71.12 Fractures of the neck of the humerus in adults

The patient, who is typically an older woman, falls on her outstretched arm and injures her shoulder. Her osteoporotic humerus breaks across its neck. Sometimes, its head is comminuted. In spite of her pain, she may be able to use her swollen, tender shoulder, so the diagnosis is often missed. Soon, she has severe bruising extending to her elbow. If the head of her humerus is impacted on the shaft, the fracture is more likely to heal with reasonable function. These fractures are less common in young adults, but when they do occur, they usually heal well.

FRACTURES OF THE NECK OF HUMERUS IN AN ADULT

Check the patient’s axillary nerve (55.8) and his radial pulse.

X–RAYS Take two X–rays at right angles. The fragments may be widely separated, but overlie one another in a single view.

Is the fracture impacted? If you can move the patient’s arm through a reasonable range without causing severe pain, it is impacted.

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Figure 71.12: REDUCING A FRACTURE OF THE NECK OF THE HUMERUS with wide separation or severe angulation. After de Palma, with kind permission.

IMPACTED FRACTURES OF THE HUMERAL NECK IN AN ADULT

Begin active and assisted shoulder movements immediately. Between these exercises, put the patient’s arm in a sling for 4 to 6 weeks. Make sure that it supports his elbow, and so prevents disimpaction. He must not lift heavy objects for 3 months.

UNIMPACTED FRACTURES OF THE HUMERAL NECK IN AN ADULT

Treatment depends on how widely separated the fragments are.

THERE IS NO SEPARATION AND ONLY MILD ANGULATION (1) The broken surfaces of the fragments are in contact. And, (2) angulation between the head and the neck is less than 90\ensuremath{^\circ }.

Shoulder exercises are too painful to begin immediately. So put the patient’s arm in a sling and give him an analgesic. If pain is unbearable, bandage it to his chest. Begin elbow, wrist, and finger movements. Wait for 3 weeks before starting active shoulder exercises.

THERE IS WIDE SEPARATION OR SEVERE ANGULATION (1) There is no contact between the broken surfaces of the fragments. Or, (2) there is angular deformity of more than 90\ensuremath{^\circ }.

Get good muscle relaxation with a general anaesthetic. Flex the patient’s elbow and pull on the humerus as in Fig. 71-12 (1).

While still pulling, adduct his elbow across his chest and flex it in the frontal plane of his body. (2) The combination of these movements will restore the length of his humerus.

Place your other hand in his axilla. Press on the head with your thumb (3), and pull the shaft outwards (4). After the fragments are aligned, release traction gradually, so that the fragments engage (5).

If the fracture is stable after reduction, put his arm in a collar and cuff. Keep it to his side for 3 weeks, then gradually begin progressive movements as pain lessens, starting with pendulum exercises and continuing with wall crawling exercises (Fig. 71-7).

If the fracture is unstable after reduction, put him in forearm traction as in Fig. 72-11 for 2 weeks, then give him a sling and arm dangling excercises.

IF THERE iS SO MUCH SEPARATION THAT THE SHAFT OF THE PATIENT’S HUMERUS IS IN HIS AXILLA, laceration of his axillary artery is the danger, so check his pulse at his wrist before you try to reduce his fracture.

If his pulse is obliterated, bind his arm to his side and refer him. If you cannot refer him, take him to the theatre, and be prepared to tie his subclavian artery above his clavicle (3.4). As you do the reduction, you may pull a spicule of bone out of his axillary artery and cause massive bleeding.

CONSCIENTIOUS EXERCISES WILL OFTEN RESTORE MOVEMENTS TO A STIFF SHOULDER