CASE REPORT

Closed Comminutive Fracture Left

Humerus With Radial Nerve Palsy

FAHRI DWI PERMANA

110 208 037
Advisor:
dr. Arnold
dr. Edwin
Supervisor:

dr. Henry Yurianto, M. Phil, PhD, Sp.OT

Department of Orthopaedic dan Traumatology

Faculty of Medicine
Makassar
2014

IDENTITY
Name

: YT

Age

: 55 years old / Male

Admission

: December 2nd, 2014 at 20:10

Registration : 69 10 64

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, 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 Left Humerus
Left Radial Nerve Palsy

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, editor2010.

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, editor2010.

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, editor2010.

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, editor2010.

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. London: Springer; 2006.

 Type B : Wedge fracture

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

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor. London: Springer; 2006.

 Type C : Complex fracture

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

Mostofi SB. Fracture Classifications in Clinical Practice. Hinves B, editor. London: Springer; 2006.

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)
Brachial Artery Injury
Clavicle, forearm, wrist & Chest injuries
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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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 PT, editors. USA: Wolters Kluwer; 2010.

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, editor2010.

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, editor2010.

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, editor2010.