II. Epidemiology

  1. Humeral Shaft Fractures represent 3% of all Fractures
  2. Age distribution bimodal
    1. Young patients (High energy Trauma)
    2. Elderly patients (Low energy injury)

III. Mechanism

  1. Direct blow to Humerus
  2. Fall on an outstretched arm

IV. Signs

  1. Upper arm with deformity
  2. Evaluate for Compartment Syndrome
    1. Complete neurovascular exam
  3. Evaluate for Radial Nerve injury
    1. Wrist Drop
    2. Finger extension weakness
    3. Supination weakness
    4. Radial Nerve decreased Sensation (e.g. Two Point Discrimination)

V. Imaging

  1. Humerus XRay (2 view)
    1. Consider XRay Shoulder for associated Shoulder Dislocation
    2. Consider XRay elbow for associated Forearm Fracture

VI. Management: Manipulative reduction with Local Anesthetic

  1. Pitfalls
    1. Avoid distraction of Fracture fragments
  2. Patient positioning
    1. Patient sits on stool, leaning forward
    2. Support wrist to overcome apprehension
    3. Elbow should hang free at 90 degrees flexion
  3. Reduction Technique
    1. Weight of arm alone may reduce Fracture
    2. Gentle traction downward at wrist
    3. Countertraction with a sling around axilla
    4. Assistant holds axilla sling and thumb
    5. While molding splint, apply valgus pressure at Fracture to overcome typical varus displacement
  4. Confirm end-to-end apposition
    1. Apply upward pressure on elbow
    2. Telescoping Humerus indicates apposition not secure

VII. Management: Splint Immobilization

  1. Coaptation Splint: U-Shaped splint "Sugar-Tong"
    1. Splint medially from axilla to elbow
    2. Closed end of "U" under elbow (flexed to 90 degrees)
    3. Splint over lateral arm to Shoulder acromion process
  2. Ace wrap around splinted arm
  3. May swath by strapping Humerus to chest
  4. Sling to support elbow and Forearm

VIII. Management: Surgery Indications

  1. Open or Comminuted Fracture
  2. Vascular Injury
  3. Brachial Plexus Injury
  4. Ipsilateral Forearm Fracture (floating elbow)
  5. Compartment Syndrome

IX. Management: Follow-up

  1. Replace initial splint with Sarmiento Brace within 2 weeks of Fracture
  2. Electromyogram Indications
    1. Indicated in Radial Nerve Palsy or other neurologic deficit
    2. Perform at 6 weeks after injury

X. Prognosis

  1. Heals in 8 to 10 weeks
  2. Heals well with closed reduction (non-operative in >90% of cases)
    1. Even malunion with mild angulation is typically well tolerated

XI. Complications

  1. Acute Compartment Syndrome
  2. Radial Nerve Injury (Radial Nerve Palsy, 11-20% of Humeral Fractures)
    1. Travels along spiral groove, in close contact with humeral shaft
    2. Most Radial Nerve injuries (80%) resolve spontaneously with time
    3. Consider surgical exploration if failure to resolve

XII. Resources

  1. Bounds (2020) Humeral Shaft Fractures, Stat Pearls
    1. https://www.ncbi.nlm.nih.gov/books/NBK448074/

XIII. References

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