eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Humerus
Updated: Oct 28, 2009
Introduction
Background
In evaluating humerus injuries, being able to classify the fracture and if necessary, reduce, immobilize, and know when to seek orthopedic consultation is important.
Eighty percent of proximal humerus fractures are nondisplaced or minimally displaced, and therefore, can be managed nonoperatively.1,2,3 Associated injuries are common in patients with osteoporosis. Distal humeral fractures are associated with ipsilateral proximal forearm fractures. Rarely, vascular or nerve injuries are associated with humerus fractures.
This article discusses fractures based on location: proximal and diaphyseal (midshaft).
For more information, see Medscape's Fracture Resource Center and Osteoporosis Resource Center.
Pathophysiology
Humerus fractures are caused by direct trauma to the arm or shoulder or by axial loading transmitted through the elbow. Attachments from pectoralis major, deltoid, and rotator cuff muscles influence the degree of displacement of proximal humerus fractures.
Humeral stress fractures occur with overhead throwing and occasionally with violent muscle contractions. These types of fractures are documented most commonly in baseball. As with other stress fractures, an increase in activity or stress on immature or unconditioned bone is the likely culprit.4,5,6
Frequency
United States
Humeral diaphyseal fractures account for 1.2% of all fractures.7
Proximal humerus fractures account for 5.7% of all fractures.7
Age
- Proximal humeral fractures are more common in elderly persons, with the average age of 64.5 years.8
- Proximal humeral fractures are the third most common fracture after hip fractures and distal radius fractures.2,9
- Humeral diaphyseal fractures occur in a slightly younger population, with the average age being 54.8 years.8
Diaphyseal humerus fracture.
- Fracture patterns are similar across all ages, though older people are more prone to fracture because of osteoporosis.
Clinical
History
- History may be of a benign fall in which the elbow is either struck directly or axially loaded in a fall onto an outstretched hand.
- Motor vehicle and sport injuries account for most humeral injuries for younger males.
- Pathologic fractures of the humerus may occur with minimal trauma. Suspect these in patients with the following history:
- Cancer metastatic to bone
- Paget disease
- Bone cyst
- Pain without trauma
- Edema
- Decreased range of motion (ROM)
Physical
- Pain occurs with palpation or movement of shoulder or elbow.
- Ecchymosis and edema are usually present.
- Perform a careful neurovascular examination. Radial nerve injury following humerus shaft fractures is relatively common.
- Proximal
- Patients present with a painful shoulder and a very restricted range of motion.
- Obvious deformity is suggestive of glenohumeral dislocation; swelling and ecchymosis are the common examination findings.
- Nerve damage with a proximal humerus fracture is rare.
- Diaphyseal
- Patients present with a painful deformed arm that may be associated with a radial nerve palsy. Usually, the radial nerve palsy is reversible.
- Crepitus may be observed.
- Shortening of the arm suggests displacement.
- Patients who complain of pain while throwing, lifting, or pushing off on affected arm should raise a clinical suspicion of humeral stress fracture.
- Examination may reveal focal tenderness and increased pain with strength testing.
- Assessment of the radial nerve
- The radial nerve's primary motor function is to innervate the dorsal extrinsic muscles in the forearm. Motor testing should include extension of the wrist and metacarpophalangeal (MCP) joints as well as abduction and extension of the thumb. Proximal injury of the radial nerve causes wrist drop.
- On examination, the fingers are in flexion at the MCP joints and the thumb is adducted.
- Rarely, the median or ulnar nerves are affected.
- With all humerus fractures, ensure strong radial and ulnar pulses.
Causes
- The most common cause of proximal humeral fractures is a fall from standing, followed by motor vehicle accident and a fall involving stairs. Additional mechanisms include violent muscle contractions from seizure activity, electrical shock, and athletic-related trauma. Proximal humeral fractures are most often closed.
- Humeral diaphyseal fractures causes include a fall from standing, motor vehicle accident, a fall from height, and pathological.
- Humeral stress fractures are often missed. Patients have described a prodrome of milder, chronic pain with focal tenderness prior to the injury while throwing. These fractures are generally mid to distal shaft spiral fractures that are minimally displaced.4,5,6
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References
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Further Reading
Keywords
broken humerus, humerus fracture, fractured humerus, broken arm, broken shoulder, shoulder fracture, arm fracture, forearm fracture
