Final Paper

Abstract

Knowing the anatomy of the humerus is very important. The structure plays a major role in how the humerus functions. Fractures in the humeral shaft are common and can happen with any physical activity. The elderly are more likely to have humeral fractions, because of decline in health, vision or bone history. Not all humerus fractions have to have surgery. Many fractures can heal without surgery, however, the healing of the humerus without surgery may lead to stiffness. Open fractures are the most difficult to deal with, because of arteries and external bleeding, infection and the tissue surrounding the wound. With antibiotics, the timing of surgical intervention and, therapy will lead to healthy healing of the bone.

Humerus Fractures and Bleeding

A humerus fracture is an injury to the bone of the upper arm that connects the shoulder the elbow (Taimela S, 2017). Surgery for these fractures is usually saved for certain circumstances, such as age, health, damaged bone or if the bone has moved out of position influences outcome among patients admitted to the hospital with a proximal humeral fracture (Taimela S, 2017). Most surgery is mostly used for proximal and distal humerus fractures. Knowing and understanding the anatomy of the humerus help surgeons when restoring the function of the bone (Taimela S, 2017). Open fractures can be difficult for surgeons because they have to deal with infections as well as external bleeding (Taimela S, 2017).

Anatomy of The Humerus When Fractured

 The proximal humerus bone is located in the upper arm and consists of the humeral head, greater tuberosity, lesser tuberosity, and the humeral shaft. It joins with the most mobile joint in the body, the glenohumeral joint, which is commonly known as the shoulder joint. Since it’s the most mobile joint in the body, it is important to fix a fracture fast and understand the anatomy of the humerus (Khmelnitskaya, 2012).

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The humerus can be set in different planes known as the coronal plane and the sagittal plane, which puts the humeral head in different angles. In the coronal plane, the humeral head is tilted backwards from the shaft at about a 20-degree angle. In the sagittal plane, the humeral head is tilted towards the head at nearly a 130 to 150-degree angle. Because the humeral head must be able to be put in the different angles, it is crucial that this part or near this part of the bone does not become fractured (Khmelnitskaya, 2012). “Fractures through the anatomic neck can result in significant vascular compromise to the humeral head leading to avascular necrosis,” Khmelnitskaya (2012).

If the proximal humerus becomes fractured, the risk of damaging the greater or lesser tuberosity increases. This is dangerous because they will no longer properly fit with the rest of the anatomy of the shoulder and the muscles that attach to the greater and lesser tuberosity risk being injured. The muscles that attach to the greater and lesser tuberosities include the supraspinatus muscle, infraspinatus muscle, teres minor muscle, subscapularis muscle, and the pectoralis major tendon (Khmelnitskaya, 2012).

The two arteries that are the major supply of blood to the humerus are the anterior humeral circumflex artery (AHCA) and the posterior humeral circumflex artery (PHCA) (Khmelnitskaya, 2012). Previously, doctors believed the AHCA to be the main blood supply to the humerus, but “the majority of the blood supply to the proximal humerus actually arises from the PHCA. Specifically, the authors report that 64% of humeral head perfusion arises from the PHCA, while the AHCA only contributed 36% of humeral head perfusion,” Khmelnitskaya (2012). This is good if the proximal head becomes fractured, which would likely damage the AHCA blood supply because the humerus will still be supplied by the PHCA.

Statistics of Fractures In The Humeral Shaft

 Fractures of the humeral shaft are fairly common. According to Taimela (2017), “Humeral shaft fractures represent 1%–3% of all fractures and 20% of humeral fractures in adults.” They are mostly caused by falls, car accidents, and sport injuries (Taimela, 2017).

Humerus fractures are normally treated without the need of surgery by securing the fracture with plastic splints, hanging casts, or functional bracing. When using conservative treatment, the heal rate is 97% union and 95% excellent function, but nearly 27% of patients did not follow up in the study. Sometimes surgery is required to help heal the fracture in cases of “open fracture, multiple trauma, bilateral humeral shaft fracture, concomitant ipsilateral forearm fracture, pathological fracture, or vascular or brachial plexus injury in association with humeral shaft fracture.” (Taimela, 2017).

Risk Factors For Fractures Of The Humeral

The highest humerus fracture risk comes from the elderly, especially when there’s a decline in their health (Nauhaus, 2013). These people commonly have other injuries or illnesses too, like osteoporosis which is the most related to proximal humerus fractures. Other risk factors include low bone mass, personal history of fractures, low level of physical activity, poor vision, insulin-dependent diabetes and alcohol consumption. Some things that may cause a fall that leads to the break are seizure medication, depression, use of a hearing aid and left-handedness, (Konrad, 2008). While in the hospital, there are risk factors for adverse events. These include, “older age and specific comorbidities—especially congestive heart failure,” (Nauhaus, 2013).

Once the elderly sustain a fracture in their humerus, it could result in an extended hospital stay so they can be monitored for discharge into a long-term care facility, for example, a nursing home. The mortality rate has been raised in recent years due to the longer life expectancy and it is also raised by alcoholism (Neuhaus, 2013).

Although the humerus fracture could result in extended hospital stays or discharge to a long-care facility, most are treated in an outpatient setting, so the patients are sent home the same day.

Proximal Humerus Fracture Treatment

 Treatment for a proximal humerus fracture is different for every patient. This fracture accounts for nearly 5% of all fractures and is the third most common fracture in elderly patients. The patients are normally over the age of 60 and usually have osteoporosis. A lot of proximal humerus fractures are nondisplaced so they are treated without surgery (Konrad, 2008). These are treated with splints or hanging casts (Ekaterina, 2008). However, “non-surgical treatment may lead to stiffness. When dealing with the few cases that affect younger people, surgery may have a better outcome. Non-locking plates and screws have been shown to provide the strongest fixation in non-osteoporotic bone,” (Konrad, 2008)

 There are many operative treatment options for the proximal humerus.Antegrade intramedullary nailing is a surgical option. It is where nails go into the head of the femur and it is supposed to have maximum primary stability. Primary arthroplasty is another option. It is supposed to be low-risk and good for people with osteoporosis (Konrad, 2008).

How To Deal With Open Fracture

 Open fractures, a fracture that breaks the skin, of the humerus can be difficult for surgeons because they have to deal with infection as well as external bleeding. If there is severe bleeding from the arteries that are the major supply of blood, the anterior humeral circumflex artery (AHCA) the posterior humeral circumflex artery (PHCA), and the brachial artery, it must be stopped as quickly as possible. Pressure should be applied and the blood should be absorbed so the doctor can see what he/she is doing (Cross, 2008).

 When determining what treatment option is best, the surgeon will look at the state of the soft tissue around the wound, patient’s condition, and the mechanism of injury. In the case of an open fracture, antibiotics are important to stop infection. They also have the goal of restoring function and uniting the bone back together in the humerus (Cross, 2008). “Important principles include antibiotic utilization, timing of initial surgical intervention, type of wound closure, antibiotic delivery methods, tetanus coverage, wound irrigation, and adjunctive therapies to assist with fracture union,” Cross (2008). These are all important in determining the best way to treat an open fracture of the humerus.

Discussion

Based on research, the humerus fractures are most common in the elderly and can be caused by direct or indirect trauma. The chance of getting a humerus fracture increases as age increases, because of a decrease in the density of bones and a decrease in bone mass, also known as osteoporosis. Based on the severity of a humeral fracture the bone can heal without surgery, however, surgery may be required when there are fragments of bone involved or if the bone has broken through the skin. When treating humeral fractures, doctors have to be very careful. The bone could have possibly hit a major artery as it went through the skin and through the healing process there is a high chance of infection. This research paper may assist future research or policy making decisions, by informing doctors and people of the importance and seriousness of humerus fractures and the medical work involved. Early arthritis is common after a humerus fracture, because of the trauma on the joint. This research paper may aid researchers in preventing early arthritis due to humerus fractions.

References

Rämö L, Taimela S, Lepola V, et al. Open reduction and internal fixation of humeral shaft fractures versus conservative treatment with a functional brace: a study protocol of a randomised controlled trial embedded in a cohort. BMJ Open 2017;7:e014076. doi:10.1136/bmjopen-2016-014076

Neuhaus, V., Swellengrebel, C. H., Bossen, J. K., & Ring, D. (2013). What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture? Clinical orthopaedics and related research, 471(5), 1698-706.

Ekaterina Khmelnitskaya, Lauren E. Lamont, Samuel A. Taylor, Dean G. Lorich, David M. Dines, and Joshua S. Dines, “Evaluation and Management of Proximal Humerus Fractures,” Advances in Orthopedics, vol. 2012, Article ID 861598, 10 pages, 2012. https://doi.org/10.1155/2012/861598.

Konrad, Gerhard & Mehlhorn, Alexander & Kühle, J & Strohm, Peter & Südkamp, Norbert. (2008). Proximal Humerus Fractures – Current Treatment Options. Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca. 75. 413-21.

Cross, W. W., & Swiontkowski, M. F. (2008). Treatment principles in the management of open fractures. Indian journal of orthopaedics, 42(4), 377-86.

Sarah P. Chu, et al. American Journal of Epidemiology, Volume 160, Issue 4, 15 August 2004, Pages 360–367,https://doi.org/10.1093/aje/kwh224