Humerus Fracture 

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

Overview

Practice Essentials

In evaluating humerus injuries, classifying the fracture and, if necessary, reducing and immobilizing the fracture are essential. Eighty percent of proximal humerus fractures are nondisplaced or minimally displaced and, therefore, can be managed nonoperatively. Associated injuries are common in patients with osteoporosis. Proximal humerus fracture accounts for 6% of all fractures and is the third most common osteoporotic fracture, after the distal radius and vertebra. Approximately 85% of proximal humerus fractures occur in individuals older than 50 years. Distal humerus fractures are associated with ipsilateral proximal forearm fractures. In adults, fractures of the distal humerus account for approximately 2% of all fractures and a third of all humerus fractures. In younger individuals, these fractures are primarily caused by high-energy traumas; in the elderly, by low-energy falls.[1]  Rarely, vascular or nerve injuries are associated with humerus fractures. Radial nerve palsy associated with fractures of the shaft of the humerus is the most common nerve lesion complicating fractures of long bones.[2, 3, 4, 5, 6, 7, 8, 9, 10, 11]

Causes

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.[12, 13, 14]

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.

Causes of humeral diaphyseal fractures include a fall from standing, a motor vehicle accident, a fall from height, and pathology related.

Distal humerus fractures are primarily caused by high-energy traumas, and in the elderly, they are most often caused by by low-energy falls.[1]

Diagnosis

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.

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.[12, 13, 14]

Fractures that occur spontaneously, without apparent injury, suggest a pathologic fracture.

For the distal and diaphyseal humerus fractures, anteroposterior and lateral views of the humerus, as well as transthoracic and axillary views of the shoulder, should be adequate to visualize a fracture. CT scans are helpful if radiographs are unclear.

Treatment

Minimize the patient's movement and provide adequate analgesia to make the patient comfortable in the acute care setting. As with all fractures, provide adequate outpatient analgesia, especially during the first few days. Narcotic analgesia may be appropriate.

Operative treatment decisions are based primarily on the number of segments involved and degree of displacement. Most fractures are displaced minimally and treated conservatively. Often, 3- and 4-part fractures require surgical management because of damage of the vasculature of the humeral head.[3, 9, 10, 15, 16]

Diaphyseal fractures are classified as simple, wedge, or complex (comminuted).

Most isolated proximal and diaphyseal humerus fractures can be managed by an orthopedist in an outpatient setting. Even patients with fractures that may eventually require surgery generally may be discharged with early follow-up care if fracture is otherwise uncomplicated.

Surgical stabilization is indicated for fractures that cannot be adequately reduced or if fracture reduction cannot be controlled with functional bracing because of patient obesity, head trauma, or soft tissue injuries.[17]

The distal humerus has a triangular shape built of 2 columns and a “tie arch.” Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation.[18]  

Open fractures represent a surgical emergency and require extensive irrigation. Administer prophylactic antibiotics, such as cephalexin or gentamicin. Penetrating trauma requires particular neurovascular scrutiny.

Glenohumeral dislocation in conjunction with a proximal humerus fracture requires orthopedic evaluation.

Floating elbow (an ipsilateral humerus and forearm fracture) requires operative repair.

For proximal humerus fractures, complete union is expected at 6-8 weeks. Older patients often exhibit a functional decrease in shoulder range of motion (ROM). Diaphyseal fractures have a high rate of union. Residual angulation is well tolerated because of compensation by shoulder and elbow ROM.

Classification systems

Classification systems include Riseborough and Radin, which classifies distal humerus fractures according to the state of the condylar fragments; Lecestre et al, which defines supracondylar, extra-articular condylar, articular intercondylar, and comminuted fractures; Jupiter, which is based on intraoperative observations, describing high T, low T, Y, H, medial, and lateral lambda fractures; and Dubberley, which distinguishes between fracture types involving the capitellum and trochlea and comprises techniques for treatment. Internationally, the American Academy of Orthopaedic Surgeons (AO) classification is most commonly used, categorizing fractures as extra-articular, partial articular, and articular.[18]

The Neer classification system is the commonly used terminology to describe proximal humerus fractures.[4]  The Neer classification for proximal humerus fractures is based on 4 fracture parts: the greater tuberosity, the lesser tuberosity, the humeral head, and the humeral shaft. If any of the 4 segments is separated by more than 1 cm from its neighbor or is angulated more than 45°, the fracture is said to be displaced. One-part fractures are nondisplaced fractures or fractures with minimal displacement. Two-part fractures are fractures in which only a single segment is displaced in relation to the other three. Three-part fractures occur when two segments are displaced in relation to the other two parts. Four-part fractures exist when all the humeral segments are displaced.[19]

Epidemiology

Humeral diaphyseal fractures account for 1.2% of all fractures.[20]  Proximal humerus fractures account for 5.7% of all fractures.[20]

Proximal humerus fractures are more common in elderly persons, with the average age of 64.5 years,[21, 15] and are the third most common fracture after hip fractures and distal radius fractures.[3, 22]

Humeral diaphyseal fractures occur in a slightly younger population, with the average age being 54.8 years.[21]

In adults, fractures of the distal humerus account for approximately 2% of all fractures and a third of all humerus fractures. [1]

(See the image below.)

Diaphyseal humerus fracture. Diaphyseal humerus fracture.

Fracture patterns are similar across all ages, though older people are more prone to fracture because of osteoporosis. A humerus fracture in a child with an inconsistent injury mechanism should raise suspicion for abuse and trigger further investigation. Young patients presenting with humeral diaphyseal fractures after high-energy injuries frequently have multiple injuries. Approximately 5% of these patients with humeral diaphyseal fractures present with spinal fractures or complex foot fractures, and about 4% present have pelvic or proximal tibial fractures.[21]  Older patients tend to present with other fractures in the ipsilateral arm, usually distal radius fractures.[21]

In an epidemiologic survey of 1800 low-energy humeral fractures in an emergency department in Parma, Italy, the following were identified[16] :

  • Predominance in women: 78%.

  • Fractures of the proximal humerus represented the largest majority of humerus fractures: >85 %.

  • Incidence progressively increased with age (more than 60-fold in women and 20-fold in men).

  • Simultaneous fractures (hip in particular) were frequent, especially after 85 years of age (1 out of 8 cases).

 

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

  • Paget disease

  • 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

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.

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]

 

DDx

 

Workup

Imaging Studies

For the distal and diaphyseal humerus fractures, anteroposterior and lateral views of the humerus, as well as transthoracic and axillary views of the shoulder, should be adequate to visualize a fracture. CT scans are helpful if radiographs are unclear.

Proximal humerus fracture

The humeral head articulates with the scapular glenoid. The proximal humerus has 4 parts: articulating surface (anatomical neck), greater tuberosity, lesser tuberosity, and humeral shaft. The surgical neck is just distal to both tuberosities.

The minimum baseline studies for the evaluation of proximal humeral fractures must include a true anteroposterior (AP) view of the scapula and glenohumeral joint, an axillary view, and a lateral Y view of the scapula, evaluating the glenohumeral joint and proximal humerus in 3 perpendicular planes.[6]

All greater tuberosity fractures should, at some point, have an ultrasound examination or an MRI to check the integrity of the rotator cuff.

Blood is supplied to the humeral head from branches off the axillary artery. Blood travels distally to proximally. Fractures of the anatomical neck may affect blood supply and result in avascular necrosis of the humeral head.

Classification

The Neer classification system is the commonly used terminology to describe proximal humerus fractures.[4]  (See the image below.)

Neer classification. Neer classification.

If any of the 4 segments is separated by more than 1 cm from its neighbor or is angulated more than 45°, the fracture is said to be displaced.

  • One-part fractures are nondisplaced fractures or fractures with minimal displacement.
  • Two-part fractures are fractures in which only a single segment is displaced in relation to the other three.
  • Three-part fractures occur when two segments are displaced in relation to the other two parts. [25]
  • Four-part fractures exist when all the humeral segments are displaced.
 

Treatment

Emergency Department Care

Minimize the patient's movement and provide adequate analgesia to make the patient comfortable in the acute care setting.

Proximal humerus fracture

Most minimally displaced proximal humeral fractures can be managed nonoperatively.

Greater tuberosity fractures may have associated rotator cuff tears. The true incidence of rotator cuff tears is unknown. They are more common in older patients, high-energy injuries, and where there is significant displacement.

Sling and swathe application is the primary treatment.

Fractures of the anatomical neck should be referred to an orthopedist because of the risk of avascular necrosis.[26]

Humerus shaft (diaphyseal) fracture

Humerus shaft fractures should be stabilized using a coaptation splint.

Wrap splinting material snugly from axilla to nape of neck, creating a stirrup around the elbow.

Fracture reduction is usually not necessary because reduction is difficult to maintain.

Because of the shoulder's ability to compensate, 30-40° of angulation is acceptable.

AAOS appropriate use criteria

The American Academy of Orthopaedic Surgeons (AAOS) has developed Appropriate Use Criteria (AUC) for the management of pediatric supracondylar fractures. Of the 3080 possible treatments and scenarios (ie, 220 patient scenarios x 14 treatments), 678 (22%) were rated as “Appropriate,” 431 (14%) were rated as “May Be Appropriate,” and 1971 (64%) were rated as “Rarely Appropriate.”[27]

Medical Care

Proximal humerus fracture

Displaced 3- or 4-part fractures frequently require surgical fixation. Open reduction and internal fixation is common in young patients. Humeral arthroplasty in older patients is common.

The most commonly performed surgical procedures include internal fixation with locking plates or humeral nails or replacement of the humeral head with a hemiarthroplasty or a total reverse prosthesis.[11]  However, randomized trials and non-randomized trials have questioned the benefits of these procedures in the elderly, even for displaced fractures.[9]

A study of surgery with locking plate of displaced 2-part proximal humerus fractures compared with non-operative treatment found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years or older.[10]

For nonsurgical fractures, continue sling for comfort and institute early range-of-motion exercises. Schedule initial follow-up visit within 1 week.

Humerus shaft fracture

Most humerus shaft fractures are treated nonoperatively, with an expected union rate of 90-100%, though surgical fixation, by either intramedullary nailing or plating, is necessary if the fracture is segmental or the vasculature is compromised.

Use coaptation splints until immediate postfracture pain has subsided, usually within 3-7 days. Then, place the patient in a functional brace. An orthopedic surgeon best addresses decisions regarding alignment, rotation, and progression to union.

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These agents are used most commonly for the relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Addaprin, Advil, Caldolor, Dyspel, Motrin IB, NeoProfen, Provil)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Ketoprofen (Active-Ketoprofen, Ketophene Rapidpaq)

Used for relief of mild to moderately severe pain and inflammation.

Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease.

Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Naproxen (Aleve, Mediproxen, Naprelan, Naprosyn)

Relieves mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Flurbiprofen

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Diclofenac (Cambia, Cataflam, Dyloject, Zipsor, Zorvolex)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Indomethacin (Indocin, Tivorbex)

Indomethacin is thought to be the most effective NSAID for the treatment of AS, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Acephen, Cetafen, Ofirmev, Aspirin-free Anacin, Valorin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs and in those with upper GI disease or taking oral anticoagulants.

Acetaminophen and codeine (Tylenol with Codeine #3, Tylenol with Codeine #4, Capital/Codeine)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Hycet, Lortab, Norco, Zamicet)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet, Endocet, Primlev, Xartemis XR)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Morphine sulfate (Duramorph, Kadian, Infumorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone.

Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Anxiolytics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve same effect.

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class with short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation.

Excellent for sedating patients for >24 h.

Monitor patient's BP after administering dose and adjust as necessary.

Diazepam (Diastat Pediatric, Diastat AcuDial, Valium)

Diazepam modulates postsynaptic effects of gamma amino-butyric acid A (GABA-A) transmission, resulting in an increase in presynaptic inhibition. It appears to act on part of the limbic system, as well as on the thalamus and hypothalamus, to induce a calming effect. Individualize dosage and increase cautiously to avoid adverse effects.