital signs:
BP HR RR T : 100/60 mmHg : 88 x/min : 22 x/min : 36,8C

Localized Status
LEFT ARM REGION Inspection : Palpation : ROM NVD : : deformity (+), Swelling (+), hematoma (+), wound (-) Tenderness (+) active and passive motion of shoulder and elbow joints were limited due to pain. Sensibility is difficult to be evaluated, extension thumb (+), apposition test (+), abduction and adduction fingers (+), radial artery is palpable, Capillary Refill Time <2

Clinical Pictures

Laboratory Findings
TEST WBC RBC HGB HCT PLT GDS RESULT 18,69 x 103 /uL 3,26 x 106 /uL 9,6 mg/dL 26,5 % 169 x 103 /Ul 92 TEST
GOT GPT

RESULT
54 U/L 20 U/L

Ureum Creatinine HbsAg

26 mg/dL 0,4 % Negative

Radiologic Finding

Resume
A 2 years old boy admitted with pain at the left arm suffered since 5 days ago due to traffic accident. On physical examination of the left arm region was found deformity, swelling and hematoma, no wound , with tenderness. Sensibility is difficult to

be evaluated. There is no abnormality for NVD.

On radiological imaging there was a closed fracture at the distal of the left humerus.

Diagnosis
Closed fracture of the distal left humerus

Management
Analgetic

Apply U-Slab

Discussion HUMERAL DISTAL FRACTURE

Epidemiology
Fractures of the adult distal humerus are relatively uncommon, comprising approximately 2% of all fractures and one-third of all humerus fractures. Intercondylar fractures of the distal humerus are the most common fracture pattern. Extension-type supracondylar fractures of the distal humerus account for >80% of all supracondylar fractures in adults.

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

Anatomi
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.

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

Classification
The AO-ASIF Group have defined three types of distal humeral fracture: Type A an extra-articular supracondylar fracture Type B an intra-articular unicondylar fracture (one condyle sheared off) Type C bicondylar fractures with varying degrees of comminution.

Mechanism of injury
Most low-energy distal humeral fractures result from a simple fall in middle-aged and elderly women in which the elbow is either struck directly or is axially loaded in a fall onto the outstretched hand. Motor vehicle and sporting accidents are more common causes of injury in younger individuals.

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

Clinical evaluation
Signs and symptoms vary with degree of swelling and displacement; considerable swelling frequently occurs, rendering landmarks difficult to palpate. A careful neurovascular evaluation is essential because the sharp, fractured end of the proximal fragment may impale or contuse the brachial artery, median nerve, or radial nerve Serial neurovascular examinations with compartment pressure monitoring may be necessary

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

Radiological examination
Standard anteroposterior (AP) and lateral views of the elbow should be obtained. Oblique radiographs may be helpful for further fracture definition. Traction radiographs may better delineate the fracture pattern and may be useful for preoperative planning. Computed tomography may be utilized to delineate fracture fragments further.

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

Treatment
General treatment principles : Anatomic articular reduction Stable internal fixation of the articular surface Restoration of articular axial alignment Stable internal fixation of the articular segment to the metaphysis and diaphysis Early range of elbow motion

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

Treatment
Distal Humeral Fracture

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

Operative

Thank you

Nonoperative
The treatment principle is concervative Apply U slap Apply hanging cast

Indication for surgery

Multiple fracture
Open fracture Displaced intraarticular of the fracture

Neurovascular compromise
Inadequate closed reduction

TREATMENT

Applying a U-slab of plaster (after a few days in a shoulder-to-wrist hanging cast) is usually adequate. Ready-made braces are simpler and more comfortable, though not suitable for all cases. These conservative methods demand careful supervision if excessive angulation and malunion are to be prevented.
Solomon L, Warwick DJ, Nagayam S. Apley's system of orthopaedics and fractures2001.

TREATMENT
NON OPERATIVE

Hanging cast
This utilizes dependency traction by the weight of the cast and arm to effect fracture reduction. Indications include displaced midshaft humeral fractures with shortening, particularly spiral or oblique patterns. Transverse or short oblique fractures represent relative contraindications because of the potential for distraction and healing complications.

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

TREATMENT
NON OPERATIVE Coaptation splint This utilizes dependency traction to effect fracture reduction, but with greater stabilization and less distraction than a hanging arm cast. The forearm is suspended in a collar and cuff. It is indicated for the acute treatment of humeral shaft fractures with minimal shortening and for short oblique or transverse fracture patterns that may displace with a hanging arm cast Disadvantages include irritation of the patients axilla and the potential for splint slippage.

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

TREATMENT
NON OPERATIVE Thoracobrachial immobilization (Velpeau dressing) This is used in elderly patients or children who are unable to tolerate other methods of treatment and in whom comfort is the primary concern. It is indicated for minimally displaced or nondisplaced fractures that do not require reduction.

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

TREATMENT
NON OPERATIVE
Shoulder spica cast This has limited application, because operative management is typically performed for the same indications. It is indicated when the fracture pattern necessitates significant abduction and external rotation of the upper extremity. Disadvantages include difficulty of cast application, cast weight and bulkiness, skin irritation, patient discomfort, and inconvenient upper extremity position.

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

TREATMENT
NON OPERATIVE

Functional bracing
This utilizes hydrostatic soft tissue compression to effect and maintain fracture alignment while allowing motion of adjacent joints. It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a hanging arm cast or coaptation splint and swelling has subsided. Contraindications include massive soft tissue injury, an unreliable patient, and an inability to obtain or maintain acceptable fracture reduction.

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