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Midshaft Fracture of Humerus Essay


Introduction

Humerus fractures are damages that affect bone of the upper arm, which bonds the shoulder with the elbow. The fractures in this zone appear in three major forms: proximal, midshaft, and distal humerus fractures.

The majority of these fractures occur due to various means, but they are often instigated by falls like in the case of John who sustained a midshaft injury in a road traffic injury. Although most humerus injuries do not require surgery for them to heal, John underwent one.

Surgery is always applicable in cases whereby the fragments are far apart. Doctors can conduct diverse orthopaedic surgeries to treat patients with midshaft humeral fracture with one of the common option being the Open Reduction Internal Fixation (ORIF).

After treatment, patient with humerus fractures undergo a rehabilitation process that lasts a minimum of three to four months. However, resuming physical activity such as sports like in the case of James may avert the healing process.

This paper discusses the rehabilitation of a midshaft humerus fracture by underscoring the underlying pathological processes as well as outlining a treatment line. The paper begins by discussing the ORIF surgery.

Open Reduction and Internal Fixation (ORIF)

ORIF is a surgery performed on patients to mend injured bone. Open reduction refers to the slitting of the limbs to access the bones and the fix in the right manner. Internal fixation refers to insertion of metal screws or sutures to hold the bone in the right position during the course of remedial.

The sutures and screws are left in the body even after healing. This type of surgery is commendable where solely using cast or splint is ineffective. Furthermore, apart from enabling the bone to heal correctly, the procedure reduces pain, reinstates the bone to its usual function, and curbs supplementary injury (Carlan 2007).

ORIF of fractures that occur in the humerus is often conducted using miscellaneous techniques. However, the technique applied will depend on the doctor’s experience, the position of the fracture and if the radial nerve is wounded (Zlotolow et al. 2006).

Physicians should adhere to the Orthopaedic Trauma Association guidelines when conducting this kind of surgery to properly reinstate anatomic alignment, avoid destroying the soft-tissue to maintain the vascularity to the bone, as well as conducting an accurate firm fixation to enable the patient to have early array of motion and impressive functional healing process (Carlan 2007).

If a patient has spiral-patterned fractures, the doctors apply a lag screw fixation to enhance the inter-fragmentary rigidity.

Patients should not only just be informed of the benefits of ORIF, but also the risks associated this type of treatment. For instance, during the process some nerves could be injured and hence, alter their performance in the arm. Some patients may develop compartment syndrome that might destroy muscles and tissue in the arm.

Other feasible risks include pulmonary embolism, partial healing of the arm, swelling of the arm, and muscle spasms (Gradl 2010). Despite these risks, patients who undergo this procedure are normally taken to a recovery room where they are watched until they wake up and start showing positive results.

The positive results are often dependent on a series of checks conducted in these recovery rooms. The blood circulation, feeling, and movement are screened (Altizer 2003).

After a maximum of two days, patients with midshaft humeral fractures are released and a physiotherapist is proposed by the physician to help in the healing process. The physiotherapist helps the patient to conduct certain exercises that will enhance the process of gaining strength and motion in the arm (Denies 2010).

The rehabilitation process often last between three to twelve months, but it relies on the level of damage caused during the injury and in case some nerves and blood vessels were wounded in the process (Ellis 2012).

Rehabilitation of Midshaft Humerus Fracture

The aftercare process of the midshaft is one of the most challenging regions both postoperatively and in the case of conservative remedial. However, every rehabilitation procedure should aim at retrieving the initial function of the bone.

Based on a long-term outlook, the therapists should give guidelines on how to avoid future falls that are likely to cause injuries to the midshaft humerus (Holey & Cook 2012).

The rehabilitation process for the midshaft humeral fracture patient is often divided into three phases as summarised in Appendix A. However, this process is normally subject to the severity of the fracture, the patient’s wellbeing, as well as the cooperation between the patient, therapists, and doctor.

The three phases include the early rehabilitation stage, intermediate rehabilitation, and the late rehabilitation phase (Carroll et al. 2012). Patients should adhere to these phases discreetly to minimise reinjury and steadily recover their normal strength (Guadalupe-Grau et al. 2009).

The early rehabilitation phase begins from the time of injury to two weeks after the surgery is conducted. In this stage, the patient is educated on the importance of early movement. The patient should avoid improper arm movement patterns.

The reflexive movements should be below the plain limits (Carroll et al. 2012). Patients should try to have inert shoulder seizure and sideways rotation aiming for half seizure during the initial three sessions.

Moreover, the patient is helped to perform gravity pendular exercises that he or she can do indoor. In case of any pain, the patient can use pain control instruments such as heat and ice (Dandy & Edwards 2009).

The second phase of the procedure last between two to eight weeks. In intermediate rehabilitation, the patient is introduced to passive arm exercises in supinc. These exercise focus on the flexion as well as lateral movement (Schoen 2000).

The patient also starts to perform simple but useful exercises that do not intensify pain. Moreover, the patient is advised to do fully do inert physiologic and proprioceptive exercises, which include bolt and unbolt chain (Carroll et al. 2012).

After the two months are over, the patient begins the late rehabilitation phase whereby he can now do dynamic exercise against gravity. This phase is normally anticipated to last for two months, but can be done for more weeks depending on the patient’s rate of recovery.

The patient is trained to use the isometric muscles to perform most duties to reinforce the rotator cuff muscles (Stannard, Schimdt & Kregor 2007). The use of sling should be minimal as the patient continues with practical exercises.

Nonetheless, passive stretches can be introduced in case the contraction increase. If the patient successfully performs his or her tasks autonomously within the two weeks, he or she can be discharged to continue with his or her normal duties and hobbies (Donegan 2010).

It is important to note that in the initial stages of the rehabilitation, when the patient still has a sling, he or she should focus on light finger movements. This element is an array of motion movements along the neck and pendular exercise to help him or her to minimise pain as well as preserve the angle in which the arm and shoulder can move.

Furthermore, patients should always continue with keeping the other parts of the body fit even before the physiotherapy process begins officially (Bandy & Sanders 2008).

A midshaft humeral fracture patient who has undergone an ORIF surgery is often advised to perform lower extremity fitness as a way of preserving the cardiovascular strength. Such exercises include light jogging, stationery bike or steppers (Holey & Cook 2012).

Patients can also use weight machines for their unwounded arm and lower parts of the body. However, these exercises should not interfere with the guidelines issued by physicians to ensure proper healing.

Lifting any type of weight with the wounded arm is disastrous and is never permissible until that time that the patient has completely recovered. Since pain is often experience soon after the sling is removed, to avert this pain various means such as use of ice, ultrasound and electrical current are utilised.

The muscles that are attached to the arm convey the pain to the upper back and neck. To eliminate this pain, the upper limbs as well as the neck are usually massaged to increase blood circulation (Bandy & Sanders 2008).

It is important for patients to adhere to the types of exercises proposed by therapists because they help one to regain the energy lost by the arm that is normally lost in the process of treatment (Rukewe et al. 2010).

Depending with the nature of the fracture and cooperation patient cooperation, machineries like the Theraband, lights weights and upper body bike may be used to promote balanced movement of the whole limb (Gradl 2010). Sometimes the joints are mobilised so that the rigid joints in the limb steadily resume their usual scope of motion.

Auspiciously, the process of retrieving the normal scope of motion of the humerus fractures is hasty and patients have no need to worry about resuming their daily duties Nonetheless, the heavier are only introduced if the capacity of motion is recovered and the bone can comfortably bear the heavy stresses (Guadalupe-Grau et al. 2009).

In the case of proprioception, it can be successfully achievable if the patient performs exercise such as rolling a ball with the hand, lifting a recommended weight above the shoulders and simple push-ups on a flexible material (Liu, Zhang & Whu, 2012).

If the patients show good progress, other exercise such as throwing ball may be incorporated. However, the success of this process relies on the coordination between the patient’s surgeon and physiotherapist.

One year after the surgery, the bone is anticipated to have fully healed. In case, witness any kind of complication within the set timeline, they should report to their surgeon for further advice (Bandy & Sanders 2008).

Potential Complications of the Midshaft Humeral Fracture

It is a common incident for every surgical process to be accompanied with some complications. In the case of midshaft humeral fracture, “fat embolism, compartment syndrome, and deep venous thrombosis may develop” (Donegan 2010, p. 71).

Nevertheless, these complications are not a frequent occurrence. The most regular types of problems include malunion, non-union, wounding of the nerves, and infection.

When the ORIF is not conducted properly, then the patient is likely to have misalignment of the fracture analogous to conservative treatment. Though this element is tolerable, the frequent movements at the area where the injury occurred may raise certain complications.

Subsequently, one may fail to move the arm laterally or in other directions. Since the arm can rotate the arm may move even on the presence of complications that minimise its scope of motion, the necessity to correction such problems may not be urgent (Rosenberg & Soundry 2006).

Nevertheless, if there are several misalignments, the patient may be obliged to go for another surgery to realign the fractures in the right position. The disadvantage of developing a malunion is that the period of recovery will be prolonged.

Fortunately, after the treatment, the scope of motion and motion will be completely recovered (Moffat, Rosen & Rusnak-Smith 2006).

Twelve weeks after the surgery, the fractures are expected to have united. If the bones are still separate by this time, the case is referred to delayed union. However, such cases are not treated with gravity like in the scenario of non-union, because it is assumed that the bone is still in the process of healing (Liu, Zhang & Whu, 2012).

Non-union is a seldom case that refers to a situation whereby healing process is unsuccessful. Although it is often witnessed on patients who are partially immobilised, it can also develop after surgery. It is caused by meagre blood circulation, smoking, having numerous fragments as well as infection (Van Middendorp et al. 2011).

Non-union develops when some scar tissue surrounding the fragmented bone fails to become a bone. This failure causes pain and the patient can feel any movement in the fragments.

To remedy the complication, a surgery is conducted whereby the scar tissues are replaced with firmly fixated plates and bone graft added to haste the healing process. The result after this replacement is often satisfactory but if the non-union persists, patients are advised to just with the complication (Rosenberg & Soundry 2006).

Infection normally occur if the fracture was stained either at the site of injury or during operation. This aspect disrupts the healing process and may result to long-term illness of the bone known as chronic osteomyelitis. Antibiotics or surgery interventions are useful as a remedy of the problem.

In the case of surgery, the wound is reopened and any dead or infected tissues are removed (Rukewe et al. 2010). Fixations such as metals are removed soon after the bone is healed so that the body defence system can alleviate any existing bacteria.

Injury of the nerve causes interim problems because once the nerves re-grow and attach to the relevant muscles, the problem ceases. However, this aspect can last for long because the growth of nerves is slow.

If the nerves are completely damaged, the situation must be repaired, but there is no certainty that all nerves will be attached to the right muscles and hence, one should expect persistent weakness (Carlan 2007).

Conclusion

Midshaft fracture of the humerus is a grave wound that is instigated by a considerable accident. After surgery, it is not requisite for the bone to utterly heal straight to function properly and resume normal scope of motion, potency and fortitude.

However, it is important for a patient to adhere to the advice of his or her surgeon as well as a therapist during rehabilitation to avoid any complication. In the case of James, he can partially resume his duties and hobbies including riding his bike after six months whereby the bone is expected to have resumed complete range of motion.

Fortunately, after twelve months everything will be back to normal. Nonetheless, he should avoid future falls especially on the injured zone to avoid further injuries.

Appendix

Treatment Plan

Recipient Information
Medical Card No. 12345678
Name: James
Problem: Rehabilitation of the Midshaft Fracture of the Humerus
Early Rehabilitation (Injury Time to 2 weeks) Immobilisation and assistance for 2-3 weeks
Pendulum exercises
Lightly aided motion
Circumvent external rotation of the upper limbs
Intermediate Rehabilitation (3-8 Weeks) Active-aided lateral flexion and seizure
Simple practical use of the arm
Steadily minimise help during movement
Late Rehabilitation (8 weeks- Full Recovery) Introduction of isotonic and fortifying exercises
Passive stretches in case of contraction persistence
Doing tasks independently
Termination of the therapy if no complication is reported

Reference

Altizer, L 2003, ‘Forearm and Humeral Fractures’, Orthopaedic Nursing, vol. 22 no.4, pp. 266-73.

Bandy, W & Sanders, B 2008, Therapeutic Exercise for Physical Therapy Assistants: Techniques for Intervention, Lippincott Williams & Wilkins, Philadelphia.

Carlan, D 2007, ‘The radial nerve in the brachium: an anatomic study in human Cadavers’, J Hand Surg Am, vol. 32 no. 8, pp.1177-1182.

Carroll, E, Schweppe, M, Langfitt, M, Miller, A & Halvorson, J 2012, ‘Management of humeral shaft fractures’, J Am Acad Orthop Surg, vol. 20 no.7, pp. 423-33.

Dandy, D & Edwards, D 2009, Essential orthopaedics and trauma, Churchill Livingstone, California,

Denies, E 2010, ‘Operative treatment of humeral shaft fractures. Comparison of plating and intramedullary nailing’, Acta Orthop Belg., vol.76 no.6, pp.735-42.

Donegan, D, Zqonis, M, Hebela, N & Mehta, S 2010, ‘Failure of internal fixation of a humerus fracture resulting from longitudinal fissuring: a case report’, J Orthop Trauma, vol.24 no.7, pp. 69-73.

Ellis, E 2012, ‘Open Reduction and Internal Fixation of Combined Angle and Body/Symphysis Fractures of the Mandible: How Much Fixation Is Enough’, Journal of Oral Maxillofac Surg, vol. 12, pp.2378-2391.

Guadalupe-Grau, A, Fuentes, T, Guerra, B & Calbet J 2009, ‘Exercise and Bone Mass in Adults’, Sports Medicine, vol. 39 no.6, pp. 439-68.

Gradl, G 2010, ‘Current concepts review – fractures in the region of the elbow’, Acta Chir Orthop Traumatol Cech, vol. 79 no.3, pp. 203-12.

Holey, E & Cook, E 2012, Evidence-based Therapeutic Massage: A practical Guide for Therapists, Elsevier Health Sciences, London.

Liu, G, Zhang, C & Wu, H 2012, ‘Comparison of initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fractures’, Orthopedics, vol. 35 no.8, pp. 702-708.

Moffat, M, Rosen, E & Rusnak-Smith, S 2006, Musculoskeletal Essentials: Applying the Preferred Physical Therapist Practice Patterns, SLACK Incorporated, New Jersey.

Van Middendorp, J, Kazacsay, F, Litchtenhahn, P, Renner, N, Babst, R & Melcher, G 2011, ‘Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients’, Eur J Trauma Emerg Surg, vol. 37 no. 3, pp. 287-296.

Rosenberg, N & Soundry, M 2006, ‘Shoulder impairment following treatment of diaphysial fractures of humerus by functional brace’, Arch Orthop Trauma Surg, vol.126 no. 7, pp. 437-40.

Rukewe A, Oqunlade, S, Idowu, A & Aderinto, D 2010, ‘Subclavian perivascular block for open reduction and internal fixation of left midshaft humeral fracture–a case report’, Afr J Med Med Sci., vol. 39 no. 1, pp. 69-71.

Schoen, D 2000, Adult Orthopaedic Nursing: An Illustrated Guide, Lippincott Williams & Wilkins, Philadelphia.

Stannard, J, Schimdt, A & Kregor, P 2007, Surgical Treatment of Orthopaedic Trauma. New York, Thieme.

Zlotolow, D, Catalano, L, Barron, A & Glickel, Z 2006, ‘Surgical exposures of the humerus’, J Am Acad Orthop Surg, vol. 14 no.13, pp.754-65.

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