Humerus fracture

Humerus fractures can result from direct or indirect trauma. They are classified by location into proximal humerus fracture, humeral shaft fracture, and distal humerus fracture. Proximal humerus fractures most commonly occur in older adults, while supracondylar fractures (a type of distal humerus fracture) are most common in children. Clinical features include pain, soft tissue swelling, and visible deformity. Nondisplaced, closed fractures are typically managed with a sling or splint. If there is evidence of neurovascular compromise or in the case of open fractures, operative management is usually required.

• Proximal humerus fractures are the most common humerus fractures.
• Incidence increases with age.
• Sex: ♀ > ♂

Epidemiological data refers to the US, unless otherwise specified.

• Direct or indirect trauma
  • Falls with axial loading on an outstretched hand (most common cause) ^[2]
  • Motor vehicle accidents
  • Violent seizures
  • Direct blow to the back of the humerus
• Pathologic fractures: : e.g., Paget disease, metastatic bone disease (less common)

Proximal humerus fracture

• Proximal humerus fractures are common in older adults and typically occur between the major segments of the proximal humerus. ^[2]
• Neer classification: Fractures are classified as one- to four-part fractures, depending on the number of displaced fracture segments. ^[3]

Humeral shaft fracture

Humeral shaft fractures are further classified based on location. ^[2]

• Proximal humeral shaft fracture
• Middle humeral shaft fracture
• Distal humeral shaft fracture

Distal humerus fracture

Distal humerus fractures, of which there are many subtypes, are a type of elbow fracture. See “Forearm fractures” for other fractures with elbow involvement.

• Supracondylar fracture
  • A fracture of the distal humerus proximal to the epicondyles
  • The most common pediatric elbow fracture ^[4]
• Transcondylar fracture
• Intercondylar fracture
• Condylar fracture
• Epicondylar fracture
• Capitellum fracture
• Trochlea fracture

• Severe local pain: exacerbated during palpation or movement at shoulder or elbow
• Local swelling (edema or bleeding), deformity, and/or crepitus
• Shortening of the arm (associated with displacement)
• Neurovascular complications such as radial nerve palsy (see “Complications” below)
• See “Signs of fracture.”

The radial nerve runs through the radial sulcus of the upper arm and is especially at risk in fractures of the middle third (midshaft) of the humerus!

Clinical evaluation ^[2]

Any findings that suggest neurovascular injury or open fracture should prompt urgent orthopedic consultation.

• Neurovascular exam
  • Assess radial and ulnar artery pulses and capillary refill time.
  • Evaluate for median nerve injury , radial nerve injury , and ulnar nerve injury.
• Skin exam: Evaluate for laceration, tearing, and tenting.

Imaging ^[2]

X-ray

Imaging for humerus fractures typically includes x-ray views of the humerus, shoulder, and elbow.

• Views
  • Shoulder: true anteroposterior, trans-scapular lateral (Y view), and axillary lateral
  • Humerus: anteroposterior and lateral
  • Elbow: anteroposterior and lateral, as well as oblique view as needed
• Findings
  • Radiographic fracture signs, fracture fragments, displacement, angulation, and/or dislocation
  • Visible fat pads in elbow views suggest an intraarticular fracture.
    • Posterior fat pad sign: a radiographic finding caused by an elbow joint effusion; results in the presence of a lucent crescent in the olecranon fossa on a lateral x-ray view of the elbow
    • Anterior fat pad sign (sail sign): a radiographic finding caused by an elbow joint effusion; results in the presence of a convex lucent crescent in the coronoid fossa on a lateral x-ray view of the elbow

A visible anterior fat pad may be normal, but a visible posterior fat pad is always abnormal. ^[2]

Advanced imaging ^[2]

• CT: indicated in preoperative planning for complicated fractures, assessment of associated injuries, and inconclusive x-ray findings
• CT angiography: indicated for suspected vascular injury
• MRI: may be indicated for diagnosis of associated tendon/ligament injuries (e.g., rotator cuff injury)

Differential diagnosis of proximal humerus fractures ^[2]

• Shoulder dislocation
• Acromioclavicular joint separation
• Clavicle fracture
• Scapula fracture
• Rotator cuff injury
• Soft tissue injury

Differential diagnosis of distal humerus fractures ^[2]

• Olecranon fracture
• Radial head fracture
• Elbow dislocation
• Radial head subluxation
• Soft tissue injury

The differential diagnoses listed here are not exhaustive.

Initial management by fracture type ^[2]

• All patients: Initiate general fracture care, including analgesia.
• Proximal humerus fractures
  • Immobilize in an arm sling.
  • Consult orthopedics urgently for:
    • Displaced fracture segments
    • Fracture-dislocation
• Humeral shaft fractures
  • Immobilize in a coaptation splint.
  • Consult orthopedics urgently for:
    • Radial nerve injury
    • Severely displaced fractures
    • Comminuted fractures
• Distal humerus fractures
  • Immobilize in a long arm posterior splint.
  • Consult orthopedics urgently for:
    • Displaced supra- or epicondylar fractures
    • All transcondylar, intercondylar, and condylar fractures
    • Presence of intraarticular fragments

Nonoperative management

• Nonoperative management is generally possible for nondisplaced, closed fractures.
• Devices include hanging-arm casts, coaptation splints, and arm slings
• See also: “Conservative treatment of fractures”

Surgical treatment

• Fractures that commonly require surgical treatment include:
  • Open fractures
  • Poor reduction of displaced fractures
  • Neurovascular injury
  • Pathologic fractures
  • Simultaneous humerus and forearm fractures (floating elbow)
• Operative techniques depend on fracture location and type and include:
  • Open reduction and internal fixation (ORIF)
  • Closed reduction and internal fixation (CRIF)
  • Intramedullary nailing (IMN)
  • Arthroplasty

• Proximal humerus fracture
  • Avascular necrosis of humeral head (axillary artery injury)
  • Adhesive capsulitis
  • Heterotopic bone formation
• Distal humerus fracture
  • Brachial artery injury (common)
    • Absent or diminished radial pulse suggests brachial artery entrapment (especially following reduction) and compartment syndrome.
    • May lead to Volkmann ischemic contracture (late complication)
  • Malunion and varus deformity of the elbow

• See “Peripheral nerve injuries in the upper extremity“ and “Complications of fractures.”

“Broken ARM:“ Axillary, Radial, and Median nerves can be injured.

Injuries to the median nerve and brachial artery, which both cross the elbow, are common complications of supracondylar fractures.

We list the most important complications. The selection is not exhaustive.