Review Question - QID 220100

This patient sustained a closed torsional humeral shaft fracture. Although nonoperative management is classically recommended for this injury pattern, operative fixation in young, healthy patients is highly successful with demonstration of earlier return to sport (Answer choice 3).

Humeral shaft fractures often result from falls or high-energy trauma, however, a more rare subset of injuries exists as well, typically seen after throwing (e.g., during sports), known as torsional humeral shaft fractures (THSFs). THSFs are spiral fractures in the humeral shaft that result from the rotational forces experienced by the humeral shaft during throwing. Classification of humeral shaft fractures generally considers location (proximal, middle, distal) and fracture pattern (transverse, oblique, spiral, segmental, or comminuted). A critical aspect of initial evaluation is a thorough neurovascular examination, with particular attention paid to the radial nerve due to its anatomical proximity to the humeral shaft. Management varies from nonoperative functional bracing, often used for closed fractures within nonoperative tolerances, to surgical options such as plate osteosynthesis, intramedullary nailing, or external fixation, with the choice dictated by fracture specifics, associated injuries, and patient factors. There has been a recent trend toward operative fixation in young, healthy patients, owing to the reliably high union rate and low complication rate with surgical management.

Altintas et al. surveyed expert shoulder and elbow surgeons regarding the management of torsional humeral shaft fractures (THSFs) in throwing athletes. The survey found data for 72 fractures, with many managed non-operatively (61%), and they demonstrated that patients treated with open reduction and internal fixation (ORIF) returned to sport significantly faster (13.5 weeks) than those treated non-operatively (22.6 weeks), although overall return to sport rates and healing times were similar. They concluded that both operative and non-operative treatment can be used for these fractures, with operative treatment leading to a faster return to sport but with a slightly higher complication rate, information that could help inform decisions and patient expectations.

Westrick et al. retrospectively reviewed humeral shaft fractures at a level 1 trauma center, comparing outcomes of operative versus nonoperative treatment in 296 patients. They found that non-operative treatment with functional bracing was associated with a significantly higher nonunion rate (23.2%) compared to operative treatment (10.2%), despite the operative group having a higher proportion of open fracture and high-energy mechanisms. They additionally concluded time to union was not significantly different between groups, and nerve palsy was more common in the operative group (20 % vs 39 %); however, only two cases were iatrogenic, and both were transient.

Figures A and B are the AP and lateral radiographs, respectively, of a spiral distal third humeral shaft fracture.

Incorrect Answer Choices:
Answer choices 1, 2, and 5: Although nonoperative management is historically the mainstay of management for most closed humeral shaft fractures, this patient has expressed a desire to return to sport rapidly, and operative management in this case would be more in line with the patient’s wishes.
Answer choice 4: Electrodiagnostic studies are often obtained in the few months after the injury to help establish baseline status in cases of persistent neurologic deficits; however, they are not indicated acutely. The majority of neurologic deficits associated with closed fracture resolve spontaneously.