Humerus Fracture Clinical Presentation

Updated: Nov 07, 2019
  • Author: Adarsh K Srivastava, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

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 and should be suspected in patients with any of the following [23, 24, 8] :

  • Cancer metastatic to bone

  • Osteoporosis/osteopenia

  • HIV infection

  • Solid organ transplantation

  • Chronic kidney disease

  • Bone cyst

  • Pain without trauma

  • Edema of the upper extremity

  • Decreased range of motion (ROM) of the upper extremity

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Physical

Pain occurs with palpation or movement of the shoulder or elbow. Ecchymosis and edema are usually present.

Perform a careful neurovascular examination. Radial nerve injury following humerus shaft fractures is relatively common. 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.

Patients with proximal fractures 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.

Patients with diaphyseal fractures 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 an affected arm should raise a clinical suspicion of humeral stress fracture. Examination may reveal focal tenderness and increased pain with strength testing.

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Complications

Proximal humerus fracture

The most common complication of proximal humerus fracture is adhesive capsulitis. This can be prevented by the early initiation of a rehabilitation program. Two-part fractures of the articular surface and 4-part fractures have a high incidence of avascular necrosis of the humeral head. Repeated forceful attempts at reduction of a fracture dislocation may be associated with subsequent heterotropic bone formation.

Humeral shaft

The most common complication in humeral shaft fractures is radial nerve injury. The nerve deficit is usually a benign neurapraxia that resolves spontaneously, although recovery may take several months. Radial nerve injuries associated with penetrating trauma or open fractures are likely to be permanent and usually warrant operative exploration.

Claessen et al conducted a study to determine the factors associated with radial nerve palsy in patients with diaphyseal humerus fracture.  In a study of open fractures, location of fracture and high-energy trauma were significantly associated with radial nerve palsy (84 of 325 patients [26%]). According to the study, iatrogenic transient dysfunction of the radial nerve occurs in approximately 1 in 5 patients who are treated with lateral exposure of the humerus, in 1 in 9 patients treated with posterior exposure, and in 1 in 25 patients treated with an anterolateral exposure. [7]

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