SHAFT HUMERUS FRACTURE

1. Introduction
- It is a common injury, representing 3% to 5% of all fractures.
- Incidence is 14.5 per 100,000 per year.
- Two percent to 10% are open fractures.
- Sixty percent involve middle third, 30% involve proximal third, and 10% involve distal third
of the diaphysis.
- Bimodal age distribution with a peak in the third decade is seen in men and peak in the
seventh/eighth decade is seen in women.

2. Anatomy
- Humeral shaft extends from the pectoralis major insertion to the supracondylar ridge.
Crosssectional shape of humeral shaft changes from cylindric proximally to a narrower
triangular shape distally.
- Vascular supply to the humeral diaphysis arises from perforating branches of the brachial
artery, with the main nutrient artery entering the medial humerus distal to the midshaft
(Fig. 16.1).
- Musculotendinous attachments of the humerus result in characteristic fracture
displacements (Table 16.1).
- Radial nerve can be identified 14 to 15 cm proximal to the lateral epicondyle or 20 to 21 cm
proximal to the medial epicondyle.

3. Mechanism of Injury
- Direct (most common): Direct trauma to the arm from a blow or motor vehicle accident
results in a transverse or comminuted fracture.
- Indirect: A fall on an outstretched arm results in spiral or oblique fractures, especially in the
elderly. Throwing injuries with extreme muscular contraction and arm wrestling have also
been reported to cause humeral shaft fractures.
- Fracture pattern depends on the type of force applied:
o Compressive: proximal or distal humerus fractures
o Bending: transverse fractures of the humeral shaft
o Torsional: spiral fractures of the humeral shaft
o Torsional and bending: oblique fracture, often accompanied by a butterfly fragment

4. Diagnosis
CLINICAL EVALUATION
- Patients with humeral shaft fractures typically present with pain, swelling, deformity, and
shortening of the affected arm.
- A careful neurovascular examination is essential, with particular attention to radial nerve
function. In cases of extreme swelling, serial neurovascular examinations are indicated with
possible measurement of compartment pressures.
- Physical examination frequently reveals gross motion with crepitus on gentle manipulation.
 - Soft tissue abrasions and minor lacerations must be differentiated from open fractures.
- Intra-articular extension of open fractures may be determined by intra-articular injection of
saline distant from the wound site and noting extravasation of fluid from the wound.
RADIOGRAPHIC EVALUATION
- Anteroposterior (AP) and lateral radiographs of the humerus should be obtained, including
the shoulder and elbow joints. To obtain views at 90 degrees from each other, the patient,
NOT the arm, should be rotated (transthoracic lateral), as manipulation of the injured
extremity will typically result in distal fragment rotation only.
- Traction radiographs may aid in fracture definition in cases of severely displaced or
comminuted fractures.
- Computed tomography, bone scans, and magnetic resonance imaging are rarely indicated
except in cases in which pathologic fracture is suspected.

5. Classification
Descriptive
- Open versus closed
- Location: proximal third, middle third, distal third
- Displacement: nondisplaced, displaced
- Direction and character: transverse, oblique, spiral, segmental, comminuted
- Intrinsic condition of bone: normal, osteopenic, pathologic
- Articular extension
Orthopaedic Trauma Association Classification
See Fracture and Dislocation Compendium at http://ota.org/compendium/index.htm.

6. Treatment
- Goals are fracture union with acceptable humeral alignment and patient return to preinjury
level of function.
- Both patient and fracture characteristics, including patient age and functional level,
presence of associated injuries, soft tissue status, and fracture pattern, need to be
considered when selecting an appropriate treatment option.

Nonoperative: Most humeral shaft fractures (>90%) will heal with nonsurgical management.
- Nonoperative treatment requirements are:
o An understanding by the treating physician of the postural and muscular forces to be
controlled
o Close patient supervision and follow-up
o A cooperative and preferably upright and mobile patient
o An acceptable fracture reduction
o Intact/innervated arm musculature (e.g., intact brachial plexus)
- Twenty degrees of anterior (sagittal) angulation, 30 degrees of varus (coronal) angulation,
and up to 3 cm of bayonet apposition are acceptable and will not compromise function or
appearance.
- Hanging cast: Utilizes dependency traction by the weight of the cast and arm to affect
fracture reduction.
 o Indications include displaced midshaft humeral fractures with shortening, particularly
spiral or oblique patterns. Transverse or short oblique fractures represent relative
contra indications because of the potential for distraction and healing complications.
o The patient must remain upright or semiupright at all times with the cast in a dependent
position for effectiveness.
o It may be exchanged for functional bracing following early callus formation.
o More than 95% union is reported.
- Coaptation splint: Utilizes dependency traction and hydrostatic pressure to effect fracture
reduction but with greater stabilization and less distraction than a hanging arm cast. The
forearm is suspended in a collar and cuff.
o It is indicated for the acute treatment of humeral shaft fractures with minimal
shortening and for short oblique or transverse fracture patterns that may displace with
a hanging arm cast.
o Disadvantages include irritation of the patient’s axilla and the potential for splint
slippage.
o It is frequently exchanged for functional bracing 1 to 2 weeks after injury.
- Thoracobrachial immobilization (Velpeau dressing): This is used only in elderly patients or
children who are unable to tolerate other methods of treatment and in whom comfort is the
primary concern.
o It is indicated for minimally displaced or nondisplaced fractures that do not require
reduction.
o Passive shoulder pendulum exercises may be performed within 1 to 2 weeks after injury.
o It may be exchanged for functional bracing 1 to 2 weeks after injury.
- Shoulder spica cast: This has limited application, because operative management is typically
performed for the same indications.
o It is indicated when the fracture pattern necessitates significant abduction and external
rotation of the upper extremity.
o Disadvantages include difficulty of cast application, cast weight and bulkiness, skin
irritation, patient discomfort, and inconvenient upper extremity position.
- Functional bracing: This utilizes hydrostatic soft tissue compression to effect and maintain
fracture alignment while allowing motion of adjacent joints.
o It is typically applied 1 to 2 weeks after injury, after the patient has been placed in a
hanging arm cast or coaptation splint and pain/swelling has subsided.
o It consists of an anterior and posterior (or medial–lateral) shell held together with
Velcro straps.
o Success depends on an upright patient and brace tightening daily, as well as functioning
upper arm musculature.
o Contraindications include massive soft tissue injury, an unreliable patient, and an
inability to obtain or maintain acceptable fracture reduction.
o A collar and cuff may be used to support the forearm, but sling application may result in
varus angulation.
o The functional brace is worn for a minimum of 8 weeks after fracture or until
radiographic evidence of union.
Operative

- Indications for operative treatment include:

o Multiple trauma
o Inadequate closed reduction or unacceptable malunion
o Pathologic fracture
o Associated vascular injury
o “Floating elbow”
o Segmental fracture
o Intra-articular fracture extension
o Bilateral humeral fractures
o Open fracture
o Neurologic loss following penetrating trauma
o Brachial plexus injury
o Radial nerve palsy after fracture manipulation (controversial)
o Nonunion
o Unfavorable body habitus such as morbid obesity or pendulous breasts (relative
indication)
o Chronic shoulder or elbow stiffness as it results in increased motion through the fracture
and increases the risk on nonunion (relative indication)
- Surgical approaches to the humeral shaft include:
1. Anterolateral approach: preferred for proximal third humeral shaft fractures; radial nerve
identified in the interval between the brachialis and brachioradialis and traced proximally.
The brachialis muscle is split to afford access to the shaft. This can be extended proximally to
the shoulder.
2. Anterior approach: muscular interval between the biceps and brachialis muscles
3. Posterior approach: provides excellent exposure to most of the humerus, including the
elbow, but cannot be extended proximally to the shoulder; muscular interval is between the
lateral and long heads of the triceps. The medial head is split. The radial nerve must be
identified in the spiral groove usually at the midportion of the arm.

Patient Positioning
- Supine on a radiolucent table
o Used for anterior or anterolateral approach
o Quick and easy setup
o Good for multiply injured patients with multiple extremity involvement
- Beach chair
o Used for anterolateral approach
o Good when fracture extends into shoulder region, as it can be extended into
deltopectoral approach
o Weight of arm may be used to help reduce fracture
- Lateral
o Used for posterior approach
o Good when fracture extends into elbow region
- Prone
o Used for posterior approach
o Good when fracture extends into elbow region

Image Positioning
- Image intensifier can be placed on same or opposite side of the injured extremity

Surgical Techniques
Open Reduction and Plate Fixation
- Associated with the best functional results. It allows direct fracture reduction and stable
fixation of the humeral shaft without violation of the rotator cuff.
- Radiographs of the uninjured, contralateral humerus may be used for preoperative
templating.
- A 3.5- or 4.5-mm dynamic compression plate (large fragment) with fixation of six to eight
cortices proximal and distal to the fracture is typically used (Fig. 16.2).
- Lag screws should be utilized whenever possible.
- One should preserve soft tissue attachments to butterfly fragments.
- One should consider bridge plating if there is considerable fracture comminution. The plate
is used to span the area of injury with avoidance of soft tissue dissection and
devascularization at the fracture site. Fracture healing will proceed by callus formation, not
primary bone healing.
- Use of locked plates has grown in popularity, particularly in osteopenic or compromised
bone.
- Recent series reporting good results with use of percutaneous submuscular plating for
stabilization of humeral shaft fractures.

Intramedullary Fixation

- Indications include:
o Segmental fractures in which plate placement would require considerable soft tissue
dissection
o Humerus fractures in extremely osteopenic bone
o Pathologic humerus fractures
- Interlocked nails
o Current humeral nails have proximal and distal interlocking capabilities and are able to
provide rotational and axial fracture stability (Fig. 16.3).
o With antegrade nailing, the axillary nerve is at risk for injury during proximal locking
screw insertion. Screws protruding beyond the medial cortex may potentially impinge
on the axillary nerve during internal rotation. Anterior to posterior screws are avoided
because of the potential for injury to the main trunk of the axillary nerve.
o Distal locking usually consists of screws in the AP plane. Distal locking screw can be
inserted anterior to posterior or posterior to anterior via an open technique to minimize
the risk of neurovascular injury. Lateral to medial screws risk injury to lateral
antebrachial cutaneous nerve and the radial nerve.
- Current antegrade nailing techniques try to avoid entry site placement at the rotator cuff
insertion to minimize postoperative shoulder problems.
 - The proximal aspect of the nail should be countersunk to prevent subacromial impingement.

External Fixation (Fig. 16.4)

- Indications include:
o Infected nonunions ■ Burn patients with fractures ■ Open fractures with extensive soft
tissue loss
- Complications include pin tract infection, neurovascular injury, and nonunion.
- Postoperative Rehabilitation Range-of-motion exercises for the hand and wrist should be
started immediately after surgery; shoulder and elbow range of motion should be instituted
as pain subsides.

7. Complication
- Radial nerve injury occurs in up to 18% of cases.
o Most common with middle third fractures, although best known for its association with
Holstein-Lewis–type distal third fracture, which may entrap or lacerate the nerve as it
passes through the intermuscular septum.
o Most injuries are neurapraxias or axonotmesis; function should return within 3 to 4
months; laceration is more common in penetrating trauma.
o With secondary palsies that occur during fracture reduction, it has not been clearly
established that surgery will improve the ultimate recovery rate compared with
nonsurgical management.
o Delayed surgical exploration should be done after 3 to 4 months if there is no evidence
of recovery by electromyography or nerve conduction velocity studies.
o Advantages of late over early nerve exploration:
 Enough time will have passed for recovery from neurapraxia or neurotmesis.
 Precise evaluation of a nerve lesion is possible.
 The associated fracture may have united.
 The results of secondary nerve repair are as good as those of primary repair.
- Vascular injury: This is uncommon but may be associated with fractures of the humeral shaft
lacerating or impaling the brachial artery or with penetrating trauma.
o The brachial artery has the greatest risk for injury in the proximal and distal third of the
arm.
o It constitutes an orthopaedic emergency; arteriography is controversial because it may
prolong time to definitive treatment for an ischemic limb.
o Arterial inflow should be established within 6 hours.
o At surgery, the vessel should be explored and repaired and the fracture stabilized.
o If limb viability is not in jeopardy, bone repair may precede vascular repair.
o External fixation should be considered an option.
o With prolonged ischemia, one should consider reperfusion injury and the potential need
for fasciotomies.
- Nonunion occurs in up to 15% of cases.
o Risk factors include fracture at the proximal or distal third of the humerus, transverse
fracture pattern, fracture distraction, soft tissue interposition, and inadequate
stabilization/immobilization.
 o It may necessitate open reduction and internal fixation with bone grafting.
- Malunion: This may be functionally inconsequential; arm musculature and shoulder, elbow,
and trunk range of motion can compensate for angular, rotational, and shortening
deformities.