Humeral Shaft Fractures

Topic updated on 03/15/14 7:51pm
  • Humerus Shaft FractureIncidence
    • 3-5% of all fractures
    • bimodal age distribution
      • young patients with high-energy trauma 
      • elderly, osteopenic patients with low-energy injuries
Relevant Anatomy
  • Osteology
    • humeral shaft is cylindrical
  • Muscles
    • insertion for
      • pectoralis major 
      • deltoid 
      • coracobrachialis 
    • origin for 
      • brachialis 
      • triceps 
      • brachioradialis 
  • Nerve
    • radial nerve 
      • courses along spiral groove 
      • 14cm proximal to the lateral epicondyle
      • 20cm proximal to the medial epicondyle
  • OTA
    • bone number: 1
    • fracture location: 2
    • fracture pattern: simple:A, wedge:B, complex:C
  • Descriptive
    • fracture location: proximal, middle or distal third
    • fracture pattern: spiral, transverse, comminuted
  • Holstein-Lewis fracture    
    • a spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (22% incidence)
  • Symptoms
    • pain
    • extremity weakness
  • Physical exam
    • examine overall limb alignment
    • preoperative or pre-reduction neurovascular exam is critical
      • examine and document status of radial nerve pre and post-reduction
  •  Radiographs
    • views
      • AP and lateral
        • be sure to include joint above and below the site of injury 
      • transthoracic lateral
        • may give better appreciation of sagittal plane deformity 
      • traction views
        • may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated
  • Nonoperative 
    • coaptation splint followed by functional brace 
      • indications
        • indicated in vast majority of humeral shaft fractures
        • criteria for acceptable alignment include: 
        • < 20° anterior angulation
        • < 30° varus/valgus angulation
        • < 3 cm shortening
      • absolute contraindications
        • severe soft tissue injury or bone loss
        • vascular injury requiring repair
        • brachial plexus injury
      • relative contraindications 
        • see relative operative indications section
        • radial nerve palsy is NOT a contraindication to functional bracing 
      • outcomes
        • 90% union rate 
          • increased risk with proximal third oblique or spiral fracture 
        • varus angulation is common but rarely has functional or cosmetic sequelae
    • Damage control orthopaedics
      • closed humerus fractures, including low velosity GSW, should be initally managed with a splint or sling  
      • type of fixation after trauma should be directed by acceptable fracture alignment parameters, fracture pattern and associated injuries
  • Operative 
    • open reduction and internal fixation 
      • absolute indications
        • open fracture 
        • vascular injury requiring repair
        • brachial plexus injury 
      • relative indications
        • ipsilateral forearm fracture (floating elbow) 
        • bilateral humerus fracture
        • polytrauma or associated lower extremity fracture 
          • allows early weight bearing through humerus 
        • pathologic fractures
        • burns or soft tissue injury that precludes bracing
        • fracture characteristics
          • distraction at fracture site
          • long oblique or spiral proximal fracture
          • intraarticular extension
    • intramedullary nailing (IMN) 
      • relative indications
        • pathologic fractures
        • segmental fractures
        • severe osteoporotic bone
        • overlying skin compromise limits open approach 
        • polytrauma
  • Coaptation Splint & Functional Bracing
    • coaptation splint 
      • applied until swelling resolves
      • adequately applied splint will extend up to axilla and over shoulder
      • common deformities include varus and extension
        • valgus mold to counter varus displacement
    • functional bracing 
      • extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles
      • sling should not be used to allow for gravity-assisted fracture reduction
      • shoulder extension used for more proximal fractures
  • Open Reduction Internal Fixation with Plating
    • approaches
      • anterolateral approach to humerus 
        • used for proximal third to middle third shaft fractures 
        • distal extension of the deltopectoral approach
        • radial nerve identified between the brachialis and brachioradialis distally
      • posterior approach to humerus  
        • used for distal to middle third shaft fractures although can be extensile
        • triceps may either be split or elevated with a lateral paratricipital exposure
        • radial nerve is found medial to the long and lateral heads and 2cm proximal to the deep head of the triceps 
        • radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm proximal to radiocapitellar joint 
        • lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach  
    • techniques
      • plate osteosynthesis commonly with 4.5mm plate (narrow or broad)
        • 3.5mm plates may function adequately
      • absolute stability with lag screw or compression plating in simple patterns 
      • apply plate in bridging mode in the presence of signficant comminution 
    • postoperative
      • full crutch weight bearing shown to have no effect on union 
  • Closed Intramedullary Nailing (IMN)
    • techniques
      • can be done antegrade or retrograde
    • complication 
      • nonunion
        • nonunion rates not shown to be different between IMN and plating in recent meta-analyses 
        • IM nailing associated with higher total complication rates   
      • shoulder pain
        • increased rate when compared to plating (16-37%) 
      • nerve injury 
        • radial nerve is at risk with a lateral to medial distal locking screw 
        • musculocutaneous nerve is at risk with an anterior-posterior locking screw 
    • postoperative
      • full weight bearing allowed and had no effect on union 
  • Malunion
    • varus angulation is common but rarely has functional or cosmetic sequelae
    • risk factors
      • transverse fracture patterns
  • Nonunion
    • incidence
      • 2 to 10% in nonoperative management
      • 5 to 10% with surgical management
    • risk factors
      • distraction at the fracture site on injury films 
      • open fracture
      • metabolic/endocrine abnormalities (Vit D most common) 
      • segmental fracture
      • infection
      • shoulder or elbow stiffness (motion directed to fracture site)
      • patient factors (smoking, obesity, malnutrition, noncompliance)
    • treatment
      • compression plating with bone grafting   
        • shown to be superior to both IM nailing with bone grafting and compression plating alone
        • lateral, posterior or paratricipital (Gerwin) approach to allow exploration of the radial nerve 
  • Radial nerve palsy 
    • incidence
      • seen in 8-15% of closed fractures
      • increased incidence distal one-third fractures
      • neuropraxia most common injury in closed fractures and neurtomesis in open fractures
      • 85-90% of improve with observation over 3 months
      • spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months
    • treatment
      • observation
        • indicated as initial treatment  in closed humerus fractures
        • obtain EMG at 3-4 months
        • wrist extension in radial deviation is expected to be regained first 
        • brachioradialis first to recover, extensor indicis is the last 
      • surgical exploration
        • indications
          • open fracture with radial nerve palsy (likely neurtomesis injury to the radial nerve) 
          • closed fracture that fails to improve over ~ 3-6 months 
          • fibrillations (denervation) seen at 3-4 months on EMG


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Qbank (19 Questions)

(OBQ12.66) A 26-year-old right hand dominant male is involved in a motor vehicle collision and sustains the left humerus injury demonstrated in Figure A. The brachial artery is disrupted and requires urgent attention in the operating room. The patient's preoperative nerve evaluation demonstrates that the patient is unable to initiate extensor carpi radialis longus, extensor carpi radialis brevis, extensor pollicis brevis, extensor indicis proprius, and extensor pollicis longus motor activity. What is the most likely etiology for this observed neurologic examination? Topic Review Topic
FIGURES: A          

1. Neurapraxia of the median nerve
2. Axonotmesis of the radial nerve
3. Neurotmesis of the ulnar nerve
4. Neurotmesis of the radial nerve
5. Axonotmesis of the ulnar nerve

(OBQ12.166) A 42-year-old man sustains the injury shown in Figure A after a fall from 6 feet. Physical exam after the injury reveals a flaccid ipsilateral limb. An MRI is performed that reveals nerve root avulsions from C5-T1. Which of the following is the most appropriate management of his fracture at this time? Topic Review Topic
FIGURES: A          

1. Closed management with a coaptation splint
2. Closed management with a coaptation splint followed by transition to a functional brace after 7-10 days
3. External fixation of humeral shaft fracture until brachial plexus injury resolves
4. Open reduction, surgical fixation with plating
5. Closed management with a sling until brachial plexus injury resolves

(OBQ10.125) A 45-year-old male sustains a Gustilo and Anderson Type II open transverse humeral shaft fracture. He undergoes the treatment shown in Figures A and B. What is the advantage of this treatment choice as compared to antegrade intramedullary nailing? Topic Review Topic
FIGURES: A   B        

1. Decreased risk of post-operative elbow pain
2. Decreased risk of radial nerve injury
3. Decreased risk of reoperation
4. Decreased risk of infection
5. Decreased risk of blood loss

(OBQ09.183) On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites? Topic Review Topic

1. Spiral groove of the humerus
2. At the arcuate ligament of Osborne
3. 10 cm distal to the lateral acromion
4. 10 cm proximal to radiocapitellar joint
5. At the origin of the deep head of the triceps

(OBQ09.188) During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves? Topic Review Topic

1. Ulnar
2. Musculocutaneous
3. Radial
4. Median
5. Axillary

(OBQ09.210) A 32-year-old man presents to the emergency department with a humeral shaft fracture. He has wrist drop as well as impaired finger and thumb extension. Which motor function would be expected to recover last? Topic Review Topic

1. Elbow extension
2. Forearm supination
3. Wrist extension in radial deviation
4. Middle finger MCP extension
5. Index finger MCP hyperextension

(OBQ08.122) Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing? Topic Review Topic

1. worse functional results
2. higher need for subsequent surgeries
3. less blood loss
4. higher union rates
5. increased postoperative shoulder stiffness

(OBQ08.177) All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT: Topic Review Topic

1. Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
2. Mid-diaphyseal fracture with radial nerve palsy from nonballistic penetrating injury
3. Proximal one-third oblique fracture
4. Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
5. Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

(OBQ07.265) Which of the following is an indication for surgical treatment of an acute humeral shaft fracture? Topic Review Topic

1. radial nerve palsy
2. long oblique fracture type
3. comminuted fracture
4. Holstein-Lewis fracture type
5. ipsilateral both bone forearm fracture

(OBQ05.74) A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status? Topic Review Topic

1. Non-weight bearing bilateral lower extremities and right upper extremity
2. Weight bearing as tolerated bilateral lower extremities and right upper extremity
3. Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
4. Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
5. Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

(OBQ05.85) A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure A. What is the next most appropriate step in treatment? Topic Review Topic
FIGURES: A          

1. exchange nailing
2. manipulation under anesthesia
3. nail removal, autologous bone grafting and plate fixation
4. percutaneous locked plating
5. nail dynamization

(OBQ05.106) A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk? Topic Review Topic
FIGURES: A   B        

1. Radial
2. Ulnar
3. Median
4. Axillary
5. Musculocutaneous

(OBQ05.110) A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. Compared with open reduction and internal fixation with a plate and screw construct, the treatment shown in Figure A is associated with all of the following EXCEPT? Topic Review Topic
FIGURES: A          

1. Increased shoulder impingement
2. Increased risk of iatrogenic comminution
3. Increased time to return to normal activity
4. Increased rate of nonunion
5. Increased risk of revision surgery

(OBQ04.96) A 33-year-old male presents 7 months after a fall from 15 feet. He complains of continued pain over his left arm and you elicit pain and gross movement with palpation of his humerus. Infectious workup is negative and a radiograph is shown in Figure A. What is the most appropriate next step in his management? Topic Review Topic
FIGURES: A          

1. Reassurance and appropriate followup
2. Sarmiento bracing
3. Use of a bone stimulator
4. Exchange humeral nailing
5. IM nail removal, open reduction internal fixation with bone grafting

(OBQ04.111) A 68-year-old male sustains the humeral shaft fracture shown in Figures A and B. Upon presentation, he is unable to extend his thumb and wrist. After 4 months of non-operative management, the fracture has healed, but his physical exam is unchanged. What is the next most appropriate step in management? Topic Review Topic
FIGURES: A   B        

1. EMG and nerve conduction tests followed by possible surgical exploration
2. Continued observation
3. Immediate surgical exploration
4. Shoulder MRI
5. CT scan of the humerus

(OBQ04.229) A patient sustained a transverse humeral shaft fracture 6 months ago and presently complains of pain and instability at the area of injury. A plain radiograph is shown in Figure A and on exam there is gross motion at the fracture site. What is the most appropriate definitive treatment? Topic Review Topic
FIGURES: A          

1. ultrasound therapy to nonunion site
2. oral bisphosphonates
3. open reduction internal fixation with autologous bone graft
4. antegrade intramedullary nail
5. retrograde intramedullary nail


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Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA
J Bone Joint Surg Am. 2000 Apr;82(4):478-86. PMID: 10761938 (Link to Pubmed)
32 responses
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Acta Orthop. 2010 Apr;81(2):216-23. PMID: 20170424 (Link to Pubmed)
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Chapman JR, Henley MB, Agel J, Benca PJ
J Orthop Trauma. 2000 Mar-Apr;14(3):162-6. PMID: 10791665 (Link to Pubmed)
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McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH
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