Midshaft Humerus Fractures

Midshaft Humerus Fractures

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Fractures of the humeral shaft account for approximately 3% of all fractures. [1, 2]  Traditionally, humeral shaft fractures have been described according to the following features [2] :

This article focuses on midshaft humerus fractures.

No classification scheme for humeral shaft fractures has gained universal acceptance, though the system developed by the Orthopaedic Trauma Association (OTA) and the Arbeitsgemeinschaft für Osteosynthesefragen (AO) is often employed (see Classification).

Although most fractures of the humeral shaft are inherently unstable, nonoperative treatment remains the standard. [3] For operative candidates, the role of surgery, as well as which type of surgery is appropriate, is dependent on the patient and the fracture characteristics. [4, 5]

For patient education resources, see the First Aid and Injuries Center, as well as Broken Arm.

The humeral shaft is the area extending from the upper border of the pectoralis major tendon to the supracondylar ridge. The proximal half is almost cylindrical, whereas distally, the anteroposterior diameter narrows into a prismatic shape. The posterior surface (between the medial and lateral borders) is the largest. The radial sulcus, which contains the radial nerve and, at its midpoint, the nutrient foramen, crosses the posterior middle third of the humerus.

The large muscles that surround the humerus prevent direct palpation. The arm is divided into anterior and posterior compartments by two intermuscular septa: medial and lateral. [6] The anterior compartment contains the following:

The posterior compartment contains the following:

Each method of humeral shaft fracture treatment is associated with a union rate of higher than 90%. Each fracture must be considered separately and treated accordingly. [7]

Connolly et al assessed the outcome of immediate open reduction and internal fixation (ORIF) in 46 patients with open humeral diaphyseal fractures. [8]  All fractures united primarily in satisfactory angulation of less than 5º in coronal and sagittal planes. In 40 patients, mean time to union was 18.4 weeks; in six, union was delayed (mean time to union, 42.5 weeks). No patient required subsequent surgery to obtain union. Complications were rare (including amputation in three patients and dysesthesia in one), with no deep infections, nonunions, or iatrogenic nerve injuries. Two implants were removed because of discomfort.

Heineman et al conducted a meta-analysis of four trials comparing treatment of humeral shaft fractures with different implants (plates and nails). [9]  After calculating the data from the four trials (203 patients), they did not find any statistically significant differences between plates and nails with respect to complications, nonunion, infection, nerve palsy, or reoperation.

In a retrospective study, Pretell et al reported that 17 of 19 patients with fractures of the humeral shaft treated with anterograde locked intramedullary nailing were satisfied with the results. [10]  The mean duration of hospitalization after surgery was 4.3 days; there were no complications related to the implants; there were no operative complications; and the average operation time was 48 minutes. The consolidation rate was 80%.

In a systematic review and meta-analysis of the clinical outcomes and pooled complication rate for the use of Surgical Implant Generation Network (SIGN) intramedullary nails in femoral (60%), tibial (38%), and humeral (2%) fracture fixation, all studies that measured clinical outcome indicated that more than 90% of patients achieved full weightbearing status, favorable range of motion (ROM; >90º), or radiographic or clinical union. [11] The overall complication rate was 5.2%; malalignment (>5º angulation in any plane) was the most common complication (7.6%), followed by delayed union or nonunion (6.9%), infection (5.9%), and hardware failure (3.2%).

A 6-year observational cohort study of 95 patients with humeral fractures (20 proximal, 75 diaphyseal) treated with antegrade intramedullary nailing documented improvements in functional recovery for all patients over time but noted better outcomes in patients younger than 65 years. [12] Fracture type and patient gender had no effect on these results at 1 month and 6 months. No infections occurred. Eighteen patients required blood transfusions, and 10 required revision surgery.

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Matthew Lawless, MD Assistant Professor of Orthopedic Surgery, Wright State University School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital and Dayton Veterans Affairs Medical Center

Matthew Lawless, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

Midshaft Humerus Fractures

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