Midshaft Humerus Fractures
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.  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]
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.  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. 
Connolly et al assessed the outcome of immediate open reduction and internal fixation (ORIF) in 46 patients with open humeral diaphyseal fractures.  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).  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.  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.  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.  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.
Garnavos C. Humeral shaft fractures. Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P III, McKee MD, eds. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer; 2015. Vol 1: 1287-340.
Lin J, Hou SM, Hang YS, Chao EY. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res. 1997 Sep. (342):147-55. [Medline].
Persad IJ, Kommu S. U cast or functional bracing following fractures of the shaft of humerus. Emerg Med J. 2007 May. 24(5):361. [Medline].
Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006 Nov. 88(11):1469-73. [Medline].
Lambert SM. Shoulder girdle and arm. Standring S, Anand N, Birch R, Collins P, Crossman AR, Gleeson M, eds. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 41st ed. Philadelphia: Elsevier; 2016. 797-836.
Mahabier KC, Vogels LM, Punt BJ, Roukema GR, Patka P, Van Lieshout EM. Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients. Injury. 2013 Apr. 44 (4):427-30. [Medline].
Connolly S, McKee MD, Zdero R, Waddell JP, Schemitsch EH. Immediate plate osteosynthesis of open fractures of the humeral shaft. J Trauma. 2010 Sep. 69 (3):685-90. [Medline].
Heineman DJ, Poolman RW, Nork Sean SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop. 2010 Apr. 81(2):218-25. [Medline].
Pretell J, Rodriguez J, Blanco D, Zafra A, Resines C. Treatment of pathological humeral shaft fractures with intramedullary nailing. A retrospective study. Int Orthop. 2010 Apr. 34(4):559-63. [Medline].
Usoro AO, Bhashyam A, Mohamadi A, Dyer GS, Zirkle L, von Keudell A. Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-analysis. J Orthop Trauma. 2018 Sep 10. [Medline].
Pautasso A, Lea S, Arpaia A, Ferrero G, Bellato E, Castoldi F. Six-year experience with antegrade intramedullary nail for the treatment of proximal and diaphyseal humeral fractures. Musculoskelet Surg. 2018 Oct. 102 (Suppl 1):67-74. [Medline].
Hartsock LA. Humeral shaft fractures. Levine AM, ed. Orthopaedic Knowledge Update, Trauma. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. 23-32.
GARCIA A Jr, MAECK BH. Radial nerve injuries in fractures of the shaft of the humerus. Am J Surg. 1960 May. 99:625-7. [Medline].
Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec. 87(12):1647-52. [Medline].
Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS. Introduction: Fracture and Dislocation Classification Compendium-2018: International Comprehensive Classification of Fractures and Dislocations Committee. J Orthop Trauma. 2018 Jan. 32 Suppl 1:S1-S10. [Medline]. [Full Text].
Foster RJ, Dixon GL Jr, Bach AW, Appleyard RW, Green TM. Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study. J Bone Joint Surg Am. 1985 Jul. 67 (6):857-64. [Medline].
Gregory PR, Sanders RW. Compression plating versus intramedullary fixation of humeral shaft fractures. J Am Acad Orthop Surg. 1997 Jul. 5(4):215-23. [Medline].
Schatzker J. Fractures of the humerus. Schatzker J, Tile M, eds. The Rationale of Operative Fracture Care. 3rd ed. New York: Springer; 2005. Chap 5.
Fractures of the shoulder, arm, and forearm. Azar FM, Beaty JH, Canale ST, eds. Campbell’s Operative Orthopaedics. 13th ed. Philadelphia: Elsevier; 2017. Chap 57.
Acklin YP, Sommer C. Fracture of the humeral shaft. Browner BD, Jupiter JB, Krettek C, Anderson PA, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. 5th ed. Philadelphia: Elsevier Saunders; 2015. Vol 2: 1389-406.
Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977 Jul. 59 (5):596-601. [Medline].
Naver L, Aalberg JR. Humeral shaft fractures treated with a ready-made fracture brace. Arch Orthop Trauma Surg. 1986. 106 (1):20-2. [Medline].
Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures–the Basel experience. J Trauma. 1993 Aug. 35 (2):226-32. [Medline].
Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD. Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma. 2000 Aug. 49 (2):278-80. [Medline].
Rodriguez-Merchan EC. Compression plating versus hackethal nailing in closed humeral shaft fractures failing nonoperative reduction. J Orthop Trauma. 1995 Jun. 9(3):194-7. [Medline].
Hoppenfeld S, de Boer P, Buckley R. The humerus. Surgical Exposures in Orthopaedics: The Anatomic Approach. 5th ed. Philadelphia: Wolters Kluwer; 2017. Chap 2.
Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996 Nov. 78(11):1690-5. [Medline].
Kosmopoulos V, Nana AD. Dual plating of humeral shaft fractures: orthogonal plates biomechanically outperform side-by-side plates. Clin Orthop Relat Res. 2014 Apr. 472(4):1310-7. [Medline]. [Full Text].
Farragos AF, Schemitsch EH, McKee MD. Complications of intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma. 1999 May. 13 (4):258-67. [Medline].
Shin SJ, Sohn HS, Do NH. Minimally invasive plate osteosynthesis of humeral shaft fractures: a technique to aid fracture reduction and minimize complications. J Orthop Trauma. 2012 Oct. 26 (10):585-9. [Medline].
Kim JW, Oh CW, Byun YS, Kim JJ, Park KC. A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis. J Orthop Trauma. 2015 Apr. 29 (4):189-94. [Medline].
Lee HJ, Oh CW, Oh JK, Apivatthakakul T, Kim JW, Yoon JP, et al. Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator. Arch Orthop Trauma Surg. 2013 May. 133(5):649-57. [Medline].
Esmailiejah AA, Abbasian MR, Safdari F, Ashoori K. Treatment of Humeral Shaft Fractures: Minimally Invasive Plate Osteosynthesis Versus Open Reduction and Internal Fixation. Trauma Mon. 2015 Aug. 20 (3):e26271. [Medline]. [Full Text].
Sims SH, Smith SE. Intramedullary nailing of humeral shaft fractures. J South Orthop Assoc. 1995 Spring. 4(1):24-31. [Medline].
Achecar F, Whittle AP. Unreamed vs reamed interlocking nailing of humeral shaft fractures. Orthop Trans. 1997. 21:1166.
Brumback RJ. The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res. 1996 Mar. (324):292-320. [Medline].
Crates J, Whittle AP. Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res. 1998 May. (350):40-50. [Medline].
Ingman AM, Waters DA. Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results. J Bone Joint Surg Br. 1994 Jan. 76(1):23-9. [Medline]. [Full Text].
Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am. 1996 Jun. 78(6):891-6. [Medline].
Shazar N, Brumback RJ, Vanco B. Treatment of humeral fractures by closed reduction and retrograde intramedullary Ender nails. Orthopedics. 1998 Jun. 21(6):641-6. [Medline].
Tomé J, Carsi B, García-Fernández C, et al. Treatment of pathologic fractures of the humerus with Seidel nailing. Clin Orthop Relat Res. 1998 May. (350):51-5. [Medline].
Mückley T, Diefenbeck M, Sorkin AT, Beimel C, Goebel M, Bühren V. Results of the T2 humeral nailing system with special focus on compression interlocking. Injury. 2008 Mar. 39 (3):299-305. [Medline].
Riemer BL, Foglesong ME, Burke CJ 3rd. Complications of Seidel intramedullary nailing of narrow diameter humeral diaphyseal fractures. Orthopedics. 1994 Jan. 17(1):19-29. [Medline].
Riemer BL, Butterfield SL, D’Ambrosia R, Kellam J. Seidel intramedullary nailing of humeral diaphyseal fractures: a preliminary report. Orthopedics. 1991 Mar. 14 (3):239-46. [Medline].
Robinson CM, Bell KM, Court-Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br. 1992 Jul. 74 (4):558-62. [Medline]. [Full Text].
Colombi R, Chauvet T, Labattut L, Viard B, Baulot E, Martz P. Is distal locking screw necessary for intramedullary nailing in the treatment of humeral shaft fractures? A comparative cohort study. Int Orthop. 2018 Aug 31. [Medline].
Brumback RJ, Bosse MJ, Poka A, Burgess AR. Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma. J Bone Joint Surg Am. 1986 Sep. 68 (7):960-70. [Medline].
Hall RF Jr, Pankovich AM. Ender nailing of acute fractures of the humerus. A study of closed fixation by intramedullary nails without reaming. J Bone Joint Surg Am. 1987 Apr. 69(4):558-67. [Medline].
O’Donnell TM, McKenna JV, Kenny P, Keogh P, O’Flanagan SJ. Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus. J Bone Joint Surg Br. 2008 Jan. 90 (1):61-5. [Medline].
Stern PJ, Mattingly DA, Pomeroy DL, Zenni EJ Jr, Kreig JK. Intramedullary fixation of humeral shaft fractures. J Bone Joint Surg Am. 1984 Jun. 66 (5):639-46. [Medline].
Lin J, Inoue N, Valdevit A, Hang YS, Hou SM, Chao EY. Biomechanical comparison of antegrade and retrograde nailing of humeral shaft fracture. Clin Orthop Relat Res. 1998 Jun. (351):203-13. [Medline].
McKee MD, Miranda MA, Riemer BL, Blasier RB, Redmond BJ, Sims SH, et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma. 1996. 10 (7):492-9. [Medline].
Mostafavi HR, Tornetta P 3rd. Open fractures of the humerus treated with external fixation. Clin Orthop Relat Res. 1997 Apr. (337):187-97. [Medline].
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am. 1981 Feb. 63 (2):239-43. [Medline].
Kettelkamp DB, Alexander H. Clinical review of radial nerve injury. J Trauma. 1967 May. 7 (3):424-32. [Medline].
Verga M, Peri Di Caprio A, Bocchiotti MA, Battistella F, Bruschi S, Petrolati M. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: review and evaluation of the long-term results of 52 cases. J Hand Surg Eur Vol. 2007 Oct. 32 (5):529-33. [Medline].
Boyd HB. The treatment of difficult and unusual nonunions. J Bone Joint Surg. 1943. 25:535.
Mast JW, Spiegel PG, Harvey JP Jr, Harrison C. Fractures of the humeral shaft: a retrospective study of 240 adult fractures. Clin Orthop Relat Res. 1975 Oct. (112):254-62. [Medline].
URIST MR, MAZET R Jr, McLEAN FC. The pathogenesis and treatment of delayed union and non-union; a survey of eighty-five ununited fractures of the shaft of the tibia and one hundred control cases with similar injuries. J Bone Joint Surg Am. 1954 Oct. 36-A (5):931-80; passim. [Medline].
Healy WL, White GM, Mick CA, Brooker AF Jr, Weiland AJ. Nonunion of the humeral shaft. Clin Orthop Relat Res. 1987 Jun. (219):206-13. [Medline].
Green E, Lubahn JD, Evans J. Risk factors, treatment, and outcomes associated with nonunion of the midshaft humerus fracture. J Surg Orthop Adv. 2005 Summer. 14 (2):64-72. [Medline].
Wu CC, Shih CH. Treatment for nonunion of the shaft of the humerus: comparison of plates and Seidel interlocking nails. Can J Surg. 1992 Dec. 35 (6):661-5. [Medline].
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
Research & References of Midshaft Humerus Fractures|A&C Accounting And Tax Services