Humeral shaft fracture
X-ray of a normal humerus showing the long shaft

Definition

Fracture of the humerus shaft comprises a break of the long humeral bone between its extremities: the humeral head, joining at the shoulder joint with the glenoid fossa of the scapula, and the distal humeral head forming the elbow joint. The humeral shaft is the middle portion of the bone.

Left: X-ray of a complex humerus shaft fracture; Right: Image of radial nerve damage caused by humeral fracture

Pathology

The fractures of the humerus shaft represent 3-5% of all fractures. They can occur at any level of the humerus shaft including the proximal, middle, or distal humerus. The involvement of the radial nerve is critical in humerus shaft fractures. This nerve travels along the humerus from the humerus neck to the hand, and spirals closely around the bone shaft. Fractures of the humeral shaft can damage the radial nerve causing the inability to extend (bend) the wrist and the fingers backwards (drop hand). Injury to this nerve is caused by its entrapment within the bone break.

Classification

Fractures of the humerus shaft can display various patterns: transverse, oblique, spiral, and comminuted. In addition they are differentiated depending on whether the fracture is displaced or undisplaced, relative to the loss of bone alignment and closed or open fracture. The AO classification is one of most used systems available to characterise humerus shaft fractures. According to the AO humerus shaft fractures are divided into their level of comminution:

Type A - No comminution

Type B - Presence of butterfly fragment (wedge-shaped fragment of bone)

Type C - Comminution

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Road traffic accidents are a frequent cause of humerus shaft fractures

Causes

Fractures to the humerus shaft are mostly caused by trauma with only a small percentage due to underlying conditions that weaken the bone density (osteoporosis, cancer, Paget’s disease). This type of fractures is common amongst middle-aged and elderly people, mostly women, due to low energy falls. More commonly in younger males, humerus fractures often result from high-energy impact injuries with direct trauma to the arm and torsion of the upper extremity. They often coexist with a shoulder dislocation. In this young population humerus shaft fractures are caused by road traffic accidents and sport injuries.

Contact sports with high energy impact increase the risk of a humerus shaft fracture

Risk factors

The most frequent risk factors leading to a humerus shaft fracture include:

Tendency to fall in elderly individuals (poor vision, lack of physical exercise)

Medical conditions (diabetes, seizure)

Sports (bicycle, horse riding)

Contact sports (football, rugby)

Post-menopausal age in women

Cancerous metastases

Symptoms

The symptoms arising from a humerus shaft fracture are quite evident: 

Sudden sharp pain on the upper arm at time of injury

Snapping noise

Deformity of the upper arm

Shortening of the upper arm

Crepitus with arm movement and palpation

Significant swelling

Subcutaneous bleeding

Inability to raise the arm

Increasing pain when attempting to move the arm

Radial nerve palsy

 A bruised arm following a humerus shaft fracture

Diagnosis

Clinical examination begins by discussing the medical history including the causes leading to a humerus shaft fracture. The main scope of the diagnosis is to determine the type of humerus shaft fracture to develop an optimal treatment plan suitable to the specific fracture. It is critical for the examiner to assess potential damage caused to the radial nerve and the vasculature. Clinical examination will determine:

Changes in the anatomy of the upper arm and bone deformities

Presence of bruises and lacerations in case of open fractures

Functional restriction in the range of movement of the arm

Increasing pain while moving the arm

Neurological symptoms relative to the radial nerve

Peripheral pulses to evaluate possible vascular injury

X-rays are taken under different angles to ascertain the type of humerus shaft fracture and whether the elbow and shoulder joints have been affected by the injury. A CT scan and MRI may be requested in more complex cases. Severe multiple injuries to the humerus shaft can lead to secondary complications and require immediate attention at the Emergency Department including the examination by an orthopaedic surgeon.

Treatment

Patient with a humerus shaft fracture treated conservatively with a cast

Nonoperative treatment

In case of undisplaced or minimally displaced humeral fractures conservative treatment is standard management. Nonoperative treatment is also accepted in case of relatively small displacement with a 30-40° angulation of the bone extremities. Standard management involves the use of a sling, cast, splint or brace and arm immobilisation for a few weeks. A coaptation splint may be used initially until swelling has subsided and then replaced with a rigid cast or a brace after 1-2 weeks. A hanging arm cast may also be used to keep the arm bone in alignment.

Intramedullary rod

Surgical treatment

Surgery is required in significantly displaced, comminute and in open fractures. This treatment option will depend on the age, general health and the osteoporotic nature of the bone. Several approaches are available to repair the humeral shaft fracture including: 

Intramedullary rod or nail involves the use of a metal rod introduced in the canal of the bone shaft that is fixed on the outer bone extremities with screws. The rod can be inserted either from the proximal or distal end of the humerus

Open reduction and internal fixation (ORIF)

Open reduction and internal fixation (ORIF) consists of accessing the humerus with a large skin incision to allow the insertion of a metal plate along the fracture length, which is fixed with multiple screws

External fixation of a comminuted humerus shaft fracture

External fixation with percutaneous screws is a temporary fixation of the humerus fracture with screws inserted through the skin to maintain the anatomical bone alignment while the fracture is healing. This procedure is often followed by permanent internal fixation within 14 days after the injury. This treatment is used in situations where an immediate internal fixation cannot be performed, eg. multiple injured patients or severe soft tissue damage. In rare cases the external fixator remains in place until the fracture has healed completely.

Complication: malunion of the bone extremities

With either conservative or surgical treatments, complications after the repair of humerus shaft fracture can occur. The most frequent complications include:

Infection

Non-union of the fracture (when the gap between the bone extremities is not closed)

Mal-union when the fracture heals with abnormal bone alignment

Temporary damage to the radial nerve

Vascular damage

Joint stiffness of the shoulder and elbow

Physiotherapy begins following stabilisation of the humerus fracture

Rehabilitation

A humerus shaft fracture requires approximately three months to heal. Major attention is drawn to restore the function of the elbow and shoulder joints that may have stiffened during the immobilisation phase. Rehabilitation will begin as soon as the fracture has become stable as recommended by the orthopaedic surgeon. Physical exercise is gradually increased in intensity to regain strength, flexibility and range of movement of the elbow and shoulder. The prognosis of humerus shaft fracture is usually good. Standard rehabilitative therapy includes: 

Massage

Joint mobilisation

Stretches

Dry needling

Electrotherapy

Activity modification advice

Return to sport/work plan

Postural taping

Monitoring osteoporosis in post-menopausal women with hip bone densitometry

Prevention

The main preventative measures aim at reducing the risk of falls and use a protecting gear during contact sports, biking/motor biking protect the arm in case of collision and accident. Other common preventive strategies include:

Postural taping

Osteoporosis treatment

Use of walking devices to improve stability and avoid falls in elderly patients

Modification of physical activities

Regular physical exercise to maintain muscle strength, joint flexibility and correct posture