Humeral shaft (arm) fractures

What are humeral shaft fractures?

Humeral shaft is a portion of the upper arm that lies in between the shoulder and elbow joint.  Humeral shaft fractures can occur due to direct fall or blow on the arm, forceful twisting of arm or due to injuries by automobile, missile, gunshot and ball throwing. The other causes of the fracture in the humeral shaft can be a low energy injury or fall in the patients with skeletal metastases (bone cancer) or osteoporosis. It accounts for nearly 3 % to 5 % of all fractures.

In 60 % of cases, humeral shaft fractures are commonly located at the middle third of the shaft of the humerus. These fractures commonly happen in young men in their third decade or in women in their seventh decade of life. 8% of these fractures are pathological and 10 % of the cases are seen in children below age 3 and above age 12 years.

 

What are the symptoms of humeral shaft fractures?

The patient complains of pain, swelling, bruising, and deformity over the affected area. Pain is experienced mainly in the middle of the arm. Soft tissue injury is also common. Shortening and abnormal motion are also reported on physical examination. In some patients with fractures close to elbow the radial nerve could be injured leading to wrist drop.

 

How is it diagnosed?

It is diagnosed by your medical history, history of injury, physical examination and an X-ray.  X-ray helps to determine the exact position of the fracture. MRI and CT scan are suggested in selected patients and electroneuromyography is also performed in patients with involvement of nerves.

 

How is it treated?

Fractures in the humeral shaft can be treated conservatively or surgically. It depends upon the personality of the fracture, associated injuries, age, healing and remodelling potential of an individual. Conservative treatments have good results leading to almost 90% of the union of the broken fragments.

Surgery is indicated in

Absolute indications

  • Open fracture
  • Vascular injury
  • Floating elbow (fracture of forearm)
  • Intra-articular fracture
  • Nerve injury
  • Non-union
  • Fracture gap with interposition of soft tissues

Relative indications

  • Pathologic fracture
  • Polytrauma
  • Malunion
  • Delayed union
  • Inadequate closed reduction
  • Radial nerve palsy (neuropraxia – temporary)
  • Bilateral humeral fractures.

 

What are the non-operative treatments?

Most humeral shaft fractures heal through non-operative treatments with 90 % union rates. It can be achieved through the following-

  • Immobilization– the patient is immobilized by the help of a back slab or U-slab for few days and changed to functional humeral brace for 12-16 weeks. Application of functional brace could be delayed in patients with severe soft tissue injury.
  • Medicines-your surgeon will prescribe you painkillers like codeine and paracetamol and anti-inflammatory drugs like aspirin and ibuprofen to control pain and swelling. However, using anti-inflammatory medications longer could lead to delayed bone healing.
  • Physiotherapy- it starts with a gentle range of motion (ROM), pendulum exercises and is gradually replaced by strenuous exercises when the healing is ensured to prevent stiffness and restore normal movement of the arm. The elbows, wrist, and hand are kept mobile during immobilization.

 

What does the operation involve?

The main purpose of the surgery is to achieve realignment of broken bone fragments and restoration of the normal functioning of the arm.

  • Surgery is usually performed as a day case under general anaesthetic, a cut is made in the skin over the fracture site and the fragments of the arm bone are first repositioned to their normal position.
  • Then, internal fixation of the fragments is done with the help of plates and screws to keep the bone in proper position during healing. In some cases with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap.
  • The skin is stitched using absorbable sutures and a bulky dressing is applied over the arm. The surgical time is usually 1-2hrs and a majority of the patients go home the same day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and pendulum exercises for the shoulder. This is necessary to prevent stiffness and to maintain the strength of the muscles near your shoulder after healing.
  • The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
  • The patient is reviewed at 2 weeks and referred for physiotherapy.
  • The fracture union is confirmed by x-rays at regular intervals, usually 6 weeks, 12 weeks and 6 months. However, in selected cases x-rays are taken in first few weeks to assess displacement/union.
  • The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
  • The physical therapy in humeral shaft fractures begins with gentle exercises and is progressed to strengthening exercises around 8 weeks. This depends on the X-ray reports and clinical union of fracture as guided by your surgeon.

 

Are there any risks?

  • Infection
  • Delayed union
  • Non-union
  • Mal-union
  • Radial nerve injury (18% of cases)
  • Vascular injury (uncommon, brachial artery)
  • Frozen shoulder
  • Ulnar or median nerve injury
  • Myositis ossificans
  • Anaesthetic complications

 

What are the results of the operation?

The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on grade and severity of the injury, associated injuries, treatment involved and adherence to physiotherapy. However, is more predictable in the author’s experience.

 

When can I return to driving and work?

You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3-6 months and depends on the severity of injury.  You should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality.  Your physician will be able to advise you.

Humeral shaft fractures

  1. 50 year old gentleman sustained fracture of his arm following a road traffic accident
  2. This was treated with plates and screws.

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