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    Proximal and Midshaft Humeral Fractures in Adults

    Orthopedic, Trauma

    Last Reviewed on Mar 13, 2024
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    By Damian Feldman-Kiss,Josh Williams, Tyler Martin

    First 5 Minutes

    • 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).


    • Acute: radial nerve injury (wrist drop).
    • Neurapraxia (most common); self-resolving in 80-90% over 6 to 9 months.1
    • Neer Classification2based 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:


    • 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.


    • 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

    Diagnostic Process

    • 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.

    Recommended Treatment

    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 splint4,5. 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.

    Criteria For Hospital Admission

    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

    Criteria For Transfer To Another Facility

    • 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.

    Criteria For Close Observation And/or Consult

    • 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.

    Criteria For Safe Discharge Home

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

    Quality Of Evidence?


    Recommendations based on results of peer reviewed studies in orthopedic literature.


    Related Information

    Reference List

    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.


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