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Humeral Shaft Fracture S42.399A 812.21

humeral shaft fracture xray

Shoulder cross sectional anatomy

humeral shaft anatomy

humeral shaft approach

humeral shaft ORIF xray

humeral shaft external fixation X-ray

humeral shaft external fixation xray

synonyms: humerus fracture, humeral shaft fx, humeral shaft fracture, broken arm

Humeral Shaft Fx ICD-10

A- initial encounter for closed fracture

B- initial encounter for open fracture

D- subsequent encounter for fracture with routine healing

G- subsequent encounter for fracture with delayed healing

K- subsequent encounter for fracture with nonunion

P- subsequent encounter for fracture with malunion

S- sequela

 

Humeral Shaft Fx ICD-9

  • 812.21(fracture of shaft of humerus, closed)
  • 812.31(fracture of shaft of humerus, open)

Humeral Shaft Fx Etiology / Epidemiology / Natural History

  • Uncommon, 3% of all fractures

Humeral Shaft Fx Anatomy

  • Musculocutaneous N pierces coracobrachialis 5-8cm distal to coracoid, supplies biceps,coracobrachialis & bracialis
  • See also Arm anatomy.

Humeral Shaft Fx Clinical Evaluation

  • Pain, swelling, deformity of arm.
  • Crepitus and motion at fracture site.
  • Document neurovascular exam, especially radial nerve.

Humeral Shaft Fx Xray / Diagnositc Tests

  • A/P and lateral views of the humerus generally clearly demonstrate fracture.
  • Consider shoulder and elbow films if there is any concern for intraarticular extension.
  • MRI /CT generally not needed.

Humeral Shaft Fx Classification / Treatment

  • AO classification
  • Majority treated non-surgically-hanging arm cast, functional brace(Sarmiento), coaptation splint.  Hanging arm cast is not recommended for transverse fractures due to potential for fracture distraction.
  • ACCEPTABLE REDUCTION =20° anterior angulation, 30° varus, 15° malrotation, 3cm shortening
  • Functional bracing =96-100% union, brace should be put on with arm relaxed and hanging at side, pendulum exercises should be begun immediately. Hand/wrist exercises aid in decreasing swelling.  Brace must be adjusted as swelling subsides to maintain compression.  Only 2% of fx heal with deformities >25 degrees .  Xrays should be taken when brace placed, 1 wk, and monthly thereafter.  Overall healing takes 11.5wks.  Closed fractures @9.5wks, open fxs @14wks.  5.8% open fx will have nonunion, 1.5% closed fx's. (Sarmiento A JBJS 2000;82A:478) (Koch PP, JSES 2002;11:143). Bracing is contraindicated in patients with ipsilateral brachial plexus palsy. (Brian WW, JBJS 1990;72A:1208).
  • Operative indication =multi trauma, floating shoulder, floating elbow, bilateral, nonunion, open, vascular injury, neurologic injury, obesity, pathologic fx, segmental, plexus injury, progressive radial N palsy, distal intraarticular fx. Low-velocity GSW is not an indication.
  • Humeral Shaft Fracture ORIF 24515: screws should be placed in different planes because osteons of humerus are in creating stress riser like splitting log
  • ORIF vs IM nail: ORIF has 90% risk reduction for shoulder impingement symptoms and a 75% risk reduction for reoperation. No difference in infection rate, nonunion rate, and radial nerve palsy.
  • Intramedullary nail. (Bhandari M, Acta Orthop. 2006;77(2):279-84)
  • Humeral Shaft External Fixation
  • Radial nerve palsy: exploration of radial nerve palsy in closed fractures is not recommended. Radial nerve transection is associated with open fractures, but direct repair has not shown good functional outcomes. (RingD, J Hand Surg 2004;29A:144).

Humeral Shaft Fx Associated Injuries / Differential Diagnosis

  • Radial nerve palsy=pts with closed fx with radial nerve injury should be treated with fracture bracing, cock-up wrist splint and observation of radial nerve with delayed exploration at 3-4 months in there are no signs of return.  (Pollak EH, JBJS 63A:239;1981). Transection most commonly occurs with spiral oblique fx throught the distal 1/3.  Neuropraxia commonly seen with middle and distal 1/3 fx’s (Holstein A, Lewis GB, JBJS 1963:45A;1382)
  • Radial nerve transection: associated with poor results even with repair (RingD, J Hand Surg 2004;29A:144).
  • Brachial artery injury
  • Proximal humerus fracture
  • Distal humerus fracture

Humeral Shaft Fx Complications

  • delayed union = failure to unite in 2-3 months
  • nonunion 4-6 months
  • malunion
  • Radial nerve palsy-most recover in 3-4 months, pts should be placed in cock-up wrist splint, given thumb abduction and finger/wrist extension exercises to avoid contracture.  EMG at 6 wks if no signs of recovery.  Brachioradialis should be first muscle to return.  11.1% of closed fx have associated Radial nerve palsy, 0.2% in closed fx's fail to recover.  18% open fx. 60% have nerve entrapped in fx. (Bostman O, Acta Orthop Scand 1986;57:316) . (Shaz JJ, Bhatti NA: CORR 1983;172:171. (Holstein A JBJS 1963;458:1382).

Humeral Shaft Fx Follow-up Care

  • Non-op: posterior splint / coaptation splint.
  • Post-op: Posterior splint, NWB.
  • 7-10 Days: Remove splint, begin passive shoulder and elbow ROM. Stress elbow ROM. Place in Humeral fracture brace for non-op patients.
  • 6 Weeks: Begin strengthening exercises provided fracture union is evident on xray.
  • 3 Months: Ensure full restoration of shoulder and elbow ROM. Consider bone stimulator if union is delayed. Sport specific rehab.
  • 6 Months: return to full activities / sport.
  • 1Yr: Follow-up xrays, assess outcomes.
  • Immediate weight bearing on a plated humerus fx with the use of crutches of a walker has been shown to safe. (Tingstad, J Trauma 2000;49:278).
  • Shoulder Outcome measures.
  • Elbow Outcome measures.

Humeral Shaft Fx Review References

  • Carroll EA, JAAOS 2012;20:423
  • Rockwood and Green's Fractures in Adults 6th ed, 2006
  • Farragos AF, Schemitsch EH, McKee MD: Complications of intramedullary nailing for fractures of the humeral shaft: A review. J Orthop Trauma 1999;13:258-267.
  • Zagorski JB, Latta LL, Zych GA, et al: Diaphyseal fractures of the humerus: Treatment with prefabricated braces.  J Bone Joint Surg 1988;70A:607-610.
  • Healy WL, White GM, Mick CA, et al: Nonunion of the humeral shaft.  Clin Orthop 1987;219:206-213.
  • Dabezies EJ, Banta CJ II, Murphy CP, et al: Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries.  J Orthop Trauma 1992;6:10-13.
  • Epps CH Jr: Nonunion of the humerus, in Bassett FH III (ed): Instructional Course Lectures XXXVII. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1988, pp 161-166
  • Gerwin, Michelle, JBJS 1996;78A:1690
  • Levy JC, JOT 2005;19:43
  • Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000 Apr;82(4):478-86.
  • Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento) bracing of humeral shaft fractures. J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):143-50.