Fractures of the humerus

Essentials

1
Fractures of the proximal humerus occur primarily in the elderly, whereas distal humeral fractures occur more often in children.
2
Falls producing fractures in elderly patients are often precipitated by an underlying medical problem that should be sought for and managed.
3
Most proximal humeral fractures do not require surgical intervention.
4
The aim of treatment is to minimize pain, maximize the return of normal function as soon as possible and achieve acceptable cosmesis.
5
Humeral shaft fractures, displaced distal humeral fractures and fractures associated with neurovascular compromise require early orthopaedic review.
6
Low-force fractures, especially in the elderly, suggest the presence of osteoporosis. At-risk patients not already identified as having osteoporosis should be referred for bone density scans, vitamin D testing and treatment.

Introduction

The function of the upper limb depends on an intact shoulder girdle; this is, in turn, affected by the integrity of muscles, tendons and ligaments, bones, joints, blood vessels and nerves. Fractures of the humerus severely limit efficient function of the upper limb; that can be divided into proximal (proximal to the surgical neck), middle (shaft) and distal (supracondylar) segments.

Fractures of the proximal humerus

Patterns of injury

Fractures of the proximal humerus represent 5% of all fractures presenting to emergency departments (EDs) and 25% of all humeral fractures. The fracture typically occurs as a result of an indirect mechanism in elderly, osteoporotic patients who fall on an outstretched hand with an extended elbow. The fractures are female-predominant. The majority do not require surgical intervention and may initially be treated in the ED. A subset with a non-viable humeral head requires early surgical intervention; it is therefore important to identify this group. Fractures of the humerus may also occur in patients with multiple injuries or in the elderly with associated fractures of the neck of femur.

Clinical assessment

Patients typically present soon after injury, holding the arm adducted. They complain of pain and exhibit swelling and tenderness of the shoulder and upper arm. Although crepitus and bruising may occur, the former should not be elicited because it causes excessive and unnecessary pain. Bruising is usually delayed, occurring several days after injury. It appears around the lower arm rather than at the fracture site as a result of gravity and blood tracking distally.

A neurovascular examination is essential, as the axillary nerve, brachial plexus and/or axillary artery may be damaged. The axillary nerve is the most commonly injured and presents with altered sensation over the badge area (insertion of the deltoid) and reduced deltoid muscle contraction (which may be hard to assess because of pain). The axillary artery is the commonest vessel to be injured and may present with any combination of limb pain, pallor, paraesthesia, pulselessness and paralysis.

As these injuries frequently occur in elderly patients, careful attention must be paid to the reason for the fall, as an underlying acute medical condition may have precipitated the event and may require management in its own right.

Clinical Investigations

Three radiographic views—antero-posterior, lateral and axillary—will allow most proximal humeral fractures to be correctly diagnosed.

Fracture classification

Although the majority of these fractures are easily managed in the ED, the challenge is to differentiate them from the minority that require orthopaedic intervention.

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