eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Midshaft Humerus Fractures

Author: Matthew W 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
Contributor Information and Disclosures

Updated: Jan 8, 2008

Introduction

Although most fractures of the humeral shaft are inherently unstable, nonoperative treatment remains the criterion standard.1 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.2,3

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Arm.

Problem

No classification scheme for humeral shaft fractures has gained universal acceptance. The Arbeitsgemeinschaft f ü r osteosynthesefragen – Association for the Study of Internal Fixation (AO-ASIF) classification is based on the amount of comminution, as follows:

  • Type A fractures - No comminution has occurred.
  • Type B fractures - A butterfly fragment is present.
  • Type C fractures - Comminution has occurred.

Traditionally, humeral shaft fractures have been described according to the following features4 :

  • Location - For example, proximal, middle, or distal
  • Type of fracture line - Such as transverse, oblique, spiral, comminuted, or segmental
  • Opened or closed status

Frequency

Fractures of the humeral shaft account for approximately 3% of all fractures.5,4

Presentation

Patients with humeral shaft fractures present with arm pain, deformity, and swelling. The arm is shortened, with motion and crepitus on manipulation. A careful neurovascular evaluation of the limb must be documented, because the incidence of radial nerve injuries is approximately 16%.6 If indicated, Doppler pulse and compartment pressures should be checked.5,7,8

Indications

The surgical treatment of humeral shaft fractures should be considered for multiple reasons. One indication for surgery is an inability to maintain the fracture in adequate alignment using closed methods. Factors that can account for this inability include the following:

  • Fracture pattern - Displaced, comminuted, or segmental (segmental fractures are at risk of nonunion at 1 fracture site or at both of them)9
  • Prolonged recumbency or an inability to maintain a semisitting or reclined position, as in a patient with multiple traumatic injuries
  • Noncompliance

Ipsilateral fracture of the ulna and/or radius is another indication for surgery, requiring stabilization of the humeral and forearm fractures to allow early range of motion (ROM).5,6,10 If the patient has bilateral humeral fractures, 1 or both should be fixed to allow patient self-care.4 Operative indications also include open fractures, existing or impending pathologic fractures, and fractures associated with a vascular injury that requires repair.

An area of controversy is the occurrence of new-onset radial nerve injuries following closed manipulation. Such injuries were once thought to be indications for surgery; however, this assumption has now been called into question.5 Spinal cord or brachial plexus injuries are indications for surgery.10 Surgery is also indicated for fractures of the humeral shaft that are associated with displaced intra-articular fracture extension.11

Relevant Anatomy

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, while 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 2 intermuscular septa: medial and lateral. The anterior compartment contains the biceps brachii, coracobrachialis, and brachialis muscles; the brachial artery and vein; and the median, musculocutaneous, and ulnar nerves. The triceps muscle and the radial nerve are contained in the posterior compartment.12

Contraindications

There are limited, if any, absolute contraindications to surgery for a midshaft humeral fracture.

More on Midshaft Humerus Fractures

Overview: Midshaft Humerus Fractures
Workup: Midshaft Humerus Fractures
Treatment: Midshaft Humerus Fractures
Follow-up: Midshaft Humerus Fractures
References
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References

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Further Reading

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Keywords

humerus fracture, humeral fracture, humeral diaphyseal fracture, humeral shaft fracture, elbow fracture, forearm fracture, broken arm

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Contributor Information and Disclosures

Author

Matthew W 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 W Lawless, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

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, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

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 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, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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