• Assess neurovascular status.
• Assess for evidence of open fracture.
• Assess joint above and joint below.

Humeral fractures can occur proximally, in the shaft (diaphysis), or distally.

Humeral Shaft Fractures:

Mechanism of Injury:

• Commonly a direct blow to the arm, severe twist, or FOOSH.
• Typical fracture patterns include transverse, oblique, or spiral fractures.

Risk Factors:

• High energy trauma.
• Pathologic fracture (benign tumors, unicameral cysts, malignancy).

Clinical features:

• Severe focal pain/tenderness.
• Swelling.
• Immobility.
• Shortening or rotation.
• Bony tenderness and swelling without obvious deformity (incomplete fracture).

Complications:

• Acute: radial nerve injury (wrist drop).
• Neurapraxia (most common); self-resolving in 80-90% over 6 to 9 months.¹
• Neer Classification² – based on the anatomical relationship of the four major segments of the proximal humerus: anatomical neck, surgical neck, greater tuberosity, and lesser tuberosity.
  • Fractures are classified according to number of segments displaced (displacement occurs when a segment is angulated more than 45 degrees or displaced > 1cm from normal anatomical position).
    • One-part fractures – no fragments are displaced.
    • Two-part fractures – one displaced fragment.
    • Three-part fractures – two displaced fragments but humeral head remains in contact with glenoid.
    • Four-part fractures – three or more displaced fragments and dislocation of articular surface from the glenoid.

Proximal Humeral Fractures:

Mechanism:

• FOOSH.
• Direct blow to the lateral side of the arm.
• Axial load transmitted through the elbow.
• High-energy mechanisms and polytrauma (younger patients).

Clinical Features:

• Shoulder adduction, internal rotation and elbow flexion.
• Guarding.
• Tenderness, hematoma, ecchymosis, deformity, or crepitus over fracture site.

Complications:

• Acute: axial nerve, brachial plexus, or axillary artery injury.
• Chronic: adhesive capsulitis, avascular necrosis, heterotrophic bone formation (myositis ossificans, especially following multiple attempts to reduce fracture-dislocations).

Differential Diagnosis:

• Shoulder fracture-dislocation
• Glenohumeral dislocation
• AC joint separation
• Rotator cuff tendon tear
• Soft tissue injury – muscle strain, ecchymosis

• Complete neurovascular exam.
• Assess for evidence of open fracture.
• Imaging:
  • Proximal humerus fractures in adults:
    • Plain radiographs of the shoulder³:
      • True AP view
      • Axillary view
      • Scapular-Y view
  • CT scan is recommended for:
    • fracture dislocations
    • humeral head-splitting fractures
    • comminuted fractures
  • Midshaft fractures in adults:
    • Lateral and AP radiographs are necessary to evaluate the amount of angulation/displacement of the fracture.
    • Include radiographs of shoulder and elbow if injury to these joints cannot be ruled out by physical exam.

Non-pharmacological, including surgical treatments

• Appropriate evaluation for additional traumatic injuries.
• Appropriate analgesia.
• Support of injured extremity to ensure patient comfort.

Most proximal and midshaft humeral fractures are non-displaced, can be treated conservatively, and do not require surgical management³.

Proximal humeral fractures:

• Immobilization in a standard sling or collar and cuff sling.
• Ice to reduce pain and swelling.
• Patients may prefer to sleep semi-recumbent (e.g., in a reclining chair or propped up with pillows/wedge in bed) with a sling.
• Repeat clinical evaluation and radiographs in 1 week.
• Closed reduction of fracture fragments is not recommended due to the forces exerted by insertion muscles on the humerus.

Most humeral shaft fractures can be treated initially in a coaptation splint^4,5. Some spiral, oblique and comminuted fractures require traction, in addition to splinting, to achieve appropriate alignment.

Midshaft humeral fractures:

• Midshaft humerus fractures associated with vascular injury or open fractures require immediate surgical referral. Other absolute indications for referral include:
  • Fractures associated with articular injury.
  • Brachial plexus injuries.
  • Associated ipsilateral forearm fractures (e.g., floating elbow).
  • Pathological fractures.
  • Concomitant major traumatic injuries.
  • High-velocity gunshot injuries.
  • Fracture associated with severe soft tissue injuries or significant skin involvement.

• Holstein Lewis Fractures (displaced spiral shaft fractures) generally require surgical evaluation due to their high association with radial nerve injury.

Consider hospital admission for patients with:

• Multiple traumatic injuries that require inpatient treatment/observation.
• Open fractures.
• Vascular or neurologic compromise.
• Fractures in the elderly that culminate in loss of independence and ability to cope.⁶

• Consider transport to another facility if the patient has a severe humeral fracture that requires specialized care that is unavailable at the current facility.
• Provide appropriate analgesia during transport.

• Referral to orthopedic surgeon recommended for patients with Neer 2-4 part proximal humeral fractures, or those with anatomical neck fractures.
• Emergent orthopedic consultation is indicated for all open fractures, fracture dislocations, severely displaced or comminuted fractures, fractures associated with ipsilateral forearm fractures, and neurovascular injuries.

• Most humeral injuries can be discharged home with appropriate orthopedic specialty follow-up.

1. Walls, R, editor-in-chief. Rosen’s emergency medicine: concepts and clinical practice. Tenth edition. Philadelphia: Elsevier; 2023.

   
   

2. Neer CS. Classification and evaluation. JBJS. 1970;52:1077-89.

   
   

3. Vachtsevanos L, Hayden L, Desai AS, Dramis A. Management of proximal humerus fractures in adults. World journal of Orthopedics. 2014 Nov 11;5(5):685.

   
   

4. Sarmiento A. Functional bracing of fractures of the shaft of the humerus. Orthopedic Trauma Directions. 2008 Jan;6(01):33-7.

   
   

5. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace. Journal of orthopaedic trauma. 2006 Oct 1;20(9):597-601.

   
   

6. Roux A, Decroocq L, El Batti S, Bonnevialle N, Moineau G, Trojani C, Boileau P, De Peretti F. Epidemiology of proximal humerus fractures managed in a trauma center. Orthopaedics & Traumatology: Surgery & Research. 2012 Oct 1;98(6):715-9.