Fractures of The Humeral Shaft

Fractures of the
Humeral Shaft
Hannan Khairu Anami
• Overview
• Anatomy
• Clinical Examination
• Radiographic Evaluation
• Treatment
• Complications
Overview
• 3% of all fractures
• Treatment opt are available : operative/nonoperative
management
• Most low-energy fractures may be amenable to closed
treatment – internal soft-tissue splinting and the biologic
potential of the humerus.
• In high-energy fractures, soft-tissue disruption and
extensive fracture comminution are frequently observed
rendering closed treatment less predictable.
Anatomy
• A. Osteology—The humeral shaft can be defined as extending from

the pectoralis major insertion proximally to the supracondylar ridge
distally. The shaft of the humerus assumes a more triangular shape
distally. The anterolateral surface of the humerus contains the
deltoid tuberosity as well as the sulcus for the profunda brachii
artery and the radial nerve. The spiral groove located on the
posterior humeral shaft contains the radial nerve as it passes
distally.
• B Musculature - The humeral musculature is divided by
medial and lateral intermuscular septa into anterior and
posterior compartments.
• The triceps brachii muscle fills the posterior compartment.
• The anterior compartment contains the biceps brachii, the
coracobrachialis, and the brachialis muscles.
• C. Nerves
• Musculocutaneous nerve
• Median nerve
• Radial nerve
• Ulnar nerve
• D. Vasculature
• The endosteal blood supply comes from branches of the
brachial artery.
• Periosteal branches : the brachial artery, the profunda
brachii artery, and the posterior humeral circumflex artery.
In addition, numerous small muscular branches.
Clinical Examination
The common signs and symptoms : swelling, pain, deformity, and crepitation.
Mechanisms of injury : Motor-vehicle accidents, direct blows, and falls on the upper
extremity
A complete physical examination is performed before concentrating on the upper extremity.
A complete neurovascular examination of the entire upper extremity is performed. Because
of the high incidence of injury, the function of the radial nerve must be documented before
any reduction maneuver or surgical intervention.
The joints above and below the humerus, as well as the ipsilateral wrist, are examined to
exclude other injuries.
The skin should be examined for abrasions, lacerations, contusions or a combination thereof.
The compartments of the arm should be palpated to assess for the possibility of a
compartment syndrome.
Radiographic Evaluation
• A complete radiographic evaluation is mandatory in the

workup of a humeral shaft fracture.
• An anteroposterior/lateral radiograph that includes both
the elbow joint and the glenohumeral joint are essential.
Treatment
• Closed Treatment—Options include hanging arm cast, shoulder spica
cast, Velpeau dressing, coaptation splint, and a functional brace.
• Because of low cost, effectiveness and minimal complications,
functional brace has become the preferred
• The ideal humeral shaft fracture amenable to a functional brace is the
long oblique shaft fracture with soft-tissue stability provided by an
intact medial and lateral intramuscular septum.
• Generally applied after 3 to 14 days of fracture splinting. Active elbow
flexion and extension are required to assist fracture healing during
bracing.
• Operative Treatment
1. Plate osteosynthesis
• Open reduction and plate osteosynthesis proven reliable
method of achieving union in humeral shaft fractures.
• Advantages include the ability to explore the radial nerve
during fixation, minimal morbidity to the shoulder joint,
low complication rates, early restoration of function, and
the opportunity to apply direct reduction techniques to the
fracture fragments
• Bone defects may be addressed with autologous bone graft,
bone substitutes, or allograft in the rare cases when a
biological adjunct is felt to be necessary to accomplish
healing.
• Dynamic compression plates—The AO group recommends a
4.5-mm broad dynamic compression (DC or LC-DCP) plate
with a minimum of six (preferably eight) cortices both
proximal and distal to the humeral shaft fracture
• Locked plating—Locked screws have dramatically expanded
the utility of plating as a treatment of humeral shaft
fractures. The opportunity to gain stable fixation in
osteoporotic bone and in fractures with short metaphyseal
segments has broadened the range of fractures amenable
to plate fixation
2. Intramedullary fixation
• • Rigid intramedullary interlocking nails— Antegrade
intramedullary nail fixation is applicable to proximal and middle
third fractures.
• The advantages of intramedullary nails include limited exposure
and the preserved fracture biology with indirect reduction.
• Static interlocking is generally recommended to enhance both
rotational and axial stability
• Pathologic fractures present a relative indication for
intramedullary stabilization as this stabilizes longer sections of
bone that are at risk for future oncologic weakening
Complications associated with antegrade nailing of humeral
shaft fractures include rotator cuff injury, shoulder pain, and
proximal prominent hardware
to avoid these shoulder complications, retrograde nail placement has

been utilized with a posterior starting point above the olecranon
fossa.
Avoiding shoulder complications this off axis starting point presents
difficulty passing a nail and places a large stress riser in the
supracondylar region
• Flexible intramedullary nail fixation—Flexible
intramedullary nails may be useful in both adult and
pediatric humeral shaft fractures.
• Many surgeons prefer the lower morbidity and simpler
techniques associated with these flexible implants.
• Flexible intramedullary devices may be inserted in an
anterograde or retrograde fashion.
• Complications with flexible nails : implant migration,
nonunion and rotational instability.
• External fixation—Open fractures, infected nonunions, burn
patients, and cases with segmental bone loss may be best
stabilized with an external fixator.
• External fixation pins should be inserted in a controlled
fashion under direct vision to guard against neurovascular
injury.
C. Surgical Approaches
• 1. Posterior approach to the humeral shaft - The posterior
approach uses the interval between the long and lateral
heads of the triceps muscle. The deep (medial) head is
subsequently divided, and the humeral shaft is exposed
• Dangers associated with this approach include damage to
the radial nerve and damage to the profunda brachii
arterymust be identified and protected.
• In addition, care should be taken not to injure the ulnar
nerve or the lateral brachial cutaneous nerve.
Posterior approach to the humeral shaft.
• 2. Anterolateral approach to the humeral shaft - In the
anterolateral approach, the humeral shaft is exposed by
developing the plane between the deltoid muscle and the
pectoralis major muscle proximally and through the
brachialis muscle distally.
• Dangers associated with this approach include the
musculocutaneous nerve and the radial nerve as it enters
the anterior compartment distally.
Anterolateral approach to the humeral shaft
• 3. Posterolateral approach to the humeral shaft —This
approach essentially follows the lateral intermuscular
septum and allows humeral exposure from the lateral
condyle to the proximal crossing of the axillary nerve. In
addition to this being an extensile exposure, its major
advantage is the ability to explore the radial nerve in both
the posterior and anterior compartments.
Posterolateral approach to the humeral shaft
Complications
Complications—Complications that may occur while treating
humeral shaft fractures include
• osteomyelitis,
• malunion,
• delayed union or nonunion,
• vascular injury, and
• radial nerve injury.

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Fractures of the

• A. Osteology—The humeral shaft can be defined as extending from

• A complete radiographic evaluation is mandatory in the

to avoid these shoulder complications, retrograde nail placement has

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