Humerus fracture

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Humerus fracture
Communitive midshaft humeral fracture callus.jpg
Midshaft humerus fracture with callus formation
Specialty Orthopedics
Symptoms Pain, swelling, bruising [1]
Complications Injury to an artery or nerve, compartment syndrome [2]
Types Proximal humerus, humerus shaft, distal humerus [1] [2]
Causes Trauma, cancer [2]
Diagnostic method X-rays [2]
Treatment Sling, splint, brace, surgery [1]
Prognosis Generally good (proximal and shaft), Less good (distal) [2]
Frequency~4% of fractures [2]

A humerus fracture is a break of the humerus bone in the upper arm. [1] Symptoms may include pain, swelling, and bruising. [1] There may be a decreased ability to move the arm and the person may present holding their elbow. [2] Complications may include injury to an artery or nerve, and compartment syndrome. [2]

Contents

The cause of a humerus fracture is usually physical trauma such as a fall. [1] Other causes include conditions such as cancer in the bone. [2] Types include proximal humeral fractures, humeral shaft fractures, and distal humeral fractures. [1] [2] Diagnosis is generally confirmed by X-rays. [2] A CT scan may be done in proximal fractures to gather further details. [2]

Treatment options may include a sling, splint, brace, or surgery. [1] In proximal fractures that remain well aligned, a sling is often sufficient. [2] Many humerus shaft fractures may be treated with a brace rather than surgery. [2] Surgical options may include open reduction and internal fixation, closed reduction and percutaneous pinning, and intramedullary nailing. [2] Joint replacement may be another option. [2] Proximal and shaft fractures generally have a good outcome while outcomes with distal fractures can be less good. [2] They represent about 4% of fractures. [2]

Signs and symptoms

Closed shaft fracture in the middle of humerus Upper arm bone fracture - Humerus fracture 2 -- Smart-Servier.png
Closed shaft fracture in the middle of humerus

After a humerus fracture, pain is immediate, enduring, and exacerbated with the slightest movements. The affected region swells, with bruising appearing a day or two after the fracture. The fracture is typically accompanied by a discoloration of the skin at the site of the fracture. [3] [4] A crackling or rattling sound may also be present, caused by the fractured humerus pressing against itself. [5] In cases in which the nerves are affected, then there will be a loss of control or sensation in the arm below the fracture. [6] [4] If the fracture affects the blood supply, then the patient will have a diminished pulse at the wrist. [6] Displaced fractures of the humerus shaft will often cause deformity and a shortening of the length of the upper arm. [5] Distal fractures may also cause deformity, and they typically limit the ability to flex the elbow. [7]

Causes

Humerus fractures usually occur after physical trauma, falls, excess physical stress, or pathological conditions. Falls that produce humerus fractures among the elderly are usually accompanied by a preexisting risk factor for bone fracture, such as osteoporosis, a low bone density, or vitamin B deficiency. [8]

Proximal

Proximal humerus fractures most often occur among elderly people with osteoporosis who fall on an outstretched arm. [9] Less frequently, proximal fractures occur from motor vehicle accidents, gunshots, and violent muscle contractions from an electric shock or seizure. [10] [5] Other risk factors for proximal fractures include having a low bone mineral density, having impaired vision and balance, and tobacco smoking. [11] A stress fracture of the proximal and shaft regions can occur after an excessive amount of throwing, such as pitching in baseball. [6]

Middle

Middle fractures are usually caused by either physical trauma or falls. Physical trauma to the humerus shaft tends to produce transverse fractures whereas falls tend to produce spiral fractures. Metastatic breast cancer may also cause fractures in the humerus shaft. [12] Long spiral fractures of the shaft that are present in children may indicate physical abuse. [5]

Distal

Distal humerus fractures usually occur as a result of physical trauma to the elbow region. If the elbow is bent during the trauma, then the olecranon is driven upward, producing a T- or Y-shaped fracture or displacing one of the condyles. [7]

Diagnosis

Definitive diagnosis of humerus fractures is typically made through radiographic imaging. For proximal fractures, X-rays can be taken from a scapular anteroposterior (AP) view, which takes an image of the front of the shoulder region from an angle, a scapular Y view, which takes an image of the back of the shoulder region from an angle, and an axillar lateral view, which has the patient lie on his or her back, lift the bottom half of the arm up to the side, and have an image taken of the axilla region underneath the shoulder. [9] Fractures of the humerus shaft are usually correctly identified with radiographic images taken from the AP and lateral viewpoints. [12] Damage to the radial nerve from a shaft fracture can be identified by an inability to bend the hand backwards or by decreased sensation in the back of the hand. [5] Images of the distal region are often of poor quality due to the patient being unable to extend the elbow because of pain. If a severe distal fracture is suspected, then a computed tomography (CT) scan can provide greater detail of the fracture. Nondisplaced distal fractures may not be directly visible; they may only be visible due to fat being displaced because of internal bleeding in the elbow. [7]

Classification

Fractures of the humerus are classified based on the location of the fracture and then by the type of fracture. There are three locations that humerus fractures occur: at the proximal location, which is the top of the humerus near the shoulder, in the middle, which is at the shaft of the humerus, and the distal location, which is the bottom of the humerus near the elbow. [9] Proximal fractures are classified into one of four types of fractures based on the displacement of the greater tubercle, the lesser tubercle, the surgical neck, and the anatomical neck, which are the four parts of the proximal humerus, with fracture displacement being defined as at least one centimeter of separation or an angulation greater than 45 degrees. One-part fractures involve no displacement of any parts of the humerus, two-part fractures have one part displaced relative to the other three; three-part fractures have two displaced fragments, and four-part fractures have all fragments displaced from each other. [13] [14] [3] Fractures of the humerus shaft are subdivided into transverse fractures, spiral fractures, "butterfly" fractures, which are a combination of transverse and spiral fractures, and pathological fractures, which are fractures caused by medical conditions. [12] Distal fractures are split between supracondylar fractures, which are transverse fractures above the two condyles at the bottom of the humerus, and intercondylar fractures, which involve a T- or Y-shaped fracture that splits the condyles. [7]

Treatment

The aim of treatment is to minimize pain and to restore as much normal function as possible. Most humerus fractures do not require surgical intervention. [4]

Proximal

One-part and two-part proximal fractures can be treated with a collar and cuff sling, adequate pain medicine, and follow up therapy. Two-part proximal fractures may require open or closed reduction depending on neurovascular injury, rotator cuff injury, dislocation, likelihood of union, and function. For three- and four-part proximal fractures, standard practice is to have open reduction and internal fixation to realign the separate parts of the proximal humerus. A humeral hemiarthroplasty may be required in proximal cases in which the blood supply to the region is compromised. [15] Compared with non-surgical treatment, surgery does not result in a better outcome for the majority of people with displaced proximal humeral fractures and is likely to result in a greater need for subsequent surgery. [16]

Middle

Fractures of the humerus shaft are most often uncomplicated, closed fractures that require nothing more than pain medicine and wearing a cast or sling. For midshaft fractures up to 12 weeks may be required for healing. [17]

In shaft and distal cases in which complications such as damage to the neurovascular bundle exist, then surgical repair is required. [18]

Prognosis

In most cases, people are discharged from an emergency department with pain medicine and a cast or sling. These fractures are typically minor and heal over the course of a few weeks. [4] Fractures of the proximal region, especially among elderly people, may limit future shoulder activity. [19] [20] Severe fractures are usually resolved with surgical intervention, followed by a period of healing using a cast or sling. [11] Severe fractures often cause long-term loss of physical ability. [21] Complications in the recovery process of severe fractures include osteonecrosis, malunion or nonunion of the fracture, stiffness, and rotator cuff dysfunction, which require additional intervention in order for the patient to fully recover. [21]

Epidemiology

Humerus fractures are among the most common of fractures. Proximal fractures make up 5% of all fractures and 25% of humerus fractures, [9] middle fractures about 60% of humerus fractures (12% of all fractures), [12] and distal fractures the remainder. Among proximal fractures, 80% are one-part, 10% are two-part, and the remaining 10% are three- and four-part. [22] The most common location of proximal fractures is at the surgical neck of the humerus. [3] Incidence of proximal fractures increases with age, with about 75% of cases occurring among people over the age of 60. [11] In this age group, about three times as many women as men experience a proximal fracture. [23] Middle fractures are also common among the elderly, but they frequently occur among physically active young adult men who experience physical trauma to the humerus. [12] Distal fractures are rare among adults, occurring primarily in children who experience physical trauma to the elbow region. [7]

Related Research Articles

<span class="mw-page-title-main">Humerus</span> Long bone of the upper arm

The humerus is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius and ulna, and consists of three sections. The humeral upper extremity consists of a rounded head, a narrow neck, and two short processes. The body is cylindrical in its upper portion, and more prismatic below. The lower extremity consists of 2 epicondyles, 2 processes, and 3 fossae. As well as its true anatomical neck, the constriction below the greater and lesser tubercles of the humerus is referred to as its surgical neck due to its tendency to fracture, thus often becoming the focus of surgeons.

<span class="mw-page-title-main">Biceps</span> Muscle on the front of the upper arm

The biceps or biceps brachii is a large muscle that lies on the front of the upper arm between the shoulder and the elbow. Both heads of the muscle arise on the scapula and join to form a single muscle belly which is attached to the upper forearm. While the biceps crosses both the shoulder and elbow joints, its main function is at the elbow where it flexes the forearm and supinates the forearm. Both these movements are used when opening a bottle with a corkscrew: first biceps screws in the cork (supination), then it pulls the cork out (flexion).

<span class="mw-page-title-main">Ulnar nerve</span> Nerve which runs near the ulna bone

In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is common. This nerve is directly connected to the little finger, and the adjacent half of the ring finger, innervating the palmar aspect of these fingers, including both front and back of the tips, perhaps as far back as the fingernail beds.

<span class="mw-page-title-main">Radius (bone)</span> One of the two long bones of the forearm

The radius or radial bone is one of the two large bones of the forearm, the other being the ulna. It extends from the lateral side of the elbow to the thumb side of the wrist and runs parallel to the ulna. The ulna is usually slightly longer than the radius, but the radius is thicker. Therefore the radius is considered to be the larger of the two. It is a long bone, prism-shaped and slightly curved longitudinally.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Joint dislocation</span> Medical injury

A joint dislocation, also called luxation, occurs when there is an abnormal separation in the joint, where two or more bones meet. A partial dislocation is referred to as a subluxation. Dislocations are often caused by sudden trauma on the joint like an impact or fall. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Dislocations can occur in any major joint or minor joint. The most common joint dislocation is a shoulder dislocation.

<span class="mw-page-title-main">Clavicle fracture</span> Medical condition

A clavicle fracture, also known as a broken collarbone, is a bone fracture of the clavicle. Symptoms typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include a collection of air in the pleural space surrounding the lung (pneumothorax), injury to the nerves or blood vessels in the area, and an unpleasant appearance.

<span class="mw-page-title-main">Avulsion fracture</span> Tearing away of a bone by physical trauma

An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma. This can occur at the ligament by the application of forces external to the body or at the tendon by a muscular contraction that is stronger than the forces holding the bone together. Generally muscular avulsion is prevented by the neurological limitations placed on muscle contractions. Highly trained athletes can overcome this neurological inhibition of strength and produce a much greater force output capable of breaking or avulsing a bone.

The pronator teres is a muscle that, along with the pronator quadratus, serves to pronate the forearm. It has two attachments, to the medial humeral supracondylar ridge and the ulnar tuberosity, and inserts near the middle of the radius.

<span class="mw-page-title-main">Surgical neck of the humerus</span> Part of one of the bones of the arm

The surgical neck of the humerus is a bony constriction at the proximal end of shaft of humerus. It is situated distal to the greater tubercle and lesser tubercle, and proximal to the deltoid tuberosity.

<span class="mw-page-title-main">Scaphoid fracture</span> Fracture of the scaphoid bone in the wrist

A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include nonunion of the fracture, avascular necrosis of the proximal part of the bone, and arthritis.

<span class="mw-page-title-main">Elbow</span> Joint between the upper and lower parts of the arm

The elbow is the region between the arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa, and the lateral and the medial epicondyles of the humerus. The elbow joint is a hinge joint between the arm and the forearm; more specifically between the humerus in the upper arm and the radius and ulna in the forearm which allows the forearm and hand to be moved towards and away from the body. The term elbow is specifically used for humans and other primates, and in other vertebrates forelimb plus joint is used.

<span class="mw-page-title-main">Supracondylar humerus fracture</span> Medical condition

A supracondylar humerus fracture is a fracture of the distal humerus just above the elbow joint. The fracture is usually transverse or oblique and above the medial and lateral condyles and epicondyles. This fracture pattern is relatively rare in adults, but is the most common type of elbow fracture in children. In children, many of these fractures are non-displaced and can be treated with casting. Some are angulated or displaced and are best treated with surgery. In children, most of these fractures can be treated effectively with expectation for full recovery. Some of these injuries can be complicated by poor healing or by associated blood vessel or nerve injuries with serious complications.

<span class="mw-page-title-main">Holstein–Lewis fracture</span> Medical condition

A Holstein–Lewis fracture is a fracture of the distal third of the humerus resulting in entrapment of the radial nerve.

<span class="mw-page-title-main">Ulna fracture</span> Medical condition

An ulna fracture is a break in the ulna bone, one of the two bones in the forearm. It is often associated with a fracture of the other forearm bone, the radius.

Jobe's test, also known as empty can test, is an orthopedic examination used to test stability of the shoulder.

Humeral avulsion of the glenohumeral ligament (HAGL) is defined as an avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus. In other words, it occurs when we have disruption of the ligaments that join the humerus to the glenoid. HAGL tends to occur in 7.5-9.3% of cases of anterior shoulder instability. Making it an uncommon cause of anterior shoulder instability. Avulsion of this ligamentous complex may occur in three sites: glenoid insertion (40%), the midsubstance (35%) and the humeral insertion (25%). Bony humeral avulsion of the glenohumeral ligament (BHAGL) refers when we have HAGL with bony fracture.

<span class="mw-page-title-main">Olecranon fracture</span> Medical condition

Olecranon fracture is a fracture of the bony portion of the elbow. The injury is fairly common and often occurs following a fall or direct trauma to the elbow. The olecranon is the proximal extremity of the ulna which is articulated with the humerus bone and constitutes a part of the elbow articulation. Its location makes it vulnerable to direct trauma.

Yergason's test is a special test used for orthopedic examination of the shoulder and upper arm region, specifically the biceps tendon.

<span class="mw-page-title-main">Proximal humerus fracture</span> Break of the upper part of the bone of the arm

A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus). Symptoms include pain, swelling, and a decreased ability to move the shoulder. Complications may include axillary nerve or axillary artery injury.

References

  1. 1 2 3 4 5 6 7 8 "Humerus Fracture (Upper Arm Fracture)". www.hopkinsmedicine.org. Retrieved 20 June 2019.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Humerus Fractures Overview". StatPearls. 6 June 2019. PMID   29489190.
  3. 1 2 3 Cuccurullo, 2014, p. 177
  4. 1 2 3 4 Cameron, et al., 2014, p. 167–170
  5. 1 2 3 4 5 Auth, 2012, p. 167
  6. 1 2 3 Cuccurullo, 2014, p. 178
  7. 1 2 3 4 5 Cameron, et al., 2014, p. 170
  8. ↑ Cameron, et al., 2014, p. 167, 169
  9. 1 2 3 4 Cameron, et al., 2014, p. 167
  10. ↑ Crosby, et al., 2014, p. 4
  11. 1 2 3 Crosby, et al., 2014, p. 23
  12. 1 2 3 4 5 Cameron, et al., 2014, p. 169
  13. ↑ Cameron, et al., 2014, pp. 167–168
  14. ↑ Crosby, et al., 2014, pp. 11–19
  15. ↑ Cameron, et al., 2014, pp. 168–169
  16. ↑ Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S (June 2022). "Interventions for treating proximal humeral fractures in adults". The Cochrane Database of Systematic Reviews. 6: CD000434. doi:10.1002/14651858.CD000434.pub5. PMC   9211385 . PMID   35727196.
  17. ↑ Bounds EJ, Frane N, Kok SJ (2018). "Humeral Shaft Fractures". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   28846218.
  18. ↑ Cameron, et al., 2014, pp. 169–170
  19. ↑ Malhotra, 2013, p. 47
  20. ↑ Crosby, et al., 2014, p. 31
  21. 1 2 Crosby, et al., 2014, p. 35
  22. ↑ Cameron, et al., 2014, p. 168
  23. ↑ Crosby, et al., 2014, p. 1

Bibliography

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