Trauma 101: Orthopedics Study Tool

Indication

Most closed isolated shaft fractures with acceptable alignment and an intact soft tissue envelope in a compliant patient.

Implant design notes

No implant. A prefabricated clamshell brace with adjustable straps; gravity and the compressive effect of surrounding muscle maintain alignment while allowing elbow and shoulder motion.

Approach

Non-operative, beginning with a collar and cuff or a U-slab for a few days until swelling settles, then transitioning to the brace.

Steps overview

1. Document radial nerve function meticulously — wrist and finger extension and first dorsal web sensation
2. Apply an initial U-slab or hanging cast for comfort for three to seven days
3. Fit the functional brace and teach the patient to retighten it as swelling reduces
4. Encourage the arm to hang dependently and start pendulum and hand exercises
5. Radiograph at two, six and twelve weeks; expect varus angulation to be tolerated well
6. Wean the brace once there is clinical and radiological union

Notes

The humerus tolerates angulation and rotation well because of shoulder and elbow compensation. Non-union risk rises with a transverse pattern, obesity, smoking and poor brace compliance.

Indication

Open fractures, associated vascular injury, floating elbow, polytrauma needing upper-limb weight bearing, failed bracing or non-union, and fractures with a radial nerve deficit after an open injury.

Implant design notes

Large-fragment compression or locking plate. Anterolateral plating suits the proximal two-thirds; posterior plating gives excellent access to the distal third but demands radial nerve identification and protection.

Approach

Anterolateral approach through the brachialis-splitting interval (its dual innervation protects the muscle), or a posterior triceps-splitting or paratricipital approach distally.

Steps overview

1. Supine with the arm on an armboard, or lateral/prone for the posterior approach
2. Develop the chosen interval and identify the radial nerve wherever it may lie in the field
3. Expose the fracture with minimal periosteal stripping and reduce it anatomically
4. Hold with a clamp and lag screw where the pattern permits
5. Apply the plate with a minimum of six cortices of fixation on each side of the fracture
6. Re-confirm radial nerve integrity and that it is not tethered beneath the plate
7. Close in layers and begin immediate elbow and shoulder motion

Notes

Iatrogenic radial nerve injury from retraction or entrapment under the plate is the complication to fear; identify and document the nerve at operation.

Indication

Pathological or impending pathological fractures, segmental fractures, and selected fractures where a smaller soft tissue insult is prioritised.

Implant design notes

Locked intramedullary nail acting as a load-sharing internal splint, ideal for lesional disease because it protects the whole bone. Antegrade insertion risks the rotator cuff; the nail must be buried below the articular surface.

Approach

Antegrade through a cuff-splitting entry just medial to the greater tuberosity, or retrograde through a posterior distal entry point.

Steps overview

1. Beach-chair position with fluoroscopy; confirm nail length and diameter by templating
2. Make the entry through a small cuff incision, planning its repair
3. Ream conservatively and pass the nail across the reduced fracture
4. Lock proximally and distally, taking great care with distal locking near the radial nerve
5. Confirm the nail is countersunk below the articular cartilage
6. Repair the cuff, close, and begin early motion

Notes

Shoulder pain from the entry site is the recognised drawback of antegrade nailing. Distal locking screws placed blind endanger the radial nerve — use an open technique.