HUMERAL SHAFT FRACTURES. Fractures of the shaft of the humerus are common, especially in the elderly.

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1 HUMERAL SHAFT FRACTURES Introduction Fractures of the shaft of the humerus are common, especially in the elderly. The majority can be treated conservatively but patient coping issues may be significant. For supracondylar fractures of the humerus, see separate document. Classification In general terms fractures of the humerus involve: 1. Fractures at the proximal humerus, (around the head and neck). 2. Mid region fractures of the shaft. 3. Distal or supracondylar fractures, (see separate guidelines for these). Fractures around the proximal humerus: A number of classifications exist which are complex. In general terms: 2 Fractures in this region may involve, the anatomical neck (rare), (1), the surgical neck, (2), the greater tuberosity (3), or the lesser tuberosity (4). Combinations of these injuries are common and it is customary to describe injuries in this region by the number of fragments involved eg 2 part (5), 3 part (6) and 4 part (7). Mechanism The mechanisms of injury include:

2 Indirect violence, fall on outstretched hand. Direct violence, fall onto the side or a blow to the arm. Pathological fractures are not uncommon in the elderly and can occur due to aneurysmal bone cysts or multiple myeloma metastases. Complications 1. Radial nerve palsy: This is usually associated with fractures of the middle third of the shaft of the radius. The injury is usually a neuropraxia. 2. Brachial artery injury: This is the most serious complication, but it is usually seen in association with supracondylar fractures. 3. Non-Union: This is most commonly seen in middle third fractures of the shaft of the humerus. Clinical Features 1. Pain and tenderness is usually severe. 2. The arm is flail and the patient will often be supporting it with the other hand. 3. Swelling and bruising can be extensive. 4. There is obvious movement and crepitus at the fracture site. 5. Deformity: With a fractured proximal third the proximal fragment tends to be pulled into adduction by the unopposed action of pectoralis major. Whereas with a fractured middle third the proximal fragment tends to be abducted due to the pull of the deltoid. 6. Neurovascular status must be checked in particular the integrity of: The brachial artery. The radial nerve.

3 Investigation Plain radiography Plain radiographs are enough to make the diagnosis in virtually all cases. Some difficulty may arise in more subtle cases of non-displaced hairline fractures and in children where greenstick type fractures around the surgical neck are possible. Management 1. Analgesia: Pain is usually severe and prompt IV opioid analgesia will be required in most cases. 2. Neurovascular compromise: If there is any vascular compromise obvious deformity should be reduced immediately. Initial management for radial nerve neuropraxia includes a wrist drop splint and physiotherapy 3. Place the arm initially in a broad arm sling for support. Management may then be conservative or surgical. Conservative management: The patient should be seated (1) and a plaster slab prepared of 8 layers of 6 inch plaster (2). The length should be able to reach from the just below the axilla, round the elbow and back up over the point of the shoulder. Wool roll is then applied to the arm (4). Pay particular attention to the elbow. The padding should extend from the shoulder to a third of the way down the forearm. The slab is now wetted and applied to the arm starting at the medial side at the axillary fold (5) and then bringing it round the elbow up to the shoulder. The slab should be carefully smoothed down. The plaster id then secured with a crepe bandage (6)

4 Most uncomplicated fractures of the shaft of the humerus (excluding supracondylar fractures) can be managed conservatively. A U shape plaster stretching from axilla to over the point of shoulder with additional padding should be placed, as shown below. 2 The arm is then supported in a collar and cuff and can be kept the arm under the clothes for extra support. The ability of the patient to cope must then be assessed in order to make a decision on whether or not admission will be necessary. A care co-ordination assessment should be undertaken to assist in regard. Considerations for admission will include: The ongoing need for narcotic analgesia. The age of the patient. Co-morbidity factors. Social factors Following immobilization follow-up should be arranged with the fracture clinic. A physiotherapy referral should also be made. Surgical management: Occasionally surgical ORIF will be necessary. Considerations in this regard will include: Two or more fractures in the one limb. Both arms are fractured. Other multiple injuries. Neurovascular involvement. Compound injury. Comminuted injury. Elite sports people.

5 Appendix 1 Anatomy of the humerus: Anatomy of the humerus 1

6 Anterior view of Humerus with muscular attachments, Gray s Anatomy, 1918

7 Posterior view of Humerus with muscular attachments, Gray s Anatomy, 1918

8 References 1. Tortora G.J, A Brief Atlas of the Skeleton, Surface Anatomy and Selected Medical Images, McRae Ronald, Practical Fracture Treatment, 3 rd ed 1996, p Dr J. Hayes Dr Peter Papadopoulos. 1 July 2007