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Updated: May 2 2024

Humeral Shaft Fractures

Images
https://upload.orthobullets.com/topic/1016/images/humerus-fracture-midshaft.jpg
https://upload.orthobullets.com/topic/1016/images/distal third humerus.jpg
https://upload.orthobullets.com/topic/1016/images/proximal third spiral.jpg
https://upload.orthobullets.com/topic/1016/images/im nail.jpg
https://upload.orthobullets.com/topic/1016/images/al fixation.jpg
  • Summary
    • Humeral shaft fractures are common fractures of the diaphysis of the humerus, which may be associated with radial nerve injury.
    • Diagnosis is made with orthogonal radiographs of the humerus.
    • Treatment can be nonoperative or operative depending on location of fracture, fracture morphology, and association with other ipsilateral injuries. 
  • Epidemiology
    • Incidence
      • 3-5% of all fractures
      • 7 to 11.3 per 100,000
    • Demographics
      • age
        • 60% occur in patients older than 50 years
        • bimodal age distribution
          • young
            • high-energy trauma
            • peak incidence in third decade of life
        • elderly patients
          • low energy falls
          • osteopenic patients
      • Location
        • 30% occur in the proximal third of the humeral shaft
        • 60% occur in the middle third of the humeral shaft
          • Most common location
        • 10% occur in the distal third of the humeral shaft
      • Risk factors
        • previous fracture history
        • smoking in men
        • elderly age
        • osteoporosis
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • ground level fall (60%)
          • most common mechanism
        • motor vehicle accident (~30%)
          • 2nd most common mechanism
        • pathologic fractures (4.3%)
        • open fractures (3%)
      • proximal third humeral shaft fractures
        • common in older individuals
        • often results from fall onto an outstretched hand resulting in impaction fracture at the surgical neck
      • middle third humeral shaft fractures
        • transverse fracture
          • result of a direct blow to the arm
        • spiral fracture
          • results from a fall onto an outstretched hand or from torsional force
      • distal third humeral shaft fractures
        • result from fall onto a flexed elbow
      • Associated conditions
        • floating elbow
          • fracture of the humeral shaft and the proximal to middle radius and ulna
          • often occurs as a result of a high-energy trauma
          • more common in pediatric patients than in adults
      • ipsilateral shoulder dislocation
        • uncommon injury pattern
        • dislocation is most likely to be a posterior dislocation rather than an anterior dislocation
  • Anatomy
    • Osteology
      • humeral shaft extends from the surgical neck of the humerus to the supracondylar ridge and is cylindrical in shape
      • distally humerus becomes triangular with the formation of the medial and lateral supracondylar ridges
      • intramedullary canal terminates 2 to 3 cm proximal to the olecranon fossa
      • radial groove is a depression along the posterolateral aspect of the humerus where the radial nerve and profunda brachii artery traverse
    • Arthrology
      • articulates with scapula proximally and distally with the radius and ulna
    • Muscles
      • insertion for
        • pectoralis major
        • deltoid
          • will abduct proximal fragment in fractures occurring proximal to the insertion of the pectoralis major
        • coracobrachialis
      • origin for
        • brachialis
        • triceps
        • brachioradialis
    • Nerve
      • radial nerve
        • exits axilla posterior to the brachial artery
        • enters the posterior compartment of the arm through the triangular interval
        • runs between the medial and long head of the triceps
        • courses along the spiral groove then become anterior to the humerus
          • ~7.5cm from the articular surface
        • 14cm proximal to the lateral epicondyle
        • 20cm proximal to the medial epicondyle
      • ulnar nerve
        • Enters the posterior compartment at the arcade of Struthers and runs medially towards cubital tunnel
        • ~8cm from the medial epicondyle
      • axillary nerve
        • runs posterior to anterior around the proximal humerus 4 to 7cm from the tip of the acromion
    • Compartments
      • anterior compartment
        • muscles
          • biceps brachii, brachialis, and coracobrachialis
        • vasculature
          • brachial artery and vein
        • nerves
          • musculocutaneous, median, and ulnar nerve
      • posterior compartment
        • muscles
          • triceps
        • nerves
          • radial nerve
  • Classification
    • OTA
      • bone number: 1
      • fracture location: 2
      • fracture pattern: simple:A, wedge:B, complex:C
    • Garnavos classification
      • location
        • P: proximal
        • M: middle
        • D: distal
        • j: extension into the joint
      • morphology
        • S: simple
          • T: transverse or oblique
          • S: spiral
        • I: intermediate
          • one or two sizable butterfly fragments
        • C: complex
          • three or more butterfly fragments, or significant comminution
    • 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 (7-22% incidence)
        • increases risk of radial nerve entrapment with the fracture
  • Presentation
    • Symptoms
      • pain
      • extremity weakness
    • Physical exam
      • swelling
      • tenderness over the fracture site
      • skin tenting
      • examinination of overall limb alignment for deformity
        • will often present with shortening and in varus
      • preoperative or pre-reduction neurovascular exam is critical
        • examine and document status of radial nerve pre and post-reduction
          • wrist and thumb interphalangeal joint extension
          • sensation over the dorsum of the hand
  • Imaging
    • 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
          • rotating the patient prevents rotation of the distal fragment avoiding further nerve or soft tissue injury
        • traction views
          • may be necessary for fractures with significant shortening, proximal or distal extension but not routinely indicated
    • CT scan
      • may be utilized if there is concern for intra-articular extension
    • CTA
      • may be indicated if there is concern for vascular injury
    • Electromyography (EMG)
      • indicated in the setting of nerve palsy to assess for nerve recovery, but is not indicated acutely as it will not dictate fracture management
  • Treatment
    • Nonoperative
      • immobilization (coaptation splint or hanging arm cast for 7 to 10 days followed by a functional brace) 
        • indications
          • indicated in vast majority of humeral shaft fractures
            • criteria for acceptable alignment include:
              • < 20° anterior angulation
              • < 30° varus/valgus angulation
              • < 30° of rotational malalignment
              • < 3 cm shortening
          • relative indications
            • community ambulator
              • noncompliant patients
        • contraindications
          • absolute
            • severe soft tissue injury or bone loss
            • vascular injury requiring repair
            • brachial plexus injury
          • relative
            • see relative operative indications section
            • worsening nerve dysfunction
            • radial nerve palsy is NOT a contraindication to functional bracing
        • outcomes
          • average union rate of 93.5% (77-100%)</p>
            • increased risk with proximal third (54%), and oblique or spiral fracture patterns (23%)
          • average time to union of 10.7 weeks (6.5-22 weeks)
          • average malunion rate of 12%
          • range of motion
            • 38-45% of patients lose  external range of motion (5-45 degrees)
            • 88.6% of patients lose less than 10 degrees of shoulder motion
            • 92% lose less than 10 degrees of elbow motion
          • varus angulation is common but rarely has functional or cosmetic sequelae
      • damage control orthopaedics (DCO)
        • closed humerus fractures, including low velocity GSW, should be initially 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
      • external fixation (Exfix)
        • indications
          • high energy complex or comminuted fracture
          • open fracture
          • significant soft tissue or bony defect
          • floating elbow
          • hemodynamically unstable polytrauma
          • concomitant vascular injury
        • typically utilized as provisional fixation until definitive treatment can be performed, but may be used definitely if needed
        • outcomes
          • average operative time of 30 minutes (18 to 50 minutes)
          • 80% achieve good to excellent outcomes
          • superficial pin track infection rate of 12%
      • open reduction and internal fixation (ORIF)
        • indications
          • absolute
            • open fracture
            • vascular injury requiring repair
            • brachial plexus injury
            • ipsilateral forearm fracture (floating elbow)
            • compartment syndrome
            • periprosthetic humeral shaft fractures at the tip of the stem
            • inability to maintain satisfactory reduction closed
            • progressive nerve deficit after closed manipulation
          • relative
            • bilateral humerus fracture
            • polytrauma or associated lower extremity fracture
              • allows early weight bearing through humerus
            • pathologic fractures
              • typically indicated if life expectancy is greater than 6 months
            • burns or soft tissue injury that precludes bracing
            • fracture characteristics
              • distraction at fracture site
              • segmental fractures
              • short oblique or transverse fracture pattern
                • OTA type A
              • intraarticular extension
              • long oblique proximal humeral shaft fracture
            • large body habitus, obesity, or large breasts
      • intramedullary nailing (IMN)
        • indications
          • relative
            • pathologic fractures
            • segmental fractures
            • severe osteoporotic bone
            • overlying skin compromise limits open approach
            • polytrauma
  • Techniques
    • 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
        • weekly radiographs for first 3 weeks to ensure maintenance of reduction
          • every 3-4 weeks after that
    • External Fixation
      • approaches
        • proximal pins
          • anterolateral surface of proximal humerus
          • mini-open approach with dissection down to bone to mitigate axillary nerve injury
        • distal pins
          • lateral aspect of distal fragment
          • requires mini-open approach with dissection down to bone to mitigate radial nerve injury
          • most distal pin is just proximal to olecranon fossa
          • visualize cortical surface prior to inserting pins
    • Open Reduction and Internal Fixation (ORIF)
      • approaches
        • anterior (brachialis split) approach to humerus
          • used for middle third shaft fractures
          • deep dissection through internervous plane of brachialis muscle
            • lateral fibers (radial n.) and medial fibers (musculocutaneous n.) in majority of patients (~80%)
        • 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 significant comminution
      • postoperative
        • full crutch weight bearing shown to have no effect on union
    • 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%)
          • functional shoulder outcome scores (ASES scores) not shown to be different between IMN and ORIF
        • nerve injury
          • while controversial, a recent meta-analysis showed no difference between the incidence of radial nerve palsy between IMN and plating
          • 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
  • Complications
    • Humeral shaft fx nonunion
      • no callous on radiograph and gross motion at the fracture site at 6 weeks from injury has a 90-100% PPV of going on to nonounion in closed humeral shaft fractures
    • Malunion
      • varus angulation is common but rarely has functional or cosmetic sequelae
      • risk factors
        • transverse fracture patterns
    • Radial nerve palsy
      • incidence
        • seen in 8-15% of closed fractures
        • increased incidence distal one-third fractures (22%)
        • neuropraxia most common injury in closed fractures and neurotomesis in open fractures
        • iatrogenic radial nerve palsy is most common following ORIF via a lateral approach (20%) or posterior approach (11%)
        • 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 NCS/EMG at ~2 months
            • useful to determine extent of nerve damage, baseline of function, and to monitor recovery
          • 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 neurotomesis injury to the radial nerve)
            • closed fracture that fails to improve over ~4-6 months
            • fibrillations (denervation) seen on EMG
        • tendon transfers
          • indications
            • persistent radial nerve palsy - optimal timing debated
            • wrist extension: PT to ECRB
            • finger extension: FCR/FCU to EDC
            • thumb extension: PL to EPL
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