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Emergency And Acute Medicine – Humerus Fracture
Basics
Overview And Definitions
Humerus fractures include injuries to the proximal humerus and the humeral shaft. Proximal humeral fractures are commonly categorized as nondisplaced, displaced, or fracture–dislocations and account for approximately 5% of all fractures. Incidence increases with age, with a female-to-male ratio of 4:1, and the majority of patients are older than 60 years. These fractures represent the third most common osteoporotic fracture, following hip and distal radius fractures.
The Neer classification system is widely used for proximal humeral fractures and describes injuries based on the number and location of fracture fragments. Fractures are classified as 2-, 3-, or 4-part injuries involving the anatomic neck, surgical neck, greater tuberosity, or lesser tuberosity. Fracture–dislocations are also included in this system.
Humeral shaft fractures account for less than 3% of all fractures and may be spiral, oblique, or transverse in pattern. The AO classification categorizes these injuries as simple, wedge, or comminuted (complex) fractures.
Mechanisms And Causes
Proximal humeral fractures most commonly result from low-energy mechanisms, particularly falls, often onto an outstretched hand. Less frequently, they occur due to violent muscle contraction during seizures or electrical shock, or from higher-energy trauma.
Humeral shaft fractures are typically caused by high-energy direct trauma, either penetrating or blunt, or by bending forces. Less commonly, they result from falls or repetitive stress injuries, such as those seen in throwing athletes.
Diagnosis
Clinical Features
Patients usually present with pain, swelling, and localized tenderness over the humerus. There is often difficulty initiating active movement, and the arm may be held tightly against the chest. Shortening of the extremity, crepitus, ecchymosis, and signs of neurovascular compromise may be present.
History
Key historical elements include the mechanism of injury, patient age, fall risk, underlying malignancy, and associated injuries.
Physical Examination
A complete examination of the affected extremity is essential. Inspection should assess for deformity, shortening, swelling, and open wounds. Range of motion at the shoulder and elbow should be evaluated as tolerated. A detailed neurovascular examination is mandatory.
Essential Evaluation
Individual nerve function must be assessed, with special attention to the radial nerve, particularly in midshaft fractures. Median, ulnar, axillary (sensation over the lateral shoulder), and musculocutaneous nerves (sensation over the lateral forearm) should also be evaluated.
Vascular assessment includes palpation of radial, ulnar, and brachial pulses and confirmation of adequate capillary refill. Imaging is required to define the extent and type of injury.
Pediatric Considerations
Humerus fractures are most common in children younger than 3 years or older than 12 years. Neonatal fractures may occur due to birth trauma, especially in infants weighing more than 4.5 kg or in breech deliveries, and may present as pseudoparalysis.
In older children, mechanisms are similar to adults. The thicker periosteum in children often limits displacement of humeral shaft fractures. Proximal humeral Salter–Harris type I injuries should be suspected when radiographs are normal but significant pain persists, with Salter–Harris type II being most common. Nonaccidental trauma must be considered, particularly in children younger than 3 years, especially with suspicious fracture patterns.
Diagnostic Studies And Interpretation
Imaging
Plain radiographs are the initial imaging modality. Proximal humeral fractures require at least three views: anteroposterior, lateral, and axillary. The axillary view is critical for evaluating tuberosity displacement, glenoid involvement, and humeral head alignment.
Humeral shaft fractures require anteroposterior and lateral views of the entire humerus, including both the shoulder and elbow joints to rule out associated injuries.
CT scanning is useful in complex or comminuted proximal humeral fractures and in suspected fracture–dislocations, helping define fracture anatomy and surgical planning.
Differential Diagnosis
Acute hemorrhagic bursitis
Traumatic rotator cuff tear
Shoulder dislocation
Acromioclavicular joint separation
Calcific tendinitis
Contusion
Tendon rupture
Neurapraxia
Pathologic fracture
Management
Prehospital Care
Excessive movement of the injured arm should be avoided to prevent further neurovascular injury. Immobilization with a sling and swath is recommended, with rapid transport for patients exhibiting neurologic or vascular deficits.
Initial Stabilization
Primary and secondary trauma surveys should be performed to identify associated injuries. Immobilization helps reduce pain, prevent displacement, and minimize neurovascular injury. An axillary pad may improve comfort. Ice application helps limit swelling. Open fractures require sterile coverage, tetanus prophylaxis, and parenteral antibiotics.
Emergency Department Management
Adequate analgesia is essential, with narcotics administered orally, intramuscularly, or intravenously as first-line therapy.
Most proximal humeral fractures are single-part injuries and can be managed nonoperatively with sling and swath immobilization and early range-of-motion exercises. Displaced or multipart fractures should be described using the Neer classification. Fractures with more than 1 cm of displacement or more than 45 degrees of angulation are considered displaced and require orthopedic consultation.
Two-part fractures may often be managed nonoperatively after reduction, whereas three- and four-part fractures may require operative fixation or hemiarthroplasty, depending on patient age, comorbidities, and functional expectations. Emergent orthopedic consultation is indicated for open fractures, irreducible fracture–dislocations, or vascular compromise.
Most humeral shaft fractures can be managed nonoperatively without reduction. Up to 20 degrees of anterior angulation, 30 degrees of varus angulation, and 3 cm of shortening are generally well tolerated. Nondisplaced fractures may be treated with a coaptation splint, except for transverse fractures, which are better managed with a sling and swath. Displaced fractures may require a hanging cast under orthopedic guidance. Emergent consultation is required for neurovascular compromise, open fractures, segmental fractures, articular involvement, or a “floating elbow.”
Medications
Pain control is achieved primarily with narcotic analgesics. NSAIDs may be used as adjunctive therapy. Procedural sedation may be required for closed reductions.
Follow-Up And Disposition
Admission Criteria
Open fractures
Fractures with vascular compromise
Displaced fractures not amenable to closed management
Significant associated injuries requiring observation
Discharge Criteria
Nondisplaced fractures
Fractures successfully treated with closed reduction
Most isolated humeral shaft fractures
Selected complex proximal humeral fractures after orthopedic consultation
Referral Considerations
Most patients require outpatient orthopedic follow-up. Proximal humeral fractures classified as Neer type 2–4 should be reviewed with orthopedics for definitive planning. Displaced humeral shaft fractures require orthopedic management with functional bracing, casting, or surgical fixation.
Follow-Up Recommendations
Early follow-up is recommended to reassess neurovascular status, pain control, and fracture alignment. Stable proximal humeral fractures should be evaluated for early range-of-motion therapy to reduce the risk of adhesive capsulitis.
Key Points And Common Pitfalls
A thorough neurovascular examination is essential for all humeral fractures and should be repeated after manipulation. Radial nerve injury is the most common neurologic deficit associated with humeral shaft fractures and typically resolves spontaneously over months. Proximal humeral fractures involving the surgical neck or articular surface carry a risk of avascular necrosis. Multipart proximal humeral fractures often do not require admission but must have a clear orthopedic management plan due to the potential need for surgical intervention.
Basics
Overview And Definitions
Humerus fractures include injuries to the proximal humerus and the humeral shaft. Proximal humeral fractures are commonly categorized as nondisplaced, displaced, or fracture–dislocations and account for approximately 5% of all fractures. Incidence increases with age, with a female-to-male ratio of 4:1, and the majority of patients are older than 60 years. These fractures represent the third most common osteoporotic fracture, following hip and distal radius fractures.
The Neer classification system is widely used for proximal humeral fractures and describes injuries based on the number and location of fracture fragments. Fractures are classified as 2-, 3-, or 4-part injuries involving the anatomic neck, surgical neck, greater tuberosity, or lesser tuberosity. Fracture–dislocations are also included in this system.
Humeral shaft fractures account for less than 3% of all fractures and may be spiral, oblique, or transverse in pattern. The AO classification categorizes these injuries as simple, wedge, or comminuted (complex) fractures.
Mechanisms And Causes
Proximal humeral fractures most commonly result from low-energy mechanisms, particularly falls, often onto an outstretched hand. Less frequently, they occur due to violent muscle contraction during seizures or electrical shock, or from higher-energy trauma.
Humeral shaft fractures are typically caused by high-energy direct trauma, either penetrating or blunt, or by bending forces. Less commonly, they result from falls or repetitive stress injuries, such as those seen in throwing athletes.
Diagnosis
Clinical Features
Patients usually present with pain, swelling, and localized tenderness over the humerus. There is often difficulty initiating active movement, and the arm may be held tightly against the chest. Shortening of the extremity, crepitus, ecchymosis, and signs of neurovascular compromise may be present.
History
Key historical elements include the mechanism of injury, patient age, fall risk, underlying malignancy, and associated injuries.
Physical Examination
A complete examination of the affected extremity is essential. Inspection should assess for deformity, shortening, swelling, and open wounds. Range of motion at the shoulder and elbow should be evaluated as tolerated. A detailed neurovascular examination is mandatory.
Essential Evaluation
Individual nerve function must be assessed, with special attention to the radial nerve, particularly in midshaft fractures. Median, ulnar, axillary (sensation over the lateral shoulder), and musculocutaneous nerves (sensation over the lateral forearm) should also be evaluated.
Vascular assessment includes palpation of radial, ulnar, and brachial pulses and confirmation of adequate capillary refill. Imaging is required to define the extent and type of injury.
Pediatric Considerations
Humerus fractures are most common in children younger than 3 years or older than 12 years. Neonatal fractures may occur due to birth trauma, especially in infants weighing more than 4.5 kg or in breech deliveries, and may present as pseudoparalysis.
In older children, mechanisms are similar to adults. The thicker periosteum in children often limits displacement of humeral shaft fractures. Proximal humeral Salter–Harris type I injuries should be suspected when radiographs are normal but significant pain persists, with Salter–Harris type II being most common. Nonaccidental trauma must be considered, particularly in children younger than 3 years, especially with suspicious fracture patterns.
Diagnostic Studies And Interpretation
Imaging
Plain radiographs are the initial imaging modality. Proximal humeral fractures require at least three views: anteroposterior, lateral, and axillary. The axillary view is critical for evaluating tuberosity displacement, glenoid involvement, and humeral head alignment.
Humeral shaft fractures require anteroposterior and lateral views of the entire humerus, including both the shoulder and elbow joints to rule out associated injuries.
CT scanning is useful in complex or comminuted proximal humeral fractures and in suspected fracture–dislocations, helping define fracture anatomy and surgical planning.
Differential Diagnosis
Acute hemorrhagic bursitis
Traumatic rotator cuff tear
Shoulder dislocation
Acromioclavicular joint separation
Calcific tendinitis
Contusion
Tendon rupture
Neurapraxia
Pathologic fracture
Management
Prehospital Care
Excessive movement of the injured arm should be avoided to prevent further neurovascular injury. Immobilization with a sling and swath is recommended, with rapid transport for patients exhibiting neurologic or vascular deficits.
Initial Stabilization
Primary and secondary trauma surveys should be performed to identify associated injuries. Immobilization helps reduce pain, prevent displacement, and minimize neurovascular injury. An axillary pad may improve comfort. Ice application helps limit swelling. Open fractures require sterile coverage, tetanus prophylaxis, and parenteral antibiotics.
Emergency Department Management
Adequate analgesia is essential, with narcotics administered orally, intramuscularly, or intravenously as first-line therapy.
Most proximal humeral fractures are single-part injuries and can be managed nonoperatively with sling and swath immobilization and early range-of-motion exercises. Displaced or multipart fractures should be described using the Neer classification. Fractures with more than 1 cm of displacement or more than 45 degrees of angulation are considered displaced and require orthopedic consultation.
Two-part fractures may often be managed nonoperatively after reduction, whereas three- and four-part fractures may require operative fixation or hemiarthroplasty, depending on patient age, comorbidities, and functional expectations. Emergent orthopedic consultation is indicated for open fractures, irreducible fracture–dislocations, or vascular compromise.
Most humeral shaft fractures can be managed nonoperatively without reduction. Up to 20 degrees of anterior angulation, 30 degrees of varus angulation, and 3 cm of shortening are generally well tolerated. Nondisplaced fractures may be treated with a coaptation splint, except for transverse fractures, which are better managed with a sling and swath. Displaced fractures may require a hanging cast under orthopedic guidance. Emergent consultation is required for neurovascular compromise, open fractures, segmental fractures, articular involvement, or a “floating elbow.”
Medications
Pain control is achieved primarily with narcotic analgesics. NSAIDs may be used as adjunctive therapy. Procedural sedation may be required for closed reductions.
Follow-Up And Disposition
Admission Criteria
Open fractures
Fractures with vascular compromise
Displaced fractures not amenable to closed management
Significant associated injuries requiring observation
Discharge Criteria
Nondisplaced fractures
Fractures successfully treated with closed reduction
Most isolated humeral shaft fractures
Selected complex proximal humeral fractures after orthopedic consultation
Referral Considerations
Most patients require outpatient orthopedic follow-up. Proximal humeral fractures classified as Neer type 2–4 should be reviewed with orthopedics for definitive planning. Displaced humeral shaft fractures require orthopedic management with functional bracing, casting, or surgical fixation.
Follow-Up Recommendations
Early follow-up is recommended to reassess neurovascular status, pain control, and fracture alignment. Stable proximal humeral fractures should be evaluated for early range-of-motion therapy to reduce the risk of adhesive capsulitis.
Key Points And Common Pitfalls
A thorough neurovascular examination is essential for all humeral fractures and should be repeated after manipulation. Radial nerve injury is the most common neurologic deficit associated with humeral shaft fractures and typically resolves spontaneously over months. Proximal humeral fractures involving the surgical neck or articular surface carry a risk of avascular necrosis. Multipart proximal humeral fractures often do not require admission but must have a clear orthopedic management plan due to the potential need for surgical intervention.
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