Humeral Shaft Fractures


Article Author:
Emily Bounds


Article Editor:
Stephanie Kok


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/8/2019 3:42:41 PM

Introduction

A direct blow commonly causes fractures that occur in the middle third of the shaft of the humerus.

Etiology

A fracture that occurs at the midshaft of the humerus usually occurs due to a direct blow to the upper arm. Most frequently, fractures are a result of trauma, such as a fall, motor vehicle accident, or motorcycle accident. In the elderly, it can also occur from a fall on the outstretched arm, where the humerus takes the brunt of the injury instead of the wrist.[1][2][3]

Epidemiology

Peak incidence occurs in males aged 21 to 30 and females aged 60 to 80, although a humerus fracture could happen in persons of any age or gender with the right mechanism of injury. Sixty percent of all humeral fractures occur in the middle-third of the humerus.[4]

Pathophysiology

The most important clinical pearl associated with midshaft humerus fractures involves injury to the radial nerve. Radial nerve injury occurs in approximately 18% of closed mid-shaft or distal shaft humerus fractures. In closed fractures, radial nerve injury is most commonly an incomplete neuropraxia rather than a complete laceration of the nerve. In open humerus fractures, the incidence of radial nerve laceration is much higher at 60%.[5][6][7]

The radial nerve originates in the brachial plexus and has nerve roots from C5 to T1. It crosses through the spiral groove on the posterior side of the humerus shaft. The spiral groove is located about 14 cm proximal to the lateral epicondyle and 20 cm proximal to the medial epicondyle.  The radial nerve is most likely to be damaged in humerus fractures that have a lateral displacement of the distal fracture segment, as the nerve is tethered to the bone and cannot withstand the forces applied to it as a result of the displacement. On physical exam, patients with a radial nerve injury may have wrist drop (loss or weakness of wrist extensors), loss or weakness of finger extension, and decreased or absent sensation to the posterior forearm, digits 1 to 3, and the radial half of the fourth digit. Up to 90% of patients with a closed humeral fracture with radial nerve injury will have a resolution of neuropraxia within three to four months following the injury.

Of note, radial nerve paralysis is rare in children with humeral fractures, though neuropraxia can still occur, also with a resolution of symptoms in three to four months.

It is also very important to confirm that the patient’s distal pulses and capillary refill are intact, as the brachial artery also traverses the humerus in proximity to the radial nerve and the above listed anatomic landmarks.

History and Physical

Patients will present with arm pain after traumatic injury. Also, patients may have a deformity to the upper arm, shortening of the extremity, swelling, and/or bruising. On exam, it is important to evaluate for skin tenting, motor function distal to the injury, sensation distal to the injury, and pulse and/or capillary refill distal to the injury. One should also evaluate the skin integrity; if there is an overlying laceration, it is classified as an open fracture. As with any fracture, one must also confirm that the limb is neurovascularly intact distal to the injury due to the risk of radial nerve and brachial artery injury, as described above.

Evaluation

Radiographic imaging of the affected upper arm with a minimum of two views should be obtained if the humeral fracture is suspected. Also, one should have a high suspicion of forearm, wrist, or clavicle fracture when a patient has a humeral fracture due to the mechanism of injury; thus, imaging of these areas should be considered as well.  If the patient has evidence of vascular injury or a large hematoma, a hemoglobin should be obtained to ensure there is no significant blood loss due to the injury. Of note, there can be significant blood loss associated with any long bone injury. Also, if urgent or emergent surgery is anticipated, basic screening labs, such as complete blood count (CBC) and complete metabolic panel or basic metabolic panel (CMP/BMP) may be obtained in the preparation of the patient going to the operating room and undergoing anesthesia. A prothrombin time or INR should be obtained on patients who are anticoagulated on warfarin. 

Vascular imaging is rarely indicated. Treatment for vascular compromise is a definitive reduction of the joint. Angiography only delays definitive management and does not add any additional information nor alter management.

With nerve injury, electromyography (EMG) may be used in the subacute or long-term phase to assess the extent of nerve damage.

Treatment / Management

Management of midshaft humerus fractures is historically conservative, meaning reduction and splint. There is approximately 90% rate of appropriate alignment and union with conservative management.[8][9][10]

A reduction should be performed more urgently if there is a loss of pulse distal to the injury or skin tenting. The reduction should not be performed without adequate pain control and/or sedation. Any overlying breaks in the skin (lacerations, abrasions, or skin tears) should be addressed before splinting of any kind. Splinting of a humerus fracture presents challenges to immobilization due to its location. As with any splint, the joint above and below the fractured bone should be immobilized, so for humerus fractures, this includes the elbow and shoulder. Appropriate splinting options for a humerus fracture would include a coaptation splint with a sling, a hanging arm cast, a long arm splint, or a shoulder immobilizer. If one is going to be performing procedural/conscious sedation, reduction, and splinting, all splinting material should be prepared and readily available in the patient’s treatment room before sedation.

Upon follow-up with an orthopedic specialist after the initial injury, a more long-term cast may be applied to immobilize the fractured extremity if conservative management is the approach of choice. This is done ten to 12 days following the date of injury.

Some indications for operative management include neurovascular injury, open fractures, comminuted fractures, inability to tolerate a splint/cast for a prolonged period, trauma with multiple fractures, other fractures to the same arm, or failed conservative treatment with nonunion of the fracture site. Conservative treatment is associated with a healing time of up to ten to 12 weeks with transverse or comminuted fractures taking longer to heal than spiral or oblique fractures. Operative management, however, is becoming increasingly popular outside of these indications due to more prompt healing times and the better promise of appropriate alignment and union.

Enhancing Healthcare Team Outcomes

Midshaft humeral fractures are best managed by a multidisciplinary team that includes an orthopedic surgeon, emergency department physician, nurse practitioner, radiologist and a therapist. The key is to ensure that there is no injury to the radial nerve. The majority of these fractures are managed non-surgically with casting. Extensive rehabilitation is required to regain muscle mass and strength once the fracture has healed.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Humeral Shaft Fractures - Questions

Take a quiz of the questions on this article.

Take Quiz
What can result from a midshaft humerus fracture?

(Move Mouse on Image to Enlarge)
  • Image 4322 Not availableImage 4322 Not available
    Contributed by Wikimedia Commons, Bill Rhodes (CC by 2.0) https://creativecommons.org/licenses/by/2.0/
Attributed To: Contributed by Wikimedia Commons, Bill Rhodes (CC by 2.0) https://creativecommons.org/licenses/by/2.0/



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following nerves is at risk of damage with mid shaft fractures of the humerus?

(Move Mouse on Image to Enlarge)
  • Image 4322 Not availableImage 4322 Not available
    Contributed by Wikimedia Commons, Bill Rhodes (CC by 2.0) https://creativecommons.org/licenses/by/2.0/
Attributed To: Contributed by Wikimedia Commons, Bill Rhodes (CC by 2.0) https://creativecommons.org/licenses/by/2.0/



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which type of humeral shaft fractures most commonly causes a radial nerve injury?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Radial nerve injury occurs with what percentage of humeral shaft fractures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following might be seen on the neurologic exam in a patient with a midshaft humerus fracture?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Where would one expect a patient with a midshaft humerus fracture and nerve injury to have decreased sensation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of splint would be appropriate for a midshaft humerus fracture?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Humeral Shaft Fractures - References

References

Rupp M,Schäfer C,Heiss C,Alt V, Pinning of supracondylar fractures in children - Strategies to avoid complications. Injury. 2019 Mar 29;     [PubMed]
Seo JB,Heo K,Yang JH,Yoo JS, Clinical outcomes of dual 3.5-mm locking compression plate fixation for humeral shaft fractures: Comparison with single 4.5-mm locking compression plate fixation. Journal of orthopaedic surgery (Hong Kong). 2019 May-Aug;     [PubMed]
Overmann AL,Colantonio DF,Wheatley BM,Volk WR,Kilcoyne KG,Dickens JF, Incidence and Characteristics of Humeral Shaft Fractures After Subpectoral Biceps Tenodesis. Orthopaedic journal of sports medicine. 2019 Mar;     [PubMed]
Hubbard EW,Riccio AI, Pediatric Orthopedic Trauma: An Evidence-Based Approach. The Orthopedic clinics of North America. 2018 Apr;     [PubMed]
Laulan J, High radial nerve palsy. Hand surgery     [PubMed]
Martin AR,Gittings DJ,Levin LS,Donegan DJ,Gray BL, Acute Radial Nerve Repair with Humeral Shaft Shortening and Fixation Following a Closed Humeral Shaft Fracture: A Case Report. JBJS case connector. 2018 Oct-Dec;     [PubMed]
Agarwal A,Chandra A,Jaipal U,Saini N, A panorama of radial nerve pathologies- an imaging diagnosis: a step ahead. Insights into imaging. 2018 Dec;     [PubMed]
Nowak LL,Dehghan N,McKee MD,Schemitsch EH, Plate fixation for management of humerus fractures. Injury. 2018 Jun;     [PubMed]
Grechenig S,Hohenberger G,Bakota B,Staresinic M,Grechenig P,Ernstberger A, Humeral shaft cerclage wiring: a safe technique to prevent radial nerve injury. Injury. 2017 Nov;     [PubMed]
Rocchi M,Tarallo L,Mugnai R,Adani R, Humerus shaft fracture complicated by radial nerve palsy: Is surgical exploration necessary? Musculoskeletal surgery. 2016 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric. When it is time for the Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric.