Humeral shaft fractures (HSFs) represent 3% of the fractures of the locomotor apparatus, and the middle third of the shaft is the section most affected. In the majority of cases, it is treated using nonsurgical methods, but surgical indications in HSF cases are increasingly being adopted. The diversity of opinions makes it difficult to reach a consensus regarding the types of osteosynthesis, surgical technique and quantity and quality of synthetic materials that should be used. It would appear that specialists are far from reaching a consensus regarding the best method for surgical treatment of HSFs.
Fracture shaft of humerus includes a group of fracture where the main fracture line lies distal to surgical neck of the humerus and proximal to supracondylar ridge distally. It accounts for nearly 3.5% of all different type of fractures of bone. 5% of injuries were associated with open wound and 63% were of simple fracture pattern.
Anatomy of Humeral Shaft Fractures
The humerus itself is a cylinder proximally, which provides strength and resistance to both torsional and bending forces, and distally it tapers to a triangular shape. It is enveloped in muscle and soft tissue, hence the favorable prognosis for healing in uncomplicated fractures. Muscles originating on the humeral shaft include the brachialis, brachioradialis, and the medial and lateral heads of the triceps brachii. The deltoid, pectoralis major, teres major, latissimus dorsi, and coracobrachialis all insert on the humeral shaft and depending on the location of the fracture, all will have specific deforming forces acting on the fracture fragments. The blood supply to the humeral shaft is provided predominantly by the nutrient artery that should be protected during surgical dissection [rx].
The arm can also be divided into anterior and posterior compartments by thick fibrous bands – the medial and lateral intermuscular septa. The brachial artery, median nerve, and musculocutaneous nerve remain in the anterior compartment for their entire course and are rarely encountered in surgical exposures to the humerus. The median nerve receives contributions from the medial and lateral cords of the brachial plexus and then travels just medial to the brachial artery, adjacent to the coracobrachialis muscle belly and along the anterior surface of the medial intermuscular septum. It provides no innervation to muscles proximal to the elbow.
The ulnar nerve arises from the medial cord of the brachial plexus and begins in the anterior compartment. It travels anterior to the medial intermuscular septum and posterior to the brachial artery. At the arcade of Struthers, approximately 8 cm from the medial epicondyle, it crosses to the posterior compartment to enter the cubital tunnel. It also provides no innervation to muscles proximal to the elbow.
The radial nerve is a terminal branch of the posterior cord of the brachial plexus. It begins in the posterior compartment and then passes through to the anterior compartment. It begins anteromedially and travels along the subscapularis proximally to join with the profound brachii at the triangular interval. About 10–14 cm from the lateral acromion, the nerve and artery travel along the posterior humerus in the spiral groove, separating the medial and lateral heads of the triceps at about the level of the deltoid tuberosity. It enters the anterior compartment through the lateral intermuscular septum approximately 10 cm from the distal articular surface, here it is tightly bound by the septum and therefore susceptible to traction injuries and radial nerve palsies [rx, rx].
Causes of Humeral Shaft Fractures
Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fractures, such as osteoporosis, a low bone density, or vitamin B deficiency.[rx]
- Humeral Shaft Fractures – most often occur among elderly people with osteoporosis who fall on an outstretched arm.[rx] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure.[rx]
- A stress fracture of the proximal – and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball.[rx]
- Sudden forceful fall down
- Road traffic accident
- Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
- Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
- Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
- Have osteoporosis – a disease that weakens your bones
- Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
- Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
- Wave an inadequate – intake of calcium or vitamin D
- Football or soccer – especially on artificial turf
In younger patients, proximal humeral fractures are usually caused by high-energy trauma, such as traffic accidents or sporting accidents. In older patients, the most common cause is a fall onto the outstretched arm from a standing position, which is a type of low-energy trauma [rx, rx]
Symptoms Humeral Shaft Fractures
- Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, a musculature may cause absence of deformity on inspection.[rx]
- Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.[rx]
- Symptoms from poor blood circulation in the arm are uncommon due to collateral circulation in the arm.[rx]
Diagnosis of Humeral Shaft Fractures
Typically, the patient holds the injured arm in a protective posture close to the chest. Pain, swelling, hematoma, and tenderness of the proximal portion of the humerus may indicate the presence of a fracture. The perfusion and sensorimotor function of the limb should be tested in the periphery. The functioning of the axillary nerve should be tested as well.
- Radiographic examination using anterior and lateral views is sufficient for diagnosing and classifying HSFs.
- Bone scintigraphy, magnetic resonance, and computed tomography are used in special situations, such as for diagnosing and staging pathological fractures.
- Electroneuromyography is only useful for diagnosing neurological lesions from the third week after the trauma. Therefore, adequate clinical examination is essential.
- Recommended views
- obtain AP and lateral of humerus and elbow
- include the entire length of humerus and forearm
Obtain wrist radiographs if elbow injury present or distal tenderness on exam
- Oblique radiographs may assist in surgical planning
- Traction radiographs may assist in surgical planning specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar fragment, this can influence hardware choice
- Often obtained for surgical planning
- Especially helpful when shear fractures of the capitellum and trochlea are suspected
- 3D CT scan improves the intraobserver and interobserver reliability of several classification systems
- Usually not indicated in acute injury
Treatment of Humeral Shaft Fractures
- Immobilization – in either a sling or a Velpeau bandage, with early gentle range of motion exercises. Some fractures may reduce with gravity alone as the patient resumes ambulating, but for some fractures, the closed reduction may improve the deformity and the amount of bony contact.
- In the acute setting – pain control can be difficult for patients. Resting in a supine position allows the arm to extend at the fracture site, and leads to pain and discomfort. Placing the injured extremity in a sling and having the patient rest in an upright or semi-reclining position with some bolsters behind the arm can help to reduce the pain. Patients may also find it more comfortable to sleep sitting in a reclining position when they are at home. Patients and caregivers should be advised that prolonged immobilization can be detrimental to the outcome.
- The range of Motion Exercises – Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.
- Strengthening Exercises – The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, the balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called “atrophy.” There are many exercises that can be done to strengthen the muscles around the shoulder so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.
- Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
- Modalities – Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
- Functional Training – Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of and maintain, a pain-free shoulder.
- Physiotherapy – which can be self-directed or in a formal setting, depending on the patient’s wishes and abilities, should begin no later than two weeks after the injury [rx, rx]. Initially, pendulum exercises will allow for a range of motion without placing weight-bearing stress on the fracture. After the patient is more comfortable, finger crawl exercises along a vertical surface can help with an overhead range of motion.
Among the various nonsurgical treatment methods (confectioners’ clamp, hanging plaster cast, thoracic-brachial plaster cast, and Velpeau immobilization), the use of brachial orthoses is the nonsurgical method most used today[rx], [rx].
This enables contraction of the adjacent muscle groups and stimulates consolidation. However, certain aspects of HSFs and patient characteristics make it difficult to carry out treatment using external immobilization. With increasing incidence of HSFs due to multiple trauma, exposed fractures and deviation caused by muscle action[rx], along with other factors such as obesity, which lead to poor results from nonsurgical treatment, many investigators have been seeking new treatment methods, such as the use of pins[rx], intramedullary nails[rx] or screwed plates[rx], [rx]. Thus, although most HSFs can be treated nonsurgically, the fracture characteristics and patient requirements should be fundamental with regard to indicating surgery[rx].
Medication can be prescribed to ease the pain.
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.[rx]
- Antidepressants – A drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
- Muscle Relaxants – These medications provide relief from associated muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
- Calcium & vitamin D3 – to improve bones health and healing fracture.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
- Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
- Dietary supplement – to remove general weakness & improved health.
- Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.
Types of interventions
We will compare different methods of surgical management for humeral shaft fractures. The comparisons will include the following:
- Plate versus intramedullary nail fixation – this will include the comparison of any plate versus any IMN fixation, as well as specific comparisons of commonly used devices such as dynamic compression plate versus locked intramedullary nailing.
- Different methods of plate fixation – this will include comparisons of dynamic compression plate versus locking compression plate; and MIPO versus conventional ORIF.
- Different methods of intramedullary nailing – this will include retrograde versus antegrade nailing; and locked nailing versus unlocked nailing.
- Closed reduction with percutaneous pinning (CRPP)
- Open reduction with internal fixation (ORIF)
- Intramedullary rod fixation
- Shoulder arthroplasty
- Reverse shoulder arthroplasty
- This technique has been described as a method to treat proximal humerus fractures and avoid the complications associated with implant placement and arthroplasty [rx, rx]. Using this method, nonabsorbable sutures are passed through the rotator cuff tissue and/or the bone fragments, in order to obtain and maintain the reduction.
- This technique avoids extensive soft tissue stripping and the risk of symptomatic implants. It also preserves the bone stock of the proximal humerus, which may allow for future procedures.
- Operative fixation of the proximal humerus has evolved over the years. Development of locking technology, as well as a site-specific implant, has helped overcome some of the problems initially seen with operative fixation. Locking screws have improved the fixation of the head and soft metaphyseal, and often osteoporotic bone, frequently associated with these patients [rx].
- The number of proximal screw options and trajectories attempts to maximize the fixation in the head of the humerus. Conventional plating may still be used in the case of a young patient with good bone quality, or for the treatment of simple two-part greater tuberosity fractures. Successful treatment with either plating technique relies on bone quality, as well as the accuracy of reduction and humeral head viability [rx, rx, rx, rx].
- The use of an intramedullary device has been advocated by some as an alternative to plate and screw fixation [rx–rx]. This technique is thought to be less invasive to the surrounding soft tissues.
- There has been concern regarding the disruption of the rotator cuff and injury to the footprint of the supraspinatus, but meticulous attention to dissection and repair of the supraspinatus tendon; establishing a starting point on the superior articular surface rather than the footprint of the tendon; and minimizing nail prominence, can decrease the chances of postoperative shoulder pain [rx, rx].
- Although the intramedullary nail fixation has been reported for two-part, three-part and four-part proximal humerus fractures, currently the most appropriate patient is one that presents with a two-part surgical neck fracture [rx, rx].
- The deltopectoral approach to the proximal humerus has been the most widely used approach for operative fixation of proximal humerus fractures. Alternative approaches have been used to allow for improved access and ease of implant positioning [rx–rx]. Both the superior subacromial approach and the extended anterolateral acromial approach use a deltoid-splitting interval while protecting the axillary nerve to access the fracture site. These approaches decrease the amount of soft tissue dissection and retraction that often necessary with a standard deltopectoral approach and improve access to the lateral and posterior regions of the proximal humerus.
- Structural and biologic augmentations have been used in the treatment of proximal humerus fractures to improve the rate of healing and decrease the chance of displacement. The use of autograft, allograft, cement, or bone substitutes can help to fill voids in the metaphyseal area as well as provide structure or biologic support to the fracture [rx, rx].
- Endosteal fibular strut allografts have also been used to provide stability to the fracture especially in cases where there is a loss of the posterior medial calcar support and subsequent varus deformity [rx].
- The role of arthroplasty for the treatment of proximal humerus fractures has fluctuated over time. Neer initially recommended the use of humeral head replacement for complex three-part and four-part fractures [rx].
- Using conventional plating techniques, the incidence of nonunion and avascular necrosis of the humeral head was high for these types of injuries. But with the development of site-specific plates and locking plate technology, the fixation of proximal humerus fractures has improved and the role of arthroplasty for acute fractures has diminished.
- Humeral head replacement may still have a role in fractures that are associated with multi fragmentary humeral head cleavage, unreconstructable humeral head, or humeral head devoid of any soft tissue rendering it avascular. Shoulder arthroplasty can also be used in the cases of delayed presentation or as a salvage procedure following failed operative fixation. The role of hemiarthroplasty in the elderly has also changed, as the functional results have been poorer than expected [rx].
There are risks associated with any type of surgery. These include:
- Nonunion (1-5%)
- Infection (~4.8%)
- Adhesive capsulitis
- 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
- Problems with wound healing
- Blood clots
- Damage to blood vessels or nerves
- Reaction to anesthesia
- Hardware prominence
- Malunion with cosmetic deformity
- Restriction of ROM
- The difficulty with bone healing
- Lung injury
- Hardware irritation
- Fracture comminution (Z deformity)
- Fracture displacement
- Increased fatigue with overhead activities
- Dissatisfaction with appearance
- The difficulty with shoulder straps, backpacks and the like
- ~30% of patient request plate removal
- Superior plates associated with increased irritation
- Superior plates associated with increased risk of subclavian artery or vein penetration.
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