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Updated: Dec 27 2021

Humeral Shaft Fracture

  • Snapshot
    • A 72-year-old woman presents to the emergency room with left arm pain after tripping and falling on the sidewalk. She developed immediate pain throughout her arm. Radiographs of her left arm demonstrate a spiral midshaft humeral fracture. She is given appropriate analgesia and placed in a coaptation splint.
  • Introduction
    • Clinical definition
      • fracture of the humeral shaft
  • Epidemiology
    • Incidence
      • account for approximately 3% of all fractures
      • increasing incidence in the elderly
    • Demographics
      • bimodal age distribution
        • fragility fractures in the elderly
        • high-energy traumatic fractures in younger patients
    • Risk factors
      • osteoporosis
  • Etiology
    • Low-energy injury in elderly patients
    • High-energy injury in younger patients
    • Pathoanatomy
      • normal anatomy
        • bony anatomy
          • spiral groove (also known as the radial sulcus) is a shallow depression in the center of the lateral border of the humerus bone
          • humeral shaft is cylindrical centrally and becomes triangular distally
        • neurovascular anatomy
          • radial nerve and deep brachial artery course along the spiral groove of the humerus
    • Associated conditions
      • radial nerve palsy
      • forearm injuries
        • combination of humeral shaft fracture and forearm fractures is termed floating elbow
  • Presentation
    • Symptoms
      • arm pain
      • weakness
    • Physical exam
      • deformity may or may not be appreciated depending on the location and severity of the fracture
      • neurovascular examination before and after reduction is critical to identify radial nerve palsy or deep brachial artery injury
        • radial nerve palsy (5-10%) results in loss of
          • wrist extension (wrist drop)
          • metacarpal phalangeal joint extension
          • thumb abduction and extension
  • Imaging
    • Radiography
      • indication
        • always indicated if a humeral shaft fracture is suspected
      • findings
        • fracture patterns can vary
          • spiral, transverse, and comminuted
        • fracture locations can vary
          • proximal, midshaft, and distal
  • Differential
    • Distal humerus fracture
      • distinguishing factors
        • radiographs will demonstrate a fracture in the supracondylar, lateral condylar, or medial condylar zones of the distal humerus
    • Proximal humerus fracture
      • distinguishing factors
        • radiographs will demonstrate a fracture in the surgical neck or anatomic neck of the proximal humerus
        • commonly injures the axillary nerve
          • deltoid muscle function (i.e., arm abduction at shoulder)
  • Treatment
    • Nonoperative
      • coaptation splint followed by functional bracing
        • indication
          • most humeral shaft fractures can be treated conservatively
    • Operative
      • open reduction and internal fixation (ORIF)
        • indication
          • severe fractures
            • open fractures
            • vascular injuries requiring repair
            • brachial plexus injury
            • concomitant ipsilateral forearm fracture (floating elbow)
            • compartment syndrome
  • Complications
    • Nonunion or malunion
    • Radial nerve palsy
      • neuropraxia
        • most resolve over 3 months of observation
  • Prognosis
    • Favorable
      • low-energy injuries
    • Unfavorable
      • delay in rehabilitation
      • high-energy injuries
        • increased likelihood of neurotmesis (complete nerve transection)
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