Please take a look at the duty roster. And now we have five ill colleagues. I don’t know how we are going to cope with that. Excuse me. We have a new patient. He has come to us directly from the pub and seems to have broken his right arm. Could you please ask him to wait a minute and we’ll be with him straight away. OK. He’s in treatment room 2. OK. I’ll check in the system. Hello, Mr. Monaco. My name is Dr. Kirchhoff. Please remain seated. So what have you been up to? As it often goes, I was arm-wrestling with my friend and I think he’s a real rogue and tricked me. I then heard a cracking sound, up there, and my arm now really hurts. How exactly did that happen? Were you pressing like this and there was then suddenly a snapping noise and it began to hurt there? I was exerting a lot of force with my arm. First of all, we need to take your shirt off and examine the arm. I’ll just sit down next to you and we’ll then need a nurse to help us take the shirt off. We need to undress the patient now. I’ll hold your arm like this the whole time and you just let it go really limp. In order to gain a better understanding of the injuries, here are the key anatomical basic principles and special points to note once again. The humeral shaft is turned in upon itself with an angle of tension of approx. 16°. This means that the articular surface of the humeral head is turned inwards in relation to the elbow. Numerous muscles and vascular tissues pull at the humeral shaft. Due to its proximity to the shaft, its radiate progress right around the humeral shaft, the radial nerve in particular is especially threatened by being pulled as an accompanying result in cases of osseous injuries. Humeral shaft fractures are classified according to the AO scheme. Within this, they are encoded with the number 1 or 2 and then classified according to the well-known scheme into A-, B- or C-injuries, depending on the severity of the fracture. Simple shaft fractures without any further fragments are Type A fractures. Fractures with one or two wedges are B-fractures and comminuted fractures or multi-layer fractures are designated as C-fractures. The majority of injuries result in Type A fractures, eaccording to the AO classification. Approx one quarter results in Type B and 10% in Type C injuries. Spiral fractures more commonly result in cases where force has been indirectly applied. Fewer than 10% of humeral shaft fractures are compound fractures and two age peaks are to be found: One among young men following high speed trauma and one among older, female patients following minimal trauma and fractures linked to osteoporosis. Can you feel everything up here OK? Yes, everything feels OK there. Do you feel any pain if I press here? No, that does not hurt. And if I press further down here and move that a little? Ouch! Excuse me, I’m sorry. Ok. OK, now down here, your wrist, if I press there, do you feel any pain there? Good. Now, just please lift your fingers. Great. And now please raise your whole hand. Great. Can you feel everything here on the outside OK? Great. Very good. Mr. Monaco, the first thing we have to do is to take an X-ray image of your arm and have a look at what is wrong with the bone and we’ll then talk about what needs to be done. Fine. We now need a pre-assembled Dynacast splint, please. So. Here you are. We now just wrap it tightly around the arm so as to ensure it does not hurt. Just like that. I’ll keep holding it. eep your arm really limp, just place it into this. Good. Very good. Now, we stick a plaster on. Now take your arm - just like this so that it does not hurt. Very good. And now I'd like you to go and have an X-ray taken. Where do I need to go? The nurse will take you. Just go that way... it's only ten meters away. Please follow me. For the diagnostic investigation, as always, the clinical examination and, in particular, blood flow, motor function and sensitivity distal to the injury are important. Assessment of the radial nerve especially is of the utmost importance. Furthermore, any soft tissue injuries and relieving postures should be described. Conventional X-ray images in two planes are targeted for imaging diagnostic investigation. In the case of extensive debris zones, a computerised tomogram is recommended. A paradigm shift has occurred recently precisely with regard to the treatment of humeral shaft fractures. These injuries were earlier treated non-operatively virtually without exception. Today, most humeral shaft fractures undergo surgical treatment. Why is this the case? The preconditions for non-operative treatment are freedom from pain, care at close intervals and regular X-ray check-ups without any further dislocation occurring. In addition, during the entire immobilisation, it should be possible for the patient to undergo physiotherapy so as to avoid neighbouring joints becoming stiff. Further reasons for non-operative treatment are too great a perioperative risk or the patient not granting their consent. DNon-operative treatment provides for immobilisation in an upper arm plaster cast for 7-9 days with 90° flexion of the elbow joint. This is then followed by treatment with a brace. “Brace” means a “shell” in this case and is intended to provide a basic means for supporting the shape of the arm. The classic Sarmiento brace can be traced back to Gus Sarmiento dwho practised in Miami and brought the non-operative form of treating fractures to ts highest form of fruition there. The brace is kept in place for approx. 6-12 weeks, interrupted by X-ray checks at regular intervals and in which identical positioning and adequate consolidation must be observed. The brace can then be removed after that period of time. Here you can see a Sarmiento Brace in situ being held in place by means of two Velcro® fasteners. What is clear is that this retention measure can only guarantee a relative degree of stability of the bone segments. Can I come in? Ah, Mr. Monaco, yes, please come in. Please take a seat. Take a look. We have now taken an X-ray of your right arm. If I can use this plastic model of a bone to illustrate what I am going to say, this up here is your shoulder and down here is your elbow. A bone must always have a smooth line and you can see from your X-ray image that, starting from your shoulder and then moving downwards along the bone, it is broken at this point here. That doesn’t look good. Various classifications for degrees of severity are employed in trauma surgery, one of them being that of the Working Group for Osteosynthesis. You don’t need to remember this, but this classifies fractures into categories from A to C. Your bone fracture would now be classified as an A2 bone fracture. That is quite a severe one, but also not too severe. The procedure which brings about the greatest success in healing and is also certainly the quickest with such a fracture is when a rod is inserted from upwards at the shoulder, meaning here at the bone, approximately in the region, which then exerts pressure downwards here, joins the fracture and the rod is then secured in place using various nails. So you just bang in a rod and that will fix everything? Look, the precarious aspect of your fracture is that precisely at this level i.e. in about this region here, dwhat is termed the radial nerve transverses the bone and that is the nerve which is joined to the fingers and the hand and among other things, controls the movement we examined previously. This nerve can also be damaged because of the bone fracture - which has not happened in your case - during the period until up to your undergoing the operation or even during the operation itself and this would mean precisely that it would not be possible to raise your hand and fingers any more. That is absolutely clear, certainly. Mr. Monaco, nurse Kathi will now accompany you to ward 1/17. There, a colleague of mine will explain to you once again precisely what the operation entails and all the risks involved and how long it will last and then the anaesthetist will call on you in the course of the day as well. The intention is then for us to be able to operate towards this evening so as to ensure we do not waste any time. Excellent. Okay. I won't offer to shake hands when saying goodbye! Nevertheless, I still wish you a Good Day. Good bye. The indications for surgical treatment are derived, on the one hand, from the form of the fracture and, on the other hand, from the fact of its being impossible to carry out and sustain the non-operative forms of treatment described above. This particularly applies to patients who have undergone polytrauma, short transverse fractures, accompanying vascular or nervous lesions, compound fractures, bilateral or multi-layer fractures, fractures with joints being involved, irreducible fractures or incidences of pseudarthrosis. The standard operation provides for open reduction and internal fixation, referred to as ORIF. In the course of this, restriction is undertaken by means of a 4.5 LCDC plate. If it proves impossible to reposition the fracture in a closed manner, it can be retained by means of intramedullary strength supports. Both antegrade and also retrograde locking nails are available for this purpose. Due to the rate of complications which can arise, retrograde nails have largely been dispensed with again. There is also the further option of applying an external fixator. Follow-up treatment aims at ensuring the shoulders can be freely moved and without axial pressure or tensile stress being exerted. This alone makes the advantage enjoyed by surgical treatment clear, as the shoulder can be mobilised much earlier and more intensively. Following an X-ray follow-up check, tensile and pressure stress can be increased to 2 kg and weight-bearing can slowly be commenced.
