Closed Comminutive Fracture

Left Humerus With Radial Nerve

Palsy

CASE REPORT

FAHRI DWI PERMANA

110 208 037
Advisor:
dr. Arnold
dr. Edwin
Supervisor:
dr. Henry Yurianto, M. Phil, PhD, Sp.OT

Department of Orthopaedic and Traumatology

Faculty of Medicine
Makassar
2014

IDENTITY
Name

: YT

Age

: 55 years old / Male

Admission : December 2nd, 2014

Registratio : 69 10 64
n

AUTOANAMNESIS
Chief Complain : Pain in the Left Arm

Suffered since 3 days before admitted to

Wahidin General Hospital due to traffic
accident. Patient was the passenger in an
ambulance when the ambulance rolled
over twice, ending upside-down.
History of loss of consciousness (-), vomit
(-)
Patient is an engineers and right-hand
dominant
Prior Treatment at Palopo Hospital.

GENERAL STATUS
Conscious / well-nourished
Vital Signs:
Blood pressure : 120/80 mmHg
Pulse rate
: 84 x/min
Respiratory rate : 16 x/min
Temperature : 36,9 0C
VAS : 6/10

LOCAL STATUS
Left Arm Region
Look
: Deformity (+), Swelling (+), Wound (-),
hematoma (+)
Feel
: Tenderness (+)
Move : Active and passive motions of shoulder and
elbow joints are not evaluated due to pain
NVD
: Sensibility is hypoesthesia along radial nerve
distribution, pulsation of radial artery is
palpable, extend thumb (-), Extend Wrist (-),
OK Sign (+), abduction and adduction digiti
(+), CRT <2 second.

CLINICAL FINDINGS

RADIOLOGY FINDINGS

LABORATORY FINDINGS

WBC : 10.830/ul
RBC : 4.300.000/ul
HBG : 13,4 g/dl
HCT : 37,1 %
PLT : 213.000/ul
CT : 300
BT : 700
HBsAg : Non-reactive

Summary
A man 55 y.o came to the hospital with chief complaint
of pain in the left arm, suffered since 3 days before
admitted to Wahidin General Hospital. Patient was the
passenger in an ambulance when the ambulance
rolled over. Patient is an engineers and right-hand
dominant.
From physical examination, there is deformity,
swelling, hematoma, tenderness at the left arm.
Extend thumb (-), extend wrist (-), Sensibility is
hypoesthesia along radial nerve distribution, pulsation
of radial artery is palpable, CRT <2 second.
The Radiologics imaging shows communitive fracture
of left humerus

DIAGNOSIS
Closed Comminutive Fracture
Humerus
Left Radial Nerve Palsy

Left

MANAGEMENT
IVFD RL
Analgetic
Apply Slab at Left Upper Limb
ORIF + Nerve exploration

DISCUSSION

Anatomy of Humerus

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic

Anatomy. 2nd ed. Philadelphia: Saunders; 2010.

Nerves of Humerus

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic

Anatomy. 2nd ed. Philadelphia: Saunders; 2010.

Upper Arm Musle (anterior view)

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic

Anatomy. 2nd ed. Philadelphia: Saunders; 2010.

Upper Arm Musle (posterior view)

O'Grady E. Arm. In: Thompson JC, editor. Netter's Concice Orthopaedic

Anatomy. 2nd ed. Philadelphia: Saunders; 2010.

MECHANISM OF HUMERUS
INJURY
Fracture usually follows a fall on the out-stretched arm
A fall on the hand may twist the humerus, causing a
spiral fracture
A fall on the elbow with the arm abducted exerts a
bending force, resulting in an oblique or transverse
fracture
A direct blow to the arm causes a fracture which is
either transverse or comminuted.
Fractures around the elbow in adults especially those
of the distal humerus are often high-energy injuries
which are associated with vascular and nerve damage.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

CLINICAL FEATURES

Pain.
Deformity.
Bruising.
Crepitus.
Abnormal mobility
Swelling.
Any neurovascular injury

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

CLINICAL FEATURES
Skin integrity .
Examine the shoulder
and elbow joints and the
forearm, hand, and
clavicle for associated
trauma.
Check the function of
the median, ulnar, and,
particularly, the radial
nerves.
Assess for the presence
of the radial pulse.
Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

CLASSIFICATION

CLOSED
OPEN
LOCATION- proximal, middle, distal
FRACTURE PATTERN-tranverse, spiral,
oblique,comminuted segmental
SOFT TISSUE STATUS Tscherene &
Gotzen
Gustilo &
Anderson
Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

AO CLASSIFICATION OF HUMERAL DIAPHYSEAL

FRACTURES

Type A : Simple
fracture
A1: Spiral
A2: Oblique (>30)
A3: Transverse
(<30)

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor.

 Type B : Wedge fracture

B1: Spiral wedge
B2: Bending wedge
B3: Fragmented wedge

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor.

 Type C : Complex fracture

C1: Spiral
C2: Segmented
C3: Irregular (significant
comminution)

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor.

ASSOCIATED INJURIES
Radial Nerve injury = Wrist Drop =
Inability of extend wrist, fingers,
thumb, Loss of sensation over dorsal
web space of 1st digit
Neuropraxia at time of injury will
often resolve spontaneously
Nerve palsy after manipulation or
splinting is due to nerve
entrapment and must be
immediately explored by orthopedic
surgery
Ulnar and Median nerve injury (less
common)
MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures
In Adults.Artery
7th ed. Bucholz
RW, Brown CMC, Heckman JD, III
Brachial
Injury

DIAGNOSIS
History
Clinical
examination
imaging

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

TREATMENT
NON OPERATIVE TREATMENT

INDICATIONS
- Undisplaced closed simple
fractures
- Spiral fractures
- Short oblique fractures

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

A humeral brace. The sling length can be altered to change the

fracture position.
MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

OPERATIVE METHODS
Indication :
Absolut :
- associated vascular injury
- associated higher grade open wound
Fracture indication :
- Failure to obtain and maintain adequate closed reductin
- Segmental fractures
- Pathologic fractures
- Intra-articular extension

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

Associated injuries
Open wound
Vascular injury
Patient indication
Multiple injuries
Head injury (GCS 8)
Chest trauma

MRCS SAA, Athwal GS, Atkins RM, Axelrad TW, Barei DP. Rookwood And
Green's Fractures In Adults. 7th ed. Bucholz RW, Brown CMC, Heckman JD, III

Lesion of radial nerve

1. Low Lession
2. High Lession
3. Very High Lession

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

LESION IN THE UPPER ARM

Causes:
Supracondylar # of the humerus.
Nerve damage
Callus bone formation following # cause
delay compression.
Newborn : prolonged labour & forceps
extraction

Clinical Features of high lesion:

Inability to extend wrist, fingers &
thumb.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

MANAGEMENT
Emergency surgery is required for
brachial plexus lesions associated with
penetrating wounds, vascular injury or
severe
(high-energy)
soft-tissue
damage, whether open or closed;
clean-cut nerves should be repaired or
grafted.

Solomon L. Apley's System of Orthopaedics and Fractures. 9th ed. Janieson G,

THANK YOU